Polite Dissent

The mystery was fairly bland in this week’s episode of House, but the medicine was much better overall. Good bye Cameron. Don’t let the door hit you on the way out.

Hank, a successful porn star is admitted to Princeton Plainsboro Teaching Hospital after developing a severe headache and photophobia (sensitivity to light) while on set. House starts off by ordering a series of tests: an STD panel (to look for sexually transmitted diseases), a toxin screen (to look for common toxins), C-Reactive Protein (”CRP”, a measure of inflammation), ANA (antinuclear antibodies, to look for autoimmune diseases) and a lumbar puncture (to look for viral encephalitis). While the patient is having his spinal tap performed, he develops severe muscle spam and pain (tetany) in his arms. Foreman orders meperidine (Demerol, a strong pain medication).

About this time, House starts hitting up Taub and Thirteen for ideas, trying to lure them back on the team. Taub suggests that Hank must have a brain problem, such as a tumor or seizure. Foreman believes that Hank suffers from cerebral vasculitis (inflammation of the blood vessels in the brain). House agrees with Foreman’s assessment and starts the patient on steroids. He also orders a brain angiogram (an x-ray of the arteries in the brain), as well as an EEG and a nerve biopsy, just to be sure. Foreman convinces Chase to perform the angiogram, but he and Cameron suspect that the patient is suffering from Vitamin D deficiency, so instead of checking the angiogram, they decide to start Hank on light therapy and intravenous vitamin replacement. Unfortunately, while undergoing the light therapy, Hank develops a nosebleed and is found to have petechiae on his legs.

Hank is now diagnosed with disseminated intravascular coagulation (DIC, a weird, but very serious, condition, where the patient is both bleeding too much and clotting too much). Sepsis is suggested as a possible cause, but since he is showing none of the shock associated with sepsis, the idea is discarded. Bacteremia (bacteria in the blood) is suggested, but Cameron shoots it down suggesting instead Meningococcemia (meningococcal bacteria in the blood — really a subset of what Chase suggested). House concurs with Cameron’s diagnosis and Hank is started on heparin (a blood thinner, for the clots) and a broad spectrum antibiotic that covers meningococcus (but if you know which bacteria you’re treating, then you don’t need a broad spectrum antibiotic).

Hank does not improve and he starts to run a fever. Taub suggests that he might have an infection hidden away in his sinuses, where the antibiotics have difficulty reaching, so Chase performs sinus surgery to clear out the sinuses. Now Hank begins to complain of severe abdominal pain and Cameron discovers something on the exam (apparent ascites — fluid in the abdomen) that makes her diagnose liver failure. She suggests a Klatskin tumor (cancer of the bile duct), but it doesn’t quite fit the symptoms. Foreman suggests that Hank has sclerosing cholangitis (a disease that damages the bile ducts). House agrees and an ERCP (an endoscopic exam of the bile duct and pancreas) is ordered — surprisingly it shows a mass in the common bile duct that ends up being a large clump of worms. Hank apparently has strongyloides (”whipworm threadworm”), and is given mebendazole to kill the worms.

Once again, Hank’s condition dramatically worsens. He develops severe pulmonary edema (fluid build up in the lungs). Chase thinks it might be a combination of a hematological (blood) problem and cardiomyopathy (a heart problem). Foremen suspects Hank has lymphoma, with peritoneal carcinomatosis (malignant spread of cancer across the abdomen) and paraneoplastic syndrome explaining his symptoms. House sides with Foreman, and Hank is started on chemotherapy. A short time later, Hank’s condition takes another turn for the worse when he starts urinating blood. Next, his blood pressure and heart rate skyrocket, and he starts to bleed from his mouth. He then suffers a cardiac arrest, but the team is able to stabilize him.

The latest labs are back and show that Hank barely has any red blood cells, white blood cells, or platelets. The differential diagnosis now includes hypopituitarism (an underfunctioning pituitary gland), renal cell carcinoma (a type of kidney cancer), or aleukemic leukemia (a leukemia that is associated with low white blood counts instead of the normally high counts found in leukemia). House tells the team that the latter is the most likely and orders them to ablate (destroy) Hank’s bone marrow in anticipation of a bone marrow transplant. There is a lot of hemming and hawing about whether this is the right thing to do, since it could make Hank sicker or kill him, but at the last moment, Thirteen and Taub call in with the correct diagnosis: extraintestinal Crohn’s disease. According to them, Hank’s exceptionally clean childhood made him more likely to develop diseases such as Crohn’s, and the worms were actually helping him keep the disease in check. Once the worms were killed off, the Crohn’s flared up with a vengeance. With some methylprednisolone (steroids), Hank should get better — but the team wants to give him some worms again, just to make sure.

I found no massive errors in tonight’s episode. There was the usual: jumping randomly between unrelated diagnoses, bizarre test interpretation, and Chase being a specialist surgeon, but nothing horrible. Of course, that’s not to say I have no complaints (as if!). As usual, minor complaints are in blue, nit-picking ones in green:

Where exactly was the extraintestinal focus of the Crohn’s?

Why did he develop a headache and photophobia in the beginning? Was that the Crohn’s? Why did everything suddenly worsen when he got in the hospital? The steroids he was given for the vasculitis should have calmed down the Crohn’s.

The strongyloides worms may not have been the cause of his disease, but their blockage of the bile duct would still cause serious problems for the patient.

Again, no oncologist is going to start chemotherapy for cancer without a tissue diagnosis.

Special precautions are taken for patients who are neutropenic (dangerously low in white blood cells, and thus more susceptible to infection) including gowning and gloving everybody in contact with the patient. You do not roll them down the hospital’s common hallway without a mask and with the wife holding his hand.

The CRP should have been significantly elevated with the Crohn’s disease (and the cerebral vasculitis too).

While the ANA is generally strongly positive for certain types of autoimmune diseases, it is not found in every autoimmune condition (or even most autoimmune conditions), so a negative ANA does not mean there is no autoimmune disease (and positive ANAs in the absence of autoimmune pathology are also possible).

How about checking the vitamin D level — an easy thing to do — before treating the patient.

I noticed how they avoided actually saying the word “ascites” and instead chose a wordier explanation. Probably because of their problem pronouncing it last time.

Cameron shoots down Chase’s idea of bacteremia, but then suggests meningococcemia, a type of bacteremia. The same argument she used against Chase would go against her as well.

Why would you ablate the bone marrow without finding a donor first? (OK, maybe House was never planning on really following through with it, but why would the others go along?)

And now credit where credit is due:
The hygiene hypothesis is a legitimate and controversial scientific theory concerning the rise in asthma and allergy rates in industrialized nations. Some researchers link it to autoimmune diseases as well.
Helminthic therapy — treatment of disease using intentional infestation of parasitic worms — is being tested in a variety of diseases, including Crohn’s/
Shocking ventricular tachycardia, like Foreman did this episode, is the right treatment.

The mystery was okay, but seemed to get lost in the shuffle as the show progressed. I give it a B. The final solution was a stretch, especially when you look back at the original symptoms. It earns a C. Overall, the medicine was better that it has been the past few weeks and earns another B. The soap opera was decent as well. I enjoy Tab and Thirteen, so I’m fine with having them back, though I know many will disagree. The soap opera earns still another B.

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The House Challenge scores are now up to date here.

Tonight’s episode of House was fairly light on actual medicine, focusing more on the personal aspects. Though there wasn’t much, for the most part, the medicine was well done.

Stewart is a thirty-five year old man with severe agoraphobia — he has not left his house since a mugging seven years before. Cameron stopped by and helped him with a case of the flu the previous year, and it is brought to her attention that he has had several days of a crushing headache as well as 3 seizures in the past 2 days; she in turn brings it to House’s attention. The initial concerns are a bleed, a clot, a tumor, a metabolic disease, or an infection (though they also mention vasculitis, which doesn’t fit in any of those categories). Since he refuses to leave the house, the team has to diagnose him with whatever they can bring to his house. The preliminary plan is to run an EEG while inducing a seizure to see if that will suggest where the problem in the brain is located. While Cameron runs that test, the rest of the team will search the house for toxins. At the end of the day, both the search of the house and the attempt to cause a seizure are fruitless.

House now decides to induce a seizure his own way, by bringing the outside world to Stewart. He pretends Stewart’s house is up for foreclosure and brings a passel of potential buyers through the house and into Stewart’s bedroom. Stewart immediately reacts, but the EEG reveals it’s not a seizure; instead he’s having severe abdominal pain caused by a partial small bowel obstruction (diagnosed by portable x-ray). Atrial fibrillation and Crohn’s Disease are mentioned as possible causes. House thinks surgery is the best option, but Stewart still refuses to leave his home. So they tell him that they will perform the surgery at his house, but plan on sneaking him to the hospital for the actual surgery, then returning him home before he awakens. Cuddy learns of the plan and insists that Stewart remain in the hospital for recovery; House agrees. Cameron decides it would be best to let Stewart know of the plan and wakes him from anesthesia to tell him that he’ll have to stay at the hospital. Surprising no one (except maybe Cameron) this causes him to freak out, and not only does he decide leave the hospital before having the surgery, but he gets a lawyer involved.

Cuddy responds by kicking Cameron, House, and Chase off the case, but since when has that stopped them? House has Cameron try some lactulose (a potent laxative) on Stewart, but his symptoms worsen. House now decides that they’re going to have to proceed with surgery, and actually perform it at Stewart’s house. Taub is roped into the job. The bowel obstruction is relieved and a bowel biopsy obtained, but not before there’s a little accident involving cautery, bowel gas, and fire. The biopsy shows flattened villi (tiny finger-like projections from the inner lining of the small intestine), which suggests Whipple’s Disease (a rare gastrointestinal infection), so House starts Stewart on antibiotics.

Stewart’s symptoms don’t improve, and in fact they worsen: he begins to develop numbness of his legs. The differential diagnosis now consists of porphyria, amyloidosis, and celiac sprue (an autoimmune disease caused by exposure to the wheat protein glutein in certain individuals), with sprue the most likely. This can be diagnosed by a blood test, but House prefers to feed Stewart wheat so that his symptoms will worsen and he’ll voluntarily decide to come to the hospital. He stops by Stewart’s house late at night to check on him, and Stewart happens to go into cardiac arrest at that moment. House views this as a chance to admit him to the hospital (it being an emergency and all), but Cameron shocks his heart back into a normal — albeit dangerously slow — rhythm. Taub sets up an external pacemaker to control the heart beat. The differential now consists of lymphoma or a toxic exposure, possibly organophosphates (a common chemical in insecticides). House then discovers that Stewart is something of a neatnik, and cleans his bathtub frequently with ammonia and bleach, which when combined, release chlorine gas. Could his symptoms all be due to chlorine gas poisoning? Stewart is started on steroids and sodium bicarbonate, but his symptoms continue to worsen. During a conversation with Cameron, House deduces that Stewart’s symptoms are not caused by chlorine gas, but instead all due to lead poisoning. When he was shot during the mugging several years before, the bullet split and some of the fragments remained in Stewart, embedded in the hip bone. As these slowly dissolved, the lead was enough to cause his symptoms. House quickly, and brutally, removes the fragments, and Cameron starts him on chelation.

Major complaints are in red, minor in blue, nit-picking in green:

Defribillation is not the treatment for a flatline. In fact, it is thought to make things worse (How can it be worse than a flatline, you ask? By making it even harder to get a normal rhythm back.)

Stewart suffered a cardiac arrest, not a heart attack. The two terms are not interchangeable.

House told the ambulance it was PEA (pulseless electrical activity), but the heart monitor showed a flatline, not PEA. Anyway, you don’t defibrillate PEA either.

I find it hard to believe that bullet fragments significant enough to cause Stewart’s symptoms would be missed on the x-ray. Hint: the hip should have no bright white spots on the x-ray. I also find it quite a stretch that bullet fragments in for seven years could be removed so easily.

Chlorine gas is extremely irritating (watery eyes, cough, sore throat), and would be hard for him to miss being exposed.

Why did Stewart need a jugular line?

Surgery is not first line for partial small bowel obstruction.

Wouldn’t Stewart be suspicious that there was no anesthetist or anesthesiologist? And once again, no eye protection during the surgery.

There’s no way Kutner made it though medical school without assisting in surgery. A large part of the third year is spent doing just what Kutner said he didn’t know how to do: retracting and keeping the field bloodless.

The medical mystery itself was rather pedestrian (for House, anyway), it was just the restrictions that made it challenging — I give it a C+. The final solution fit well, but was it ever mentioned before the final reveal that Stewart had been shot? I give it an A-. The medicine actually followed a more-or-less logical progression this week, though shocking a flatline is big mistake in my book, no knocks the score down to a B-. The soap opera aspects were all well done, particularly the Chase/Cameron aspect: another A-.

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Justice League of America #13 “Unlimited Chapter 2”
Dwayne McDuffie, writer
Joe Benitez, penciller

Poison Ivy: It’s the flora in your digestive tract. Mycobacterium paratuberculosis to be precise. They’ve octupled in population by now.
Poison Ivy: That’s not going to get rid of them, dear heart. They’re quite a bit deeper than your stomach.
Poison Ivy: If I hadn’t just called them off, you’d be well on your way to a bad case of colitis. But I didn’t want to be around for the explosive diarrhea.

Mycobacterium paratuberculosis* is an interesting choice of bacteria for Poison Ivy to use. As the name suggests, it is a member of Mycobacteriaceae, the Mycobacterium family. This is the family of bacteria that contains the germs responsible for both tuberculosis and leprosy. While most bacterial infections take place outside of the actual cells of the body, in the surrounding tissues and fluids, Mycobacteria are one of the few types of bacteria that manage to infect and live inside the cells of the human body. This makes them difficult to detect and hard to treat, usually requiring long courses of multiple antibiotics.

There is controversy regarding how infectious M. paratuberculosis is in humans, or whether it is infectious to us at all. It does not cause the acute gastroenteritis John demonstrates, with abdominal pain and vomiting (but maybe Poison Ivy just souped up virulence of the germ). he bacteria may cause the diarrhea she threatens him with later: there is a suspicion that M. paratuberculosis may somehow cause or be related to Crohn’s Disease — an inflammatory disease of the bowel — because it is known to cause a similar condition in cattle (Johne’s Disease) and it has been found in patients with Crohn’s. However, curing the infection appears to have no effect at all on the Crohn’’s, so there is debate about how much the germ is actually involved in the condition. That’s pretty much it in terms of what we know about M. paratuberculosis and human infections.

Also, since when have Poison Ivy’s powers been able to affect bacteria? As far as I know, they’re only effective against plants, and that’s a separate kingdom entirely. Of course, this is only an initial chapter of the story, so maybe Ivy’s expanded powers will be explained later (I blame Luthor. That’s almost always a safe bet).

*also known as “Mycobacterium avium subspecies paratuberculosis” or “Map.”

Episode Title: In Which Addison Has a Very Causal Get-Together

The medical ethics were better this week (except for everyone looking in other people’s medical charts), but the medicine was equally questionable. This show would really benefit from some Grey’s Anatomy style continuing storylines; this patients-of-the-week format just doesn’t sustain the interest here.

Dr. Addison Montgomery and Dr. Sam Bennett
After seeing Sam on a local morning news show, a pregnant patient named Rebecca arrives in the clinic seeking medical care. She claims that she just escaped from the hospital because they were trying to kill her and her baby. She is five months pregnant, but surprisingly skinny. In short order, it turns out that she was involuntarily committed to the hospital because she was a psychiatric patient with Munchausen’s Syndrome, and now the hospital – and her mother whois her medical guardian — wants her back in the psychiatric ward.
Addison is not convinced that Rebecca has Muchausen’s, though some lab values which suggest she has not been eating give Addison pause. In the end, the team gets the hospital to run a capsule endoscopy (”GI camera”) which reveals that Rebecca has Crohn’s Disease — a type of Inflammatory Bowel — and not a psychiatric disorder.
Five months along and she is just now feeling the baby kick? That’s not a good sign.
I’m concerned by the amount of x-rays and CT scans performed on Rebecca. There was an entire wall full. Radiation is not good for developing babies. (And if the Crohn’s was that bad, something should have shown up on the CT).
Involuntary psychiatric admission laws vary greatly between states and I’m not familiar with the laws in California. I can see an involuntary admission being granted in this case though, for fear of Rebecca harming herself and harming her baby.
I’m not sure what labs would show Rebecca hadn’t been eating when she claimed she had been. Albumin and other proteins can be low in malnutrition, but that’s in the long term, not short term. Ketones in the urine can also suggest starvation — though it can mean other things as well including diabetic ketoacidosis and an Atkins dieter.
I don’t know why the team was thinking they could get a capsule endoscopy performed in under an hour. It takes the better part of a day to run a capsule endoscopy, let alone the prep beforehand. An actual colonoscopy would be faster and give more definite answers.
There are simple blood tests to detect active autoimmune diseases. They’re not always good at pinpointing which disease in particular, but would at least let the team know that something physical is going on.
Sam uses the word “occult” way too many times in this episode.

Dr. Cooper Freedman
Cooper was dealing with Michael, a ten year-old boy who was in love with a friend. When Cooper encourages Michael to ask his friend out, the boy returns to the office bruised and bloody. It was not a girl he asked out, but another boy. Now he runs away and Cooper — of course — finds him and manages to bring him back home.
No skateboarding or contact sports if you have Mononucleosis because the spleen can become enlarged during Mono and there is a chance of rupturing it with any blunt trauma.

Dr. Violet Turner and Dr. Naomi Bennett
Violet become obsessed (well, more obsessed) when she sees her ex-husband’s (or is it ex-boyfriend’s — it’s not clear) new wife visiting Naomi. It turns out she was there to be treated for a urinary tract infection, not pregnancy as Violet feared.
Violet’s one note characterization is quickly becoming tiresome.
What kind of doctor is Naomi exactly? Who goes to see a fertility specialist for a UTI?

Dr. Pete Finch
Pete is seeing Stan, the curmudgeonly fiancée of Sylvie, an old patient of his. Stan has been having fainting spells and Sylvie is secretly concerned that the fainting spells are a subconscious sign that Stan does not want to marry her. Pete runs some “basic tests” which are all negative, but after some more probing, he determines that the Arthur has a “trigger point” that causes a “painless migraine” (a type of Atypical Migraine) which causes him to pass out when he is in certain positions.
An EKG, echocardiogram, and carotid Doppler all are good tests for this situation. Some sort of head imaging is indicated, but I would never consider an MRI a “basic test.” Maybe that’s just because I practice in small town Illinois and not a big city in California.
As for a muscle trigger point causing a painless migraine, that’s a rather cavalier diagnosis. I have seen atypical migraines that cause symptoms that look just like a stroke, but never one that causes passing out, one that shuts one and off that quickly, or one caused by a “trigger point.” I’m not saying it can’t happen; it’s just quite a stretch.

Tags: television medicine private practice munchausen’s syndrome crohn;s disease syncope

Marvel Knights Spider-Man #3 and #4 Down Among the Dead Men, parts 2 and 3
Mark Millar, writer
Terry Dodson, penciller

I don’t always criticize medical scenes in comics, sometimes I even compliment them. This is one of those rare times, and a double-header at that.

After a ho-hum start, Marvel Knights Spider-Man came into its own in issues #2 and #3. A few brief medical items of interest came up in these issues as well.

First, I thought the Owl’s thug kvetching about his Crohn’s Disease in issue #2 was worth a chuckle. The details were right on the money too.

Second, after a rough fight with Electro (and what was with his mask? bolts up, bolts down, bolts up…), Spider-Man is rushed to the hospital in issue #3. The medical scene was portrayed well. Sure there were some small nit-picks (e.g. the EMTs not mentioning which arm was injured; Spider-Man going straight to surgery instead of being triaged in the ER), but overall it was handled skillfully. The surgeon was absolutely right to cut Spidey’s mask off, secret identity or not, because examining the patient – and I mean all of the patient – is key in traumatic injuries.