Polite Dissent

This week’s episode of Fringe was fairly creepy, and the science wasn’t all that bad

The Plot: A boat from Hong Kong has run aground in the harbor and dozens of illegal Chinese immigrants have washed up on the shore, dead. It turns out it wasn’t the water or cold that killed them, but giant tentacled parasite worms lodged in their gastrointestinal tracts. The Fringe team is called in. One of the immigrants, Mai Lin, managed to survive. She tells the team that all her fellow immigrants were given a strange capsule to treat sea-sickness, but since she was raised in a fishing village and never got sea sick, she didn’t take it. The team suspects these capsules contained the larvae for the giant worms. She tearfully tells the team that her husband and daughter are on the next boat arriving in few days.

The immigrant smugglers are tied to a local Triad gang best known for smuggling and selling illegal drugs. The team initially surmises that the worms secrete some form of opiate, and this is why they’re being smuggled. After being bitten himself, Walter realizes that the worms produce a powerful immune boosting agent. Walter does some research and discovers that the worms are genetically modified Ancylostoma duodenale (hookworm), an intestinal parasite used in traditional Chinese medicine. The genetically modified versions make an immune boosting agent that is stored in their lymph glands.

Some financial documents tie a local woman to the one of the Triad’s front. She tells Agent Dunham that she has no knowledge of any illegal activity and only invested the money where her financial adviser suggested. Peter notices that her house has a surprising number of air filters and hermetically-sealed windows. Once the team learns about the immune-boosting aspect of the worm, they realize this woman knows more than she is telling. This time, Peter approaches her son who tells him that he has a rare immune deficiency. He receives a special monthly treatment of worm-powder delivered surgically, directly into his spleen.

Walter, with some reluctant help from Astrid, heads off to Chinatown to find a herbalist that sells Ancylostoma that is genetically similar to the giant worm. He finds several shops that sell the worms, and inadvertently discloses to one of the shop owners — the wrong one, of course — that he has a giant worm back at the lab. The Triad follow Astrid back to the lab, beat her up, and steal the parasite.

The ship carrying Mai Lin’s family is found and boarded, but it is too late — all the immigrants have already been carted off. Luckily, Peter is spying on the shop in Chinatown where they have been taken. He calls Agent Dunham then decides to do some investigating of his own. He breaks in to the shop and is in the process of freeing one of the immigrants when he is captured. The Triad and their crooked doctor are force feeding Peter one of the larva when the FBI team arrives, just in the nick of time. The villains are shot or captured, Peter is saved, the immigrants are taken to the hospital where they are treated, and everything ends happily.

(Oh, and Walter implanted a tracking chip in his neck.)

Overall, the science — what little there was of it — was passable this episode, so I just have a few nit-picks an observations:

1. As the Worm Turns
Nematodes such as Ancylostoma are too primitive an organism to have a lymphatic system. They don’t even have a circulatory system.
Admittedly, these are “genetically engineered” hookworms, and for a worm to grow as large as those shown, thanks to the square-cube law and other similar concepts, they would have to have some sort of circulatory system.
In the actual worms, the many-tentacled end is the tail, not the head.

2. Glad I Don’t Have to Take Them Out
Matt’s staples should have been removed long ago. He was 3 ½ weeks out from his surgery. By this far out, the incision is healed with 80-90% strength. Leaving in staples or stitches that long serves no purpose, is going to lead to train-track scarring, possible stitch abscesses, and skin-growth around the staples.
Open abdominal surgery is to be avoided whenever possible, especially in immune compromised individuals. Why not just inject the powder into the spleen?
Credit-Where-Credit-Is-Due Dept: That is where an incision for splenic surgery would be made.

3. High is Not Always Better
A high white blood count is a sign of infection (or leukemia, not the sign of a healthy immune system).

4. Ahhh, Just Right
I was starting to have concerns with Walter’s mention of “boosting the immune system” — a common alternative medicine/quackery claim. In reality, the human immune system is finely tuned: too little leaves you open for infection; too much and you get allergy problems and autoimmune disease. If all the alternative “medicine” boosted the immune system like it was claimed, we’d have an epidemic of autoimmune problems in this country. I’ll give the episode credit for having the medication be used by immune-compromised patients — a proper use.

5. What Does the FBI Teach These People?
Walter’s about as good an investigator as Olivia — that is, very bad. The logic of his whole “find a matching worm” plan had more holes than Swiss cheese (though this is Walter we’re talking about). For instance, who’s to say the various different herbalist shops didn’t all use the same importer of worms — which they probably did — so the worms from the various shops would be identical.
And Peter’s not any better. Why would he think breaking into a shop owned by the Triad — known for their brutality — would be a good idea at all?

5. Lions and Tigers and Bears, Oh My!
The song Walter was singing was “The Menagerie“, which was also mentioned in the first season (episode 16, Unleashed).

While there was some errors of scientific-concerned, most of them were minor and could be hand-waved area. Thus, for the second week in a row, there is a one-minute improvement on the Doomsday Clock.

Tags: television fringe parasite ancylostoma worm

Almost entirely a Wilson character episode, so the medicine was fairly straightforward, if surprisingly sloppy

Wilson is out hunting turkeys with Tucker, a friend who he helped defeat leukemia five years earlier. Tucker nearly shoots Wilson when his left arm becomes suddenly numb and paralyzed. Wilson has Tucker brought to the Princeton Plainsboro Hospital emergency room for evaluation. A head CT is negative, and the blood count is normal, which tells Wilson that Tucker has not had a recurrence of his cancer. Noticing a fever blister on the lip of Tucker’s girlfriend, Wilson diagnoses him with tranverse myelitis (inflammation of the spinal cord, it can have many causes, in this case the Herpes simplex virus passed from the fever blister). He admits him to the hospital for treatment with acyclovir (an antiviral drug). House chides Wilson for his diagnosis, telling him that Tucker has cancer. Wilson disagrees and they end up betting $100 on the final diagnosis.

Paying a visit to Tucker a little later, Wilson discovers that he now complains of tingling in his left foot in addition to the continuing numbness and paralysis of his left arm. Wilson sticks with his diagnosis of transverse myelitis, but adds a second antiviral — Ribavirin — to the therapy. There is no improvement, and in the meantime Tucker has developed a nasty cough that eventually devolves into a respiratory arrest (which he survives, or it would have been a very short episode).

Perplexed, Wilson enlists House’s team in reviewing the case. Cancer is suggested, as is a subdural hematoma (bleeding around the brain), bacterial infection, or fungal infection. Wilson agrees with the fungal infection, and suspects that Tucker has aspergillosis (infection by the Aspergillus fungus) including fungal balls (exactly what they sound like) in the lungs and spine. He declares that Tucker is too sick for tests and rushes him into surgery. Chase sees no Aspergillus, but instead finds “global lung damage” suggesting PCP (Pneumocystis carinii pneumonia, a fungal infection of the lungs).

House is watching the surgery beside Wilson, and points out that a PCP infection means that Tucker must have a weakened immune system (since healthy immune systems can easily defeat the Pneumocystis carinii). He states that Tucker must have HIV (the virus that causes AIDS), acquired SCID (Severe Combine Immune Deficiency), or cancer. He suggests that Wilson test for all three.

Sure enough, this round of testing shows cancer — more specifically ALL (Acute Lymphocytic Leukemia, also known as Acute Lymphoblastic Leukemia). This is not a recurrence of Tucker’s original leukemia, but a different one, possibly caused by the chemotherapy required to treat the initial cancer. ALL is fairly treatable, so Wilson starts Tucker on chemotherapy. Twenty-four hours later, there is no change in his condition, and Tucker is concerned he may be in the 10% of ALL cases that Wilson says do not respond to therapy. Wilson decides to double the dose of chemotherapy. It works, more or less. The high dose chemotherapy knocks out the ALL, but it also severely damages Tucker’s liver (the yellow eyes were a sign of jaundice). In fact, the liver damage is so bad that Tucker will die in twenty-four hours if not given a transplant. When it becomes apparent that no transplant is available, Tucker asks Wilson to donate part of his liver to him (he know that they have the same blood type). Wilson thinks on it, and drinks on it, but eventually acquiesces and Tucker receives part of his liver. After the operation, both are doing well and expected to recover fully.

House’s first patient had Popcorn Lung, and diverticulitis (from the popcorn kernels). The second, apparently, had a screw in his lung.

No deal-breaker errors this week, but worse than the last couple of episodes. Some real sloppiness in writing/editing/continuity as well. As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Wilson is being generous with his ALL prognosis of 90%. The remission rate of ALL in children is 95%. In adults, it is 60-80%, with patient have CNS disease (which Tucker does) having a worse prognosis.
Chemotherapy cures leukemia completely in twenty-four hours? Nonsense. That’s too soon to tell if it’s working at all. Best case scenario is usually remission in 4-6 weeks.

There is no surgeon — even Chase — who would operate on Tucker without at least getting a CT first to show where the suspected fungal ball is. You don’t just slice up the lung indiscriminately. If there were a fungal ball, it would have shown up on the CT, as would PCP severe enough to cause a respiratory arrest.

By my understanding, SCID is currently defined to be a genetic disease, not one acquired later in life. There are acquired immune deficiencies, some severe (most notably HIV), but they are not “SCID.”

I’m surprised none of Wilson’s original blood work showed the cells associated with ALL.

Not my area of expertise or interest, but would a patient with a history of two cancers (though admittedly, no liver cancer or liver metastases) be placed that high on the transplant list?

Left arm or right arm? The episode description and House referred to right arm paralysis, yet the patient was clearly paralyzed in the left arm. Wilson later mention left arm. This is just sloppy.

“PCP Pneumonia” is redundant. The second P stands for “Pneumonia.”

A real nit-pick here, but by the time a patient has PCP, it is considered AIDS, no longer just an HIV infection.

I enjoyed the scenes with Wilson and his other patients.

The medical mystery was routine (as far as House episodes go), but well constructed. I give it a B. The final solution was fairly obvious, but entirely logical: B+. Overall, the medicine was OK, but way too sloppy, and gets marked down to a B-. The soap opera was good, though I would have liked to see a little more of the team. B+.

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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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A good episode of House with a fascinating premise and some good soap opera and social moments. The medicine was average, but didn’t hurt the episode much.

Nick Greenwald is a successful book editor who, while at a party launching his star author’s latest book, finds himself blurting out truth after uncomfortable truth to those around him. He then develops a nosebleed and collapses.

Nick is admitted to House’s service where the team notes that he reminds them of the classic case of Phineas Gage (a railroad worker who suffered personality changes after a spike was driven through his brain). Nick is showing signs of frontal lobe disinhibition, but there is no sign of a frontal lobe tumor as his head MRI is negative. Thirteen suggests that there may be a tumor hidden in the nasal cavity, but a nasopharyngoscope shows nothing. Next, an fMRI (functional MRI — an MRI that looks at blood flow within the brain) is obtained and reveals an abnormal area in the cingulate gyrus. Thirteen remarks that it’s too near the brainstem to biopsy, then Foreman mentions that it might be neurosarcoidosis (sarcoidosis which affects the central nervous system). Steroids are started to treat the presumed sarcoidosis.

Nick suddenly becomes very short of breath. Foreman states that it’s not his heart because the EKG is normal, so it must be kidney failure, and starts him on dialysis.

The differential now includes systemic sclerosis and chronic lymphocytic leukemia (both of which are quickly dismissed), as well as diabetes, and some sort of “congenital genetic disorder.” Foreman points out that there are too many genetic disorders to test for them all. House has Taub run a glucose tolerance test to check for diabetes, and has Kutner check Nick’s daughter for peripheral nerve damage because she suffers from some ill-defined neurological disorder and he thinks the condition might be inherited. The peripheral nerve test is normal, and Taub reports that the glucose tolerance test was completely normal and never above 120 for the entire night. House now wants to check the thyroid, but before the test can be ordered, Nick develops a fever, coughing, and pulmonary edema. Kutner orders 200MG of furosemide (a diuretic) and 2MG of morphine (primarily a pain killer, it also helps with pulmonary edema).

With Nick’s temperature at 103° (39C), the team now considers infection as the likely cause of his symptoms. Foreman mentions Staph aureus, tuberculosis, and strongyloides (threadworm). Kutner determines that a stray dog is living with Nick’s family and he and House suspect that Nick has developed Weil’s Disease (leptospirosis — an infection caused by the Leptospira genus of bacteria). He is started on doxycycline (an antibiotic) and his condition improves. Kutner and Foreman tell him that while the infection is cured, his brain damage and disinhibition are going to be permanent. Nick wants surgery to remove the damaged area, but they tell him it is too risky. He talks to House, who apparently sees some of himself in Nick, and talks Chase into getting his boss — a neurosurgeon — to perform the surgery. Initially, the surgery seems successful, but then it quickly becomes clear that Nick still blurts out whatever crosses his mind. That’s not all though, as his temperature starts falling dangerously low and he develops unstable ventricular tachycardia (and this is the right time to use the paddles). The arrhythmia is corrected and an echocardiogram is obtained, but shows no structural heart damage. Nick continues to have an abnormal temperature. The differential diagnosis now leans toward cancer, but Foreman rather cavalierly dismisses the idea. He orders a full body scan. This shows a small abdominal aneurysm (dismissed as an incidental finding), a cyst in the pleura (the membrane surrounding the lungs — also dismissed as an incidental finding), and a density in the liver. Foreman suspects this density represnts an ateriovenous malformation (AVM) and that multiple AVMs would explain the patient’s condition. He wants to go forward with angiography with embolization (a test to find and then block off the AVMs).

House is in New York with Wilson, but the team is texting him to keep in touch. In the middle of a conversation about Wilson’s guilt over his schizophrenic brother, House has his Eureka! moment. The glucose tolerance test that was normal should not have been normal because Nick was on steroids, which raise a person’s blood sugar. The fact that it did not rise, combined with the cyst — which is really a fibroma — in the pleura means that Nick has Doege-Potter Syndrome (a fibrous tumor that secretes insulin-like compounds and causes low blood sugar; Kutner mentions human growth hormone, but other similar chemicals can also be secreted). Nick has also developed an autoimmune reaction to the tumor, and his immune system has gone into overdrive and attacked his own body (brain, kidney, heart in this case). Removing the tumor should solve his problems — the medical ones at least.

They’re really weren’t any huge medical errors this week, just the usual hodge-podge of symptoms and diagnoses that really don’t fit. The worst was Foreman’s clueless statement about cancer, so that gets the prize this week. Well, there was also that one scene, but I’ve already spent enough space talking about it.

As usual, major complaints are in red, minor in blue, nit-picking in green:

A normal PSA, normal colonoscopy, and normal blood count absolutely do not rule out cancer. Admittedly, colon cancer and prostate cancer are the most common cancers in a man Nick’s age, but there are plenty of other cancers out there (plus there are concerns about how reliable the PSA test actually is).

Diabetes doesn’t really fit his symptoms at all — other than the kidney disease. Of course, it was just an excuse to run the glucose tolerance test.
Speaking of the glucose tolerance test, the patient needs to be fasting, and it doesn’t take 12 hours to run.
It’s true that the steroids should have raised Nick’s sugars, but even a normal patient whose blood sugar didn’t rise above 120 after a hefty glucose load would be unusual.

Brain damage and peripheral nerve damage are two different things. It’s more common to have one without the other than both together.

If Nick’s kidneys are shot and he requires dialysis (a very important fact that was never mentioned again in the show; the dialysis that is, not the kidneys), then even 200MG of Lasix is not going to have any effect.

An MRI of the brain should have shown any nasal cavity tumor, especially one that was eroding into the brain.

Too many genetic disorders to test for them all? But they tested for them all in at least two previous episodes.

House doesn’t like full body scans? Then why does the team order them so regularly.

A cyst is hollow, a fibroma is solid. A scan should be able to tell the difference.

I thought the medical mystery was good this week, it was interesting not only from a medical perspective, but also fascinating from a social perspective. It made me wonder what horrible secrets I might spill. I give it an A. The solution was fairly logical, even if it did require two diagnoses (Doege-Potter + autoimmune). It earns a B+. The medicine was average for the show and I give it a C; it might have scored higher had that one scene been clearer. The soap opera was the best part of the episode. There were good House/Wilson and House/Taub interactions (the squash racket was great), and the patient’s social interactions were like a car crash: painful, but impossible to look away. The soap opera earns a solid A.

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A much better episode of House this week. While it wasn’t quite up to the standards of the first two seasons, there were definite that classic House was trying to break through.

Sarah is a 29 year old teacher of special needs children who suddenly begins to cough up blood during class and then collapses. She is admitted to the hospital under House’s care. The team’s initial differential diagnosis includes ulcer, leukemia, von Willebrand’s disease (a blood clotting disorder), or a thoracic tumor. House agrees with Foreman that the problem is likely within the patient’s blood and orders a bleeding time test. The test is abnormal, showing that her blood is not clotting correcting. A check of her clotting factors is normal, but her platelets turn up abnormal. The differential diagnosis now includes lymphoma and ITP (idiopathic thrombocytopenic purpura), with the latter being more likely. House elects to start her on methotrexate (which really isn’t a recommended treatment for ITP), but he also wants to treat her with total body irradiation (which is also not a recommended treatment for ITP, only it can have even nastier side effects than methrotrexate). In actuality, House has no intention of using the radiation but is just trying to test Cameron’s limits. She calls his bluff and allows the procedure, so now House and his team pretend have to pretend to use it. In the meantime, the methotrexate has shown no benefit, so House doubles the dose and adds Prednisone (a steroid, and the actual recommended treatment for treating ITP). During the (fake) radiation treatment, Sarah mentions that she has to pee. When she tries to get off the table, she collapses and is found to be pulseless. Thirteen and Taub rapidly pull out the defibrillator and shock her back into a normal rhythm.

The team meets again to discuss the latest findings. Tests, including a transthoracic echocardigram and a bubble test, show no structural defects of Sarah’s heart. Thirteen suggests a high vagal tone from urinating may have caused her to develop an arrhythmia and collapse. The rest of the team half-heartedly suggest heavy metal poisoning, toxin exposure, drug use, or alcohol use. Thirteen then mentions cold agglutinin disease, which seem to fit the case. House wants to put Sarah in an ice bath to test the diagnosis, but Cameron wants him to test some of the blood first. Reluctantly House agrees. The blood clots when exposed to the cold, confirming the presence of cold agglutinins, so Sarah is put into a three minute ice bath. The test, though uncomfortable, is normal (so while she may have some cold agglutinins — and most people do at various levels — she doesn’t have the disease; but please note this is not the recommended way to diagnose the condition).

House now decides that Sarah’s offhand story of transposing the digits of her room number, combined with her need to urinate during the radiation treatment, are signs of a brain lesion — a left hippocampal lesion to be precise. He thinks it is most likely multiple sclerosis (MS), and wants to perform a brain biopsy to confirm his diagnosis. Kutner thinks she has a pancreatic tumor and wants to perform an ERCP instead, but House wins — sort of. Cameron won’t let him go through with a brain biopsy, wanting an MRI first. Reluctantly, House orders the MRI, but it is normal, so Sarah doesn’t have MS. Kutner performs his ERCP and it is normal, but Sarah starts to have problems breathing during the test. She is found to have pleural effusions (fluid build up around the lungs), which are drained (off camera). House now decides that Sarah has equine encephalitis, a mosquito-borne disease caused by a picornavirus (there are actually several types of equine encephalitis, but none that I can find are caused by a picornavirus), which is causing conduction problems in her brain. He wants to test nerve conduction tests along the surface of her brain. This, of course, requires removing the top of her skull and thus needs approval from Cameron. She declines. Meanwhile, Kutner now thinks that she has a lymphoma of her spleen and wants to perform a splenectomy (surgically remove the spleen). House has Thirteen and Foreman search the classroom for evidence of encephalitis, but they turn up nothing significant. Nevertheless, Cameron allows him to perform the nerve conduction study and even assists. The test is going smoothly until Kutner tattles by calling Cuddy. She demands to speak with House and is placed on speakerphone. In the background, her baby Rachel is crying, and the sound is annoying Sarah quite a bit. Her reaction is paradoxical, though, in that her blood pressure drops while she is annoyed (it should rise). The team ends the test and puts her skull back together. House is puzzled and cannot figure out what is going on with Sarah. Puzzled, that is, until Cuddy and Rachel stop by. The baby spits up on House which leads him to start a monologue about evolution which leads him to have his Eureka! moment and diagnose Sarah with a PDA (patent ductus arteriosus).

As usual, major complaints are in red, minor in blue, nit-picking in green:

Even though the PDA may not have been open when the heart was scanned, the fact that the duct still existed (it should have withered away) should have been evident.
Why would only the left part of her brain been affected?

Apparently no one in the hospital likes to run CT scans or MRIs (this week anyway). Most of the diagnoses mentioned (MS, lymphoma, tumor) would have shown up and not required brain biopsy, ERCP, etc.

A blood test for cold agglutinins is not simply a “cool the blood and see if it clots” test, but a test to see how much it clots.
An ice bath is by no stretch of the imagination a good test for cold agglutinin disease, if they have it, you’ve just done the patient a major disservice as systemic clotting is not a good thing.

ITP, by definition, has low platelet numbers — which were never mentioned, just abnormal looking platelets (though her red blood cells should have looked chewed up as well).
MTX is not a treatment for ITP. It has been investigated, and continues to be investigated, but hasn’t shown a lot of promise. IV steroids are first line.

There seems to be confusion among the team about heart attacks (myocardial infarctions) and cardiac arrest. The terms are not synonymous.
Shocking a pulseless patient? How about — at least — some CPR first, if not checking the rhythm before shocking?

If I were the doctors I would have taken a closer look at the vitals during the test. Her resting oxygen saturation was 97% — on oxygen. That’s not normal. Nor is a heart rate of 116 , even though they called it “normal”. It didn’t change at all during her ice bath, when it should have shot up. Sure, I know the fancy vital sign machine was just there as a prop, but at least put in a little effort to make it authentic, prop people.

It would have been nice if they had run labs on the fluid they pulled out of the effusion. It would have helped to rule out cancer and pancreatic disease at least.

On another note, parent/baby bonding is often delayed in adoption situations and post-adoption depression in common, so what Cuddy was feeling was fairly normal. I’m glad to see she did not give up Rachel because of it.

The medical mystery started out weak (coughing up blood? That’s it?), but got better earns a B. The final solution was a stretch, but at least it fits more symptoms and seems more logical than usual and thus deserves a B+. The medicine had too much jumping from diagnosis to diagnosis while overlooking the most common and useful testing, so can’t really be considered anything more than average: C. The soap opera was subdued this week, but that felt appropriate, and earns a B.

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Two good episodes of House in a row, what are the odds? Sure, the medicine was a little sketchy, but overall it was pretty well done.

Natalie is a sixteen year-old overweight high school student and the victim of frequent bullying. At the school Christmas show, she develops visual hallucinations and vomiting. After admission to the hospital, she is found to have liver failure as well. The initial differential diagnosis is Wilson’s Disease, alcohol abuse, or something the other kids slipped her. Sure enough, some of the kids in the choir do admit secretly giving her a hallucinogenic mushroom. Additionally, a search of Natalie’s locker reveals a large bottle of acetaminophen (Tylenol) — an over-the-counter painkiller than can cause liver failure — raising the possibility of a suicide attempt. Natalie denies any suicidal thoughts or intentions, but Cuddy wants to go ahead and start her on acetylcysteine, the antidote for acetaminophen poisoning.

Next, Natalie develops a rapid heart rate and increased blood pressure, along with pulmonary edema (fluid filling up in the lungs). The differential now a toxic exposure (glue sniffing is mentioned), or infection. When House discovers she has been volunteering at a homeless shelter, he sends Taub to check it out. He returns suspicious that Natalie might have TB (tuberculosis) because one of the residents there has a severe case of it. About this time, Natalie has a seizure. Cuddy remarks that Natalie’s liver functions are very bad; she suspects hepatic fibrosis. Other possibilities mentioned include a severe mold allergy or a fungal infection. House has the team test for the allergy (the prick test) and start her on antifungal medication. The allergy test is negative. One of her “friends” from school visits and drops off some homework for her. He mentions that she used to be a heavy drinker, but stopped a few months ago. This again raises the specter of alcohol abuse, or possibly even alcohol withdrawal as it can cause seizures. Cuddy wants to start benzodiazepines (“benzos”) because they help with alcohol withdrawal, but her parents refuse. House decides to go ahead and start them, but not for alcohol abuse, but for her seizures (“wink, wink” — though they are used to treat seizures as well).

Natalie now passes out and is found to have a dangerously low heart rate. The differential shifts to multiple endocrine neoplasia, a hypothalalmic brain tumor, or leukemia. Wilson and Cuddy want to start treatment for the suspected leukemia, but House wants to wait for a bone marrow biopsy to confirm the diagnosis. Cuddy remains concerned that they may be missing something. She mentions autoimmune disease, particularly microangiopathic vasculitis (inflammation of tiny blood vessels such as capillaries and arterioles). When House tells her about a clinic patient of his, she has her own Eureka! moment and realizes that Natalie has eclampsia (toxemia of pregnancy). It was not caught initially because Natalie gave birth prematurely several weeks before her symptoms appeared and eclampsia has been known to occur several weeks postpartum. Unfortunately, the damage to her liver and heart are permanent and it is likely that Natalie will die in the next few days, particularly when the transplant committee turns down her case. On the bright side, Natalie’s daughter has miraculously survived — she was found by a homeless couple — and now Cuddy wants to adopt her.

The medicine was not particularly deep this week, but there was nothing I’d consider a big error. Minor complaints in blue, nit-picks in green.

Giving antifungal medications — which are universally hard on the liver — to a patient in liver failure is not a good idea.

You don’t give chemotherapy for leukemia without first determining what type of leukemia it is.
Surely the leukemia showed up on an ealier blood count. They did check a blood count, right?

Acetylcysteine is used for treating acute acetaminophen poisoning, not for treatment well after the fact.
Checking an acetaminophen level first would be a good idea — it’s an easy test.

Magnesium sulfate is the treatment of choice for seizures due to eclampsia (of course, it helps to know that you are treating eclampsia). Benzodiazepines are not as effective, though they do work.

What shot was Cuddy giving Natalie in the leg when she was having the rapid heart rate and high blood pressure? Any “code” medication should have gone in the IV (faster action).

Yes, eclampsia can occur after delivery — I was taught that it could occur up to six weeks later (and you’ll notice it was one of my original predictions for the show). The β-HCG (the hormone checked for in a pregnancy test) drops after delivery, and within a few weeks it generally is back to normal, so it is entirely possible to have eclampsia without a positive pregnancy test.

The medical mystery was modestly interesting this week and deserves an B. The final solution was good and earns an A. The medicine was shallow (lots of jumping to diagnoses that make little sense, no good testing), but not terrible. I’ll give it a weak B. The soap opera was well done — Wilson yanking the team’s chain and Cuddy’s happy ending were both high point, though I don’t buy Foreman/Thirteen — so I’ll give it an A-.

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An above average episode of House. The medicine was better than recent episodes, though the soap opera was turned way down.

Sophia is a 16 year old emancipated minor working as a factory foreman. She sought emancipation after both of her parents were killed. While talking with a floor worker, she begins to have chest pain and shortness of breath, and then collapses, red frothy sputum flowing from her mouth.

She is admitted to the hospital for evaluation of her pulmonary edema. The initial differential diagnosis consists of parasite infection, gastrointestinal problem, pregnancy, or damage to the heart from drug use. House has Kutner perform an echocardiogram while Taub and Thirteen search Sophia’s apartment. The echo shows no structural heart disease, but the apartment search shows that she likes to build her own furniture, but it also turns up a bong. When confronted with this, Sophia claims that it is her ex’s bong, and it’s the reason that he’s an ex.

The team now considers that she may have intermittent tachycardia (occasional episodes of an abnormally fast heartbeat) due to drugs, though Kutner favors a diagnosis of vasculitis. He wants to giver Sophia steroids, but House turns him down, stating that a steroid could make an arrhythmia worse. House wants to start her on beta-blockers (a drug that lowers the heart rate) to control the suspected arrhythmia. Kutner decides to go ahead with his original plan and gives her steroids instead. A short time later, Sophia is violently yelling at the staff and having paranoid delusions. She is given Haldol (haloperidol — a potent antipsychotic) to control her outbursts. Kutner reports that labs show that her psychotic break is not due to any metabolic problem, and it was too soon to be related to the steroids.

Given the symptoms of lung problems and delirium, Foreman suggests Prinzmetal’s angina (heart pain caused by spasms of the coronary arteries) — only he suggests it involves arteries in her brain, not the heart. House thinks the idea shows promise, so has the team place her on ergonavine )a drug which can trigger blood vessel spasms) and check an fMRI (functional MRI – an MRI that looks at blood flow). Medically, this part makes little — if any — sense, but is really just used to set up the subsequent revelation. The fMRI shows no arterial spasms, but it suggests that she is lying when she talks about her dead parents. Kutner confronts Sophia and she admits that she lied about the death of her parents, and the truth is that she ran away from home because her father raped her.

The team now adds sexually transmitted disease (especially gonococcal endocarditis) and stress to her differential. House feels it is the latter and suggests that Sophia be put on diazepam (Valium) to help with the stress. As Thirteen is about to give her the medication, Foreman notes that she has reddish-brown urine which wouldn’t be caused by stress. A microscopic examination of the urine reveals “shredded red blood cells.” E.coli, Shigella, and Legionnaires Disease are all suspected, but House believes her symptoms are caused by arsenic poisoning from building furniture with treated lumber. The tests apparently support this and she is started on chelation therapy for the arsenic. After the therapy, when Sophia is ready to be discharged (which is always dangerous in House’s world), she suffers a seizure. A repeat MRI shows brain lesions that were not there just a few days before. Infection (syphilis in particular) and cancer are suggested, but shot down. Then Thirteen suggests acute promyelocytic leukemia (APL). A brain biopsy confirms the diagnosis. Arsenic is used to treat APL, so removing it from her system allowed the leukemia to spread. Giving her more arsenic may slow down the cancer, but according to House, bone marrow transplant is needed for the cure. A family donor would be best, but Sophia refuses to let them tell her parents. Disregarding her wishes, Thirteen visits Sophia’s family only to discover that Sophia has been lying and using a stolen identity. Told of this, House believes her responses are too rational and confronts her. She admits that she ran away from home because she killed her younger brother. House convinces her to contact her parents, and in the end we witness a tearful family reunion.

Meanwhile, Foreman is treating his own patient: Jonah, a four year old boy with several days of unexplained lethargy, diarrhea, and bloody vomiting. The standard tests are all normal, so Foreman proceeds with a capsule endoscopy (a swallowed wireless camera to transmit pictures of the inside of the gastrointestinal tract). As he swallows the camera, Jonah starts giggling uncontrollably with no provocation.

Foreman asks Cameron and Chase for help, and they consider meningitis, thyroid, stomach cancer, and porphyria, but all tests are negative. As they are wondering whether they should involve House, Jonah has a cardiac arrest, but is successfully revived.

Foreman does finally go to House and ask for help, but House turns him down. Commiserating with Cameron and Chase he has his own Eureka! moment when he realizes that Jonah is suffering from iron toxicity from all the extra vitamins his brother had been feeding him to make him stronger.

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

Once again, you do not shock a flatline.

I mentioned this above, but “Prinzmetal in the brain” to be diagnosed with ergonovine and fMRI is nonsense — and dangerous if it worked. If it did cause a spasm, then they just caused a stroke (or at least a TIA) in sixteen year old. How were they planning on correcting that?

fMRI has been studied as a lie-detector – Mythbusters featured it in one of their episodes. It doesn’t work quite as neatly as it did on the show. For one thing, small movements — like talking — will throw it off. Also, while the limbic region of the brain may house “imagination,” it is also important in emotions and long term memories — so it lighting up while talking about dead parents would be expected.

From my reading on APL, it is treated primarily with specialized chemotherapy (including arsenic trioxide) and has a very good response rate. Bone marrow transplant is not considered unless there is a recurrence.

Valium is overkill for an anxiety disorder. That class of drug (benzodiazepines) is not a bad choice for acute anxiety, but there are better choices than Valium, particularly in a sixteen year old.

I don’t know what procedure Wilson was going to perform, but it’s best to put on your surgical mask and eyewear before scrubbing.

Interesting how they immediately ruled out cancer as a cause of the brain lesions…and then ended up diagnosing APL, a type of cancer.

Neither medical mystery featured dramatic symptoms, but both were solid puzzles and earn a B+. The solutions were both logical and fit fairly well so deserve an A-. The medicine was better than the past several episodes but still had some large holes. Foreman’s case was handled better, but he was still stumbling around more than he should. Still, it was better than average (especially this season), so earns a strong B-. The soap opera aspects were minimal, though it was nice to see House interacting directly with the patient. I give this aspect another B-.

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An interesting medical mystery on this week’s House, unfortunately bogged down with a solution that makes no sense. Meanwhile Cuddy is having problems of her own.

There were two medical stories on tonight’s episode of House. I will look at them each in turn.

Jerry Harmon, a 37 year old single father, is admitted to House’s service for evaluation of recurring blackouts, some lasting as long as nine hours. He has also been experiencing hallucinations. A prior work-up including an EEG and CT scan have ruled out drugs, alcohol, and epilepsy. The team’s initial differential diagnosis consists of post-concussion syndrome, TIA (transient ischemic attack, i.e. “mini-stroke”), toxins, or cavernous sinus thrombosis. An examination of Harmon’s strangely plain house also adds the possibility of a mold exposure.

The team later encounters Harmon in the hospital elevator where he ignores the doctors and makes some cryptic remarks about an appointment. They quickly realize he is sleepwalking. The differential diagnosis now consists of stress induced insomnia, narcolepsy, or a toxic exposure. House suggests that the team let him sleepwalk again and follow him to his “appointment” because it might provide more clues. Taub and Thirteen do just that and follow as Harmon climbs into his car and drives downtown to buy some cocaine, all while sleepwalking. The team now suspects that the cocaine may be causing the problems in a sort of vicious cycle (cocaine use leads to insomnia which leads to sleepwalking which leads to buying more cocaine, etc.), or possibly it is whatever the cocaine is cut with that is causing the problem. Taub and Thirteen buy some cocaine from the same dealer and find that lactose powder has been added to the cocaine. The team concludes that a lactose allergy may be causing the symptoms.

As Taub is giving Harmon a final exam he discovers that Harmon is sweating blood, and this rules out both a cocaine-induced or milk-induced cause. The team now considers a hemorrhagic fever (an infection like Ebola), DIC (disseminated intravascular coagulation), or leukemia. They all seem unlikely possibilities, but House is intrigued by the leukemia diagnosis, so orders a bone marrow biopsy. During the biopsy, Taub notices that Harmon has unusually dark skin (”bronze skin“)and this leads him to run some tests which show that Harmon is in severe kidney failure and in need of a kidney transplant. The differential now consists of hemochromatosis, vasculitis, or scleroderma. When talking to Harmon’s daughter about the possibility of donating a kidney to her father, House notices that she too is sleepwalking (or sleep talking, as the case may be). Soon she starts sweating blood. This means that whatever is affecting Harmon is affecting his daughter as well. The team comes up with three possibilities: it could be an infection, or a toxin (though tests have pretty much ruled those two out) or it could be an inherited condition, of which there are dozens to test. During a conversation with Wilson a short time later, House has his “Eureka” moment as he realizes that both father and daughter are anhedonic (they have the inability to feel happiness or joy). Foreman suggest this could be due to schizophrenia and Thirteen suggests depression, but under House’s questioning, Jerry Harmon admits that his name is really Jamal Hamoud and he is of middle eastern descent. He and his daughter have Familial Mediterranean Fever. Some colchicine and anti-inflammatory medication and they should be better.

Cuddy is excited because she will soon be adopting a baby girl who is due in 2 weeks. She meets Becca, the mother, at a local restaurant and notices a lacy rash on her left forearm. Concerned that it might be Fifth Disease (a viral infection which can be passed from mother to child and cause developmental problems, but only earlier in the pregnancy), Cuddy brings Becca to the ER for evaluation. Cameron examines her and doesn’t think it is Fifth Disease, and the labs support her. Cuddy decides to admit Becca anyway. An ultrasound reveals that the baby’s lungs are not fully developed yet. Cuddy orders steroids to help the baby’s lungs develop quicker, and magnesium to prevent any contractions. A little while later, as Cuddy is explaining things to Becca, she notices that Becca’s heart rate is accelerating and there is what appears to be vaginal bleeding. It is later confirmed that Becca has a grade II placental abruption (the placenta is pulling away from the uterus, causing bleeding. This can be fatal for the baby, who requires the placenta to live, and the blood loss can be devastating to the mother as well).

Cuddy is now faced with hard choice: deliver the baby now (better for the mother, riskier for the baby due to the under-developed lungs), or wait for a week or more (better for the baby’s lungs, but a higher risk for bleeding). She recommends waiting (but it is not clear whether it is Cuddy-the-doctor, or Cuddy-the-mom-to-be talking), but Becca is scared and elects to deliver the baby now. Chase is called in the baby is delivered by c-section. There are some tense moments after delivery, but eventually the baby starts crying and does very well. Everything seems to be moving towards a nice happy ending, but then Becca decides that she wants to keep the baby after all, leaving an emotional distraught Cuddy.

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

The case presentations and symptoms don’t match Family Mediterranean Fever at all (for instance, there’s a reason it’s called a fever). FMF is marked by recurrent bouts of severe inflammation including fever, joint pain, and abdominal pain that last a few days at a time. Rashes are common as well. Anhedonia can (rarely, very rarely) occur. The patients were showing no symptoms of inflammation. The medications given by House treat the attacks of inflammation only and would not have corrected the anhedonia.

Magnesium Sulfate is not a good drug for stopping premature contractions; recent studies show it is no better than placebo and it can have significant side effects.
Why give Becca a drug to stop contractions when she’s not having any? All tocolytics (drugs that stop contractions), especially magnesium, carry risks.

The most common cause of anhedonia is not schizophrenia, but depression. It’s not a common symptom of schizophrenia at all.

After 2 doses of betamethasone (a steroid) and 24-48 hours, the baby’s lungs will show significant improvement. The preferred treatment in this case would be to wait forty-eight hours (not two weeks) while carefully watching mom and the baby and then carry out the c-section. Cuddy may not have been able to talk Becca into 1-2 weeks of waiting, but 1-2 days would be a good compromise.

Classically, placental abruption is marked by painful vaginal bleeding. Painless vaginal bleeding is more likely a placenta previa.
Cameron should have caught the abruption on the ultrasound.
What is Cameron doing on the OB floor doing the U/S anyway?

Fifth disease has other prominent symptoms: bright red cheeks (hence its other common name “slapped cheek disease”) and bad cold symptoms, usually with a fever. These symptoms all occur a day or two before the lacy rash. Surely Becca would have noticed these (though admittedly the symptoms are worse in children). Fifth disease can cross the placenta and cause birth defects but only much earlier in the pregnancy.

This show loves to throw around fancy medical terms without any explanation. Why then does Taub use the vague term “mini-stroke” instead of the proper medical teram TIA? No doctor, especially one on House’s team, would ever do that. (I’d make another joke about plastic surgeons, but I think I’ve beat that dead horse enough).

There may not be any postpartum depression, but post-adoption depression is quite common.

This is another case where a good physical exam on admission would have caught the significant symptoms earlier (bronze skin in this case).

C-sections are performed by obstetricians, not surgeons. Or is Chase an OB too now?

The medical mystery had some interesting symptoms and lots of potential, so gets a B+, but unfortunately it was squandered potential and the final solution only deserves a D. The medicine, while less hap-hazard than last week, still left large parts out (suddenly he needs a transplant because of kidney failure? from bronze legs?) and earns a C. The obstetric medicine was equally mediocre and shares that grade. The soap opera was good, if depressing (and tantalizing, I guess, at the end), but we needed more Wilson: B+.

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This week’s episode of House had a great set-up and a clever medical mystery. The medicine itself was only so-so, but the rest of the episode mostly made up for it.

The episode starts with House getting a lap dance at a strip club. He soon realizes that he has no recollection of how he got there. Seeing blood on his fingers, he has the stripper look at his head and she sees a scalp laceration. From this, he deduces that he has suffered a concussion with retrograde amnesia (unable to remember what happened before the concussion). Leaving the strip club, he comes across the remnants of a tremendous bus crash and realizes that he must have been on the bus and was injured in the crash. He also has a fleeting memory that he saw something important while on the bus. He remembers that he noticed a symptom in one of the other passengers signifying that he or she had a fatal disease. The trouble is, he can’t remember who it was or the symptom that he saw

He stalks around the emergency room, looking over the other patients, and spots some bruising on the bus driver’s shoulder. He declares it a sign of leukemia, but in reality it is only the bruise left from the seatbelt. Another patient complains of a stiff neck and House immediately announces that he has meningitis and no one is to leave the emergency room (he doesn’t really think the patient has meningitis, he’s just trying to keep all the crash victims where he can find them. 22 of the 30 victims are at Princeton Plainsboro, 8 are across town).

Kutner suggests that House undergo “medical hypnosis” to improve his focus and assist with memory retrieval. Chase just happens to be trained in hypnosis, so he puts House under. Remembering the bus ride, House recalls a punk rocker (or “emo Guitar Hero wannabe”) with a cough and a bad nose picking habit. House figures this must be nasal pruritis (an itchy nose), a sign of a tumor — but the exam is normal.

A short time later, the bus driver discovers that he cannot move his legs. The differential diagnosis of this sudden onset of paralysis includes subdural hematoma, stroke, and subarachnoid hemorrhage — but all were ruled out by CT scan. Guillain Barre is suggested, as is tranverse myelitis based on the patient’s increased white count. Foreman starts him on antibiotics for the tranverse myelitis.

House now begins smelling the clothes of the patients who were involved in the bus accident, reasoning that smell is powerful at evoking memories. He hallucinates that he is back on the bus, talking to the driver, but the driver seems more focused on House than himself. Wilson and the team break his hallucination and order him to undergo an MRI to evaluate his brain. Edema and swelling in the temporal lobe are noted, as well as a fracture of the temporal bone.

The bus driver is able to walk again, but now is now suffering from acute abdominal pain. A peptic ulcer is a possible cause, but House wonders if it might be Addison’s Disease (a condition where the adrenal glands do not make enough steroid hormones) caused by a tumor.

House places himself in a sensory deprivation tank to better remember what he saw on the bus. This time, Cuddy is there with him. They conjecture that he saw something in the bus driver that caught his attention, but it could only be something he saw from behind, possibly a bobbing head or wiggling ear lobes. The differential they concoct includes aortic insufficiency (a leaky aoritc valce in the heart), Marfan’s syndrome (an inherited disease of the connective tissues), syphilis, Ehlers Danlos Syndrome (another inherited connective tissue disease), and Cutis Laxa (still another inherited disease of the connective tissues). There are also suggestions of early Huntington’s or Parkinson’s Disease. House decides it is the latter. He comes out of the deprivation tank and immediately vomits and passes out. When he comes to, he is in his apartment with a nurse to look over him and a security guard to keep him from leaving.

The bus driver is not doing well. He has developed liver failure, jaundice, and has a low albumin. The team suggests Wilson’s Disease (a disease of copper metabolism affecting the liver), hepatitis, hepatic fibrosis, and Thyrotoxic Periodic Paralysis. To rule out the latter, they carbohydrate-load the patient and put him on a treadmill. This should induce the paralysis, but since it doesn’t, the team concludes that the patient does not have the condition. He does become acutely short of breath and hypoxic, however. The team believes the patient has suffered a pulmonary embolus (a clot blocking one of the blood vessels of the lungs), but House deduces that the bus driver developed an air embolism from some recent dental work and as this air bubble has moved throughout his body, it has caused all his symptoms. He positions the patient in such a way that the air is trapped in the heart and has Dr. Thirteen remove it with a syringe. The patient immediately improves.

At home that night, House has a dream featuring a striking woman with a red scarf. The dream convinces him that the bus driver was not the patient he remembered. He reenacts the bus ride, with co-workers playing the role of passengers. He also downs a handful of phisostygmine to help him remember. He flashes back to riding on the bus, and realizes that it was Amber who was on the bus with him, and she is the patient in question. She was critically injured in the crash and hauled off to another hospital as “Jane Doe.” (And we’ll have to wait until next week for the conclusion of the story.)

The medicine was more haphazard than usual tonight, and it’s been very haphazard recently. Of course, part of that could be blamed on House’s own haphazard state tonight.

Hypnosis, even “medical hypnosis” simply doesn’t work like that. If it were that miraculous, it would be used by every police department in the country.

Stroke, subarachnoid hemorrhage, and subdural hematoma aren’t going to cause bilateral leg paralysis and shouldn’t have been so high on the list of possible diagnoses.

Tranverse myelitis is not a bacterial infection, and is not treated with antibiotics. It can be caused by certain viral infections or systemic conditions, but is most often caused by an overactive immune system attacking the spinal cord. Steroids are the treatment of choice.

While physostigmine has been used in cases of Alzheimer’s and other dementias, it has shown at best only minimal improvement. Several decades ago it was tested as a memory aid, but with lackluster results. It is also not available commercially in the U.S. as an oral formulation, unless House has access to a researcher’s stash.

For someone with an open fracture of the skull — indicated by House’s bleeding ear — submerging in a tub full of water is a great way to get an infection straight to the brain.

Nasal pruritis can suggest many things. Seasonal allergies would be at the top of my list. A tumor is a possibility, but a very very remote one. If the concern is that high for a tumor, a quick look up the nose is not going to be enough.

The air embolism from a dental procedure would have been tiny — too tiny to cause all the patient’s symptoms. Once an air embolus gets into the blood vessels, it either rises (going to the brain, since it started in the mouth) or is pushed along the circulation until it reaches the heart and then the lungs (where small ones are absorbed; large ones cause a pulmonary embolus). The air embolus wouldn’t travel elsewhere in the body unless the patient had a severe heart defect with a left-to-right right-to-left shunt.

The medical mystery was very good — one of the best ones yet and easily earns an A. The medicine was very haphazrd, but even so, it was better than it has been the last two weeks so deserves a B-. The final solution (bus driver) didn’t really fit the patient (or the anatomy or the scenario), so is knocked back down to a C. The final solution (Amber), will have to wait until next week, but come on — “resin?” House would have figured it out then and there. The soap opera was minimal, but intriguing, especially the hallucinatory and remembered parts. I give it a B.

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Challenge scores from the past two weeks are in the post immediately beneath this one (or click here). This week’s scores are posted here.

Another “just average” episode of House. I’ve come to expect more exciting and improbable medicine, and the show is just not delivering lately. To some extent, tonight’s episode was an ethics episode instead of a medical episode, and as such, it was still average.

Matty and Nick are brothers. Nick is fourteen and has leukemia. He has received total body irradiation to kill off his own bone marrow so that he can receive a transplant from his younger brother Matty, who is a perfect match. On the day of the procedure, Matty is found to be sick: he is sneezing and has a fever and an enlarged spleen. House’s team has only a few days to find out what is causing Matty’s infection and get him cured so that he can donate his blood marrow before his brother dies.

The team decides to make him sicker so that it will be easier to find the cause of the infection. They expose Matty to cold, wet condition and they also remove his white cells (the infection-fighting cells of the blood) through leukophoresis. Matty is getting sicker, but no clear causative agent has emerged. In addition to a snotty nose, Matty complains of a sore right shoulder and a swollen testicle. House suspects Matty’s acute scrotum is infectious and has the team runs tests for E. coli, tuberculosis, Brucella, Klebsiella, and entero- and adenoviruses. The tests all turn up negative (which really is no surprise as an acute scrotum in a ten year-old is unlikely to be infectious). Looking over other test results, Chase notes a high CKMB (an enzyme that is often elevated with heart damage or injury). A transesophageal echocardiogram is obtained and shows a thickened mitral valve. The team believes that Matty has bacterial endocarditis and that this is the source of the infection. The normal treatment for endocarditis is several weeks of antibiotics, but House decides to rush things. He wants Matty’s mitral valve to be surgical removed and replaced to eliminate the source of infection. He believes that this will allow Matty’s bone marrow to be ready in time to donate to Nick. Of course, Matty will probably end up on blood thinners for the rest of his life (depends on whether they would use a mechanical valve or a porcine valve).

As the surgery is being performed, Wilson discovers that the mitral valve growth is fibrous and not infectious and the surgery is called off. The team now suspects that Matty’s condition may not be infectious, but instead an autoimmune disease such as Lupus or Behçets Disease. Tests show no evidence of autoimmune disease.

Meanwhile Nick has started to bruise, suggesting that he needs the bone marrow transplant fast. Foreman suggests pressing ahead with a partial match donor, but House and Wilson believe that there is too much of a risk of graft versus host disease.

Matty is now bleeding from his ears and his blood counts are dropping. Whatever infection he has is suppressing his bone marrow — or it could be the medicine he’s on that’s suppressing the marrow.

The partial match bone marrow transplant is carried out, but Nick has developed high grade graft versus host disease and the medication is not controlling it. His prognosis is very poor.

The team stops Matty’s medication, but there was no bone marrow recovery, so it is unlikely to be the medication’s fault (though they only waited a few hours and it can take days for medications to clear the body, particularly in ill patients). Blood cultures are negative. Knowing that Nick’s condition is fatal and he is immune suppressed, House wants to expose him to Matty’s infection so they can get a better chance to identify it. The parents refuse. Wilson and Foreman continue to run tests on Matty, hoping to find the cause of the elusive infection. In the meantime, House talks to Nick and convinces him to save his brother’s life. Nick agrees to play incubator to Matty’s germs. Luckily, at the last moment, Wilson and Foreman have discovered that Matty has contracted histoplasmosis, a fungal infection he developed because his house was built on farmland and he was exposed to soil from an old chicken coop. Matty should be cured with a course of Amphotericin B. The parents ask if he’ll be better in time to donate bone marrow to Nick. Cuddy sadly tells them no, that the infection has weakened Matty’s bone marrow too much. This doesn’t stop Foreman: he straps Matty down and performs a painful bone marrow collection procedure (which seems to contradict what Cuddy just said). It all ends happily, with both brothers recovering and living happily ever after (one presumes).

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The medicine was mediocre, and I expect better from House. The mystery was good and the solution logical, but there seemed to be a great deal of forgotten symptoms (and/or red herrings) this episode: shoulder pain, the increased CKMB, and acute scrotum for starters. At the very least, the team needed to ultrasound his testicle to rule out testicular torsion, a devastating condition. Histoplasmosis generally causes only mild disease in immunocompetent patients; diffuse disease occurs in immunocompromised patients (such as AIDS patients). Of course, Matty’s white cells were removed so that did compromise his immune system — but fungi are slow growing so it would take at least several days to see any response (and similarly it would take at least several days of Amphotericin to treat the infection, not one dose then slap him down and take his bone marrow). Taking his white cells may have seemed a good idea in theory, but really wasn’t a good idea in practice. For one thing, white cells are responsible for many of the signs of infection we look for such as fever. The contradiction between what Cuddy told the parents and what Foreman did right after didn’t help the storyline either. And I hope I don’t need to mention that Foreman’s actions were entirely unethical. He needs informed consent, and a ten year-old is way too young to truly understand the risks and benefits of the procedure. What Foreman did was no better than assault and child abuse. So as not to end on a downer, the show’s portrayal of Nick’s acute graft versus host disease was well done.

There were a bunch of stupid lines that stood out badly in this episode. First was House’s contention that narrow spectrum antibiotics work faster than broad spectrum ones. The spectrum of the antibiotic has nothing to do with its speed, they’re unrelated. Then there was Cameron’s claim that Matty’s blood was “literally turning into water.” Even if there aren’t many blood cells left, there are still plenty of other proteins, enzymes, and chemicals in blood to make it a lot more than water — I sure wouldn’t drink it. Finally, there was Foreman’s statement that Matty was too sick for sedation. That’s simply ridiculous. Collecting bone marrow without analgesia is a hell of a lot harder on the body than anesthesia — or at the very least pain medicine — would be.

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I give the medical mystery and the solution both a B. Like last week, the medicine was haphazard and and just average, which is why it earns a weak C. The House/Wilson/Hector soap opera was good, but the Foreman scenes were too heavy-handed for my taste. I give this aspect of the show a B as well as an N (Needs more Cuddy).

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Tonight’s episode started well, but seemed to make less sense as the episode went on. Medically, that is. The character relationships and interactions just got better and better as the night progressed. Spoiler and a long narrative (sorry folks) below:

Hannah is a teen-age girl with CIPA (Congenital Insensitivity to Pain and Anhidrosis), a rare condition in which she can not feel pain, hot, or cold. She is also unable to sweat and regulate her body temperature. As the episode begins, Hannah’s mother is rushing her to the hospital emergency room on a snowy night. Hannah had been playing on the ice with some friends and slipped and fell. Her mother is concerned that Hannah may have injured herself, so she wants her to get checked out at the hospital. Unfortunately, they are involved in a serious car accident — Hannah takes a nasty laceration to the leg while her mother is knocked unconscious.

The ER is overcrowded, so Foreman is filling in and treating Hannah, who has purposefully neglected to tell Foreman about her CIPA. House strolls into the room and immediately diagnoses her when she mimics flinching to a painful stimulus, but does it wrong. He decides to admit her and run x-rays, blood tests, and an EEG. He also wants to perform a spinal nerve biopsy, but Cuddy tells him there is no need for a nerve biopsy unless the EEG is abnormal.

Hannah is a very reluctant patient. She is worried about her mother and won’t sit still for the test. House asks Foreman to sedate her, and Foreman tells him that they tried but she fought back and they were afraid of pushing any harder for fear of breaking one of her bones. House decides to take matters into his own hands. He and Hannah have a “whine-off” over whose life is more pitiful (and I think this scene does an excellent job of showing what Hannah’s daily life is like). When Hannah turns around to show House the scars on her buttocks, he injects her with the sedative and they run the EEG. In the end, all the tests are normal.

When Cameron goes to tell Hannah the results, she finds her unresponsive with a temperature of 105° (that’s 40.6°C for you non-Americans). Her temperature is brought back to normal, but there is no clear cause of her fever. A lumbar puncture (spinal tap) was negative, suggesting no meningitis. While there is an elevated bilirubin, the rest of her liver tests are normal. Her urine drug screen is negative. House decides to talk Cuddy into letting him perform the spinal nerve biopsy. Meanwhile, the Young Guns decide that a spinal nerve biopsy is too risky, and they want to find a better way to diagnose Hannah. Chase suggests that if the pain levels are high enough, Hannah may be able to feel some pain after all and pinpoint where the problem is. He recommends that they purposefully overload her pain sensors and monitor what happens. Chase has Hannah alternate her hand between warm water and boiling water while he runs a brain scan. Unfortunately, she is so worried about her mother that she leaves her hand too long in the boiling water and gives herself second degree burns. Foreman tries the next test. He has some bizarre set-up where he is drilling into the skull and injecting some medication into her brain to stimulate pain receptors. It seems to be working as Hannah starts screaming in pain. However, as soon as they unhook her from the machine, she bolts for the door. She was just faking the pain in order to escape because she has developed a full blown paranoia and thinks everyone is out to get out.

Hannah runs to the lobby balcony and threatens to jump off. The team tries to talk her down, but her legs suddenly become numb and lose control and she falls to the lobby below. She now has several broken bones and a concussion in addition to whatever is causing her fever and leg numbness. House suspects some form of nerve disease. HIV and syphilis are suggested, but he points out that all STD tests were negative. He also states that the cause can’t be vascular because her ANA (Anti-Nuclear Antibody) is normal. Cameron suggests thyroid storm (a rare life-threatening condition where the thyroid gland goes into massive overdrive) as the cause. He checks with Cuddy (who is apparently an endocrinologist) but she shoots down that idea.

House wants to proceed with the spinal nerve biopsy. Wilson talks to him in private, accusing House of wanting what’s best for himself, and not what’s best for the patient. House relents and grudgingly allows the Young Guns to perform a much less risky peripheral nerve biopsy. The results show a demyelinating disease that is affecting outside fibers first. (If you think of a nerve as a wire, then myelin is the insulation surrounding the wire. Demyelinating diseases strip this insulation.) House now suspects some sort of metabolic disease. Hearing that Hannah had a headache after visiting her mother in the ICU, he decides that it was an emotional — a guilty — headache and this guilt means that she has a vitamin B12 deficiency. Foreman points out that she received B12 in the ER. House is now concerned about leukemia and the team is ready to start a bone marrow biopsy. Talking to Wilson (and eating his food), House has a sudden realization and stops the biopsy. He rushes her to the OR in a ridiculous scene where he personally opens up her abdomen and stomach to reveal a long tapeworm. This tapeworm led Hannah to become B12 deficient which led to her loss of sensation in her legs. With some B12 replacement, Hannah should be good to go (of course, she’ll still have CIPA).

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A clever mystery on tonight’s episode of House. The medicine wasn’t as good, but House’s wheelchair bet was at least fun to watch. Spoilers below, so watch the episode before you read.

Stevie, a sixteen year-old boy, is making out with his girlfriend when he suddenly becomes short of breath and starts gasping for air. He’s brought to the hospital and admitted to House’s service. According to Foreman, Stevie has no history of trauma, asthma, or allergies. An EKG and echocardiogram are both normal. He does have a bloody pleural effusion (a pleural effusion is a build up of fluid in the membrane surrounding the lung). An x-ray reveals no tumors or pneumonia. The team’s initial thoughts are cocaine or some other recreation drug, or a venous aneurysm.

House orders a venogram, which is negative. Chase and Cameron inspect Stevie’s house only to discover it isn’t his house. It seems he lied to them. He is Romani (Gypsy) and he was brought up not to trust outsiders.

Foreman suspects Stevie has a deep venous thrombosis (DVT – blood clot in one of the veins of his legs), but House still suspects a venous aneurysm. He thinks the leak is so small it didn’t show up on the first test. He wants to thin Stevie’s blood and then try the venogram again (not a good idea. There are nuclear medicine tests that are used to discover small amounts of bleeding — much safer). Foreman decides to go ahead and perform an arteriogram first to look for a DVT. The study shows that blood is going into the liver but not coming out, which Foreman and Cameron interpret to mean that one of the three hepatic vein is blocked. (Strangely, this arteriogram which showed a venous abnormality is never mentioned again, except incorrectly when Foreman states that he performed two venograms). Meanwhile, Stevie is having severe stomach pain so the test is stopped.

The team now considers cirrhosis, disseminated intravascular coagulopathy (DIC), and leukemia, but House rules them all out. They next suspect diseases which could cause a granuloma in the liver (this granuloma would be obstructing the hepatic vein); considerations include tuberculosis (TB) or sarcoidosis. An obstructing liver tumor is also a possibility. House orders a CT, MRI (to look for granulomas and tumors), sputum culture (for TB), and an ACE level (which is usually high in sarcoidosis).

The MRI shows what appears to be a granuloma in the liver, so the team shifts their focus to Wegener’s Granulomatosis. Foreman wants to perform a liver biopsy, but House tells him to go ahead and start cyclophosphamide to treat the Wegener’s.

In the meantime, Stevie’s parents have arrived and are causing a commotion. They are redecorating his hospital room and serving him traditional Romani herbal soups. In the middle of a scene between Foreman and the parents, Stevie again complains of severe pain. Foreman pulls back the blankets to reveal a large amount of blood in his groin. It turns out that while his liver seems to have improved, his bladder has now started hemorrhaging. House wants to start FT-28, an experimental drug not approved for Wegener’s, but Stevie’s parents refuse the treatment. Foreman tricks them into leaving the room, and then talks Stevie into taking the medication. Before Stevie can take the medication, however, he double over in severe abdominal pain.

Stevie is rushed to surgery where a ruptured spleen is found. Foreman looks at the spleen under the microscope, but can find no evidence of any granulomas. House wants the surgeon to examine the small bowel for granulomas, but he refuses. House enters the operating room himself and examines the bowel, but he can find no granuloma.

The diagnosis of Wegener’s seems less likely now, particularly when the surgeon tells them it wasn’t a granuloma in the liver, but instead some scar tissue. House wants to look at Stevie’s large intestine so the Young Guns sneak in and perform a quick colonoscopy while House distracts the parents. The test reveals the culprit: a toothpick. Stevie swallowed the toothpick at some point in the past. His contortions while making out in the car had driven it into his lung, and then it migrated into his liver, bladder, spleen, and then large intestine. Once the toothpick is removed, Stevie recovers.

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I liked the fact that the answer to the medical mystery this time was not some obscure disease, but instead something as simple as a swallowed toothpick. It does fit the symptoms, and Foreman is right that wood does not usually show up on x-ray (but I’m not sure about MRI).

While the solution was clever, the medicine was just so-so. House’s fixation on Wegener’s Granulomatosis was strange since it seemed to come out of nowhere. Sure Wegener’s can cause granulomas in the liver (so then it should have been on the differential diagnosis), but so can TB and sarcoidosis, the diseases they were looking for in the first place. The team also continued to confuse pleural effusion (fluid in the membrane surrounding the lungs) with pleural edema (fluid within the lung). Stevie had a bloody pleural effusion, but a bleed within the lung would lead to blood inside the lung, not around it.

The surgery scene seemed off as well. Never mind the House-barging-into-the-OR scene, that’s passé now. I have some concern about the use of silk suture to ligate the blood vessels as silk is only slowly absorbed and extremely irritating to the body. However, a quick perusal of the surgical literature suggests that silk is still used at times to tie off blood vessels, so I’ll let House off the hook on this one, unless some surgeon knows better. I will point out that anatomically, the small intestine is tethered to the mesentery and a variety of blood vessels; it’s not just sitting out like a giant sausage.

Ethically everything was ludicrous, but since when has House or his team bothered to get informed consent?

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Tonight’s medical mystery was a solid B, and the solution was logical as well as unexpected, so earns an A. The medicine wasn’t as good, purely average (for House, above average for most other medical shows), and deserves a C. The character interaction/soap opera between the team members was minimal. Most of this week’s non-medical content was reserved for members outside the team. House got in his “wheelchair duel” — and won in his usual Machiavellian way, but this was primarily a Foreman show. What “soap opera” was present was well done though, and earns a B+.

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This episode was mostly about House, Wilson, and Vicodin, but they did manage to squeeze in some medicine as well. The mystery was fair, the solution clever, but the medicine — even though they ordered less tests than usal — still had too many errors. Here is this week’s review of House (with spoilers, of course):

Abigail is a 15 year-old dwarf with cartilage hair hypoplasia dwarfism (CHH). She was recently in the hospital for a collapsed lung and is now following up in Dr. Cuddy’s clinic. House convinces Cuddy to admit Abigail to the hospital to find out what’s really wrong with her. He presents her case to his team, at this time noting that she also has anemia. Cameron points out that individuals with CHH dwarfism have compromised immune systems and the PPD (tuberculosis test) that Dr. Cuddy placed may not be reliable. A gallium scan is ordered to look for infection. The scan shows no infection, but House notes that the liver is the darkest area of the scan, which makes him suspicious that something is wrong with her liver. He wants an ultrasound of the liver, but at this point, Cuddy intervenes. She removes House from the case until he accepts Tritter’s plea bargain and she takes over as lead physician. She orders a lung MRI to look for lung cancer, but it is negative. As the scan is finishing, Abigail develops a bad coughing spell and begins to cough up blood (hemoptysis). A further work-up reveals variceal bleeding (enlarged easily bleeding blood vessels in the esophagus related to liver problems) and liver failure. The diagnosis at this time includes schistosomiasis (a parasitic infection of the liver), cirrhosis, hepatitis, hepatoma (liver cancer), Budd-Chiari syndrome (an obstructing clot of the hepatic vein), and drug or alcohol abuse.

A liver biopsy shows sclerosing cholangitis. Surreptitiously, House tells Foreman that he believes Abigail has a condition that will affect her whole body, starting with the pancreas. Foreman order an alpha-1 antitrypsin level, but it is normal (This is good thinking on Foreman’s part, sort of; an antitrypsin deficiency can lead to lung and liver disease, so that part is right — but it really has nothing to do with the pancreas). Cuddy discounts House’s theory about the pancreas and orders an ERCP. Just before the test is to begin, Wilson and Foreman realize that Abigail in unconscious. They detect fruity breath and diagnose her with diabetic ketoacidosis. Her pancreas has failed leading to diabetes; House was right.

At this point, the differential includes Langerhans Cell Histiocytosis, cystic fibrosis, Hodgkin’s Lymphoma, and lupus. A lumbar puncture is obtained to look for signs of Hodgkin’s and antibody levels are drawn to look at autoimmune diseases. Cameron visits House who deduces that Abigail has Still’s Disease (better known as Juvenile Rheumatoid Arthritis) — a particularly nasty autoimmune disease. She is started on steroids, methotrexate, and cyclosporin. Sadly, she starts bleeding from her mouth and ears. A head CT is normal. Wilson suspects she has leukemia and wants to perform a bone marrow biopsy but Cameron feels that it is still an autoimmune disorder, as Abigail did initially improve on therapy.

House examines an x-ray of Abigail’s leg to make the diagnosis. The growth plates on her bones are normal, suggesting that she does not have CHH. Instead, she has growth hormone deficiency caused by a pituitary tumor caused by Langerhans Cell Histiocytosis (and Chase was right again).

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I thought the idea of Abigail not really being a genetic dwarf was particularly clever, unfortunately the route (and medical care) they used to get there was poor. In several cases, the timing was off. Gallium scans take 2 to 3 days to complete (it takes gallium a while to build up in the tissues), and diabetic ketoacidosis would not kick in that quickly unless the team inexcusably missed some earlier abnormal labs. Neither of Abigail’s diagnoses really fit her case. Look at the signs and symptoms of Still’s Disease and Langerhans cell histiocytosis. Few of them are even close to her symptoms, and nothing explains her lung collapse and liver failure — her main complaints. Finally, people with short limb dwarfism (of which CHH is one) have a different body build than people with growth hormone deficiency; someone should have caught that sooner. I was also a little disappointed that they presented such a rosy ending (or close, anyway), apparently forgetting that poor Abigail still has liver failure, pancreatic failure, and diabetes. She has a rough road ahead.

The soap opera/personal relationship aspect of the episode was good again this week, with several good scenes involving House and Wilson, House and Cuddy, and then House and Foreman and Cameron. I’m still not sure how much of House’s actions are signs of addiction, or are signs of an obnoxious person with pseudoaddiction. I’m certainly no lawyer or policeman, but I was confused why Tritter was offering the deal. Isn’t that what lawyers are for? Sure, he mentioned the DA, but at this point House hasn’t been arrested or even indicted.

This episode earns a B for the mystery and an A for the solution. The medicine, however, was only average (for House at least) and deserves a C. The soap opera was good, but not as good as last week’s and earns an A-.

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A very somber (but sadly, not sober) episode this week. As usual, there are significant spoilers for this week’s episode of House ahead, so don’t come crying to me claiming nobody warned you.

A husband returns home to find his wife Kara have a seizure in the bathtub and their four-week old son Mikey drowning. By the time they reach the hospital, Mikey has resumed breathing and Kara has stopped seizing. Mikey is taken to the neonatal intensive care unit (NICU), where Chase happens to be working. Kara’s case is tackled by House, Cameron, and Foreman. Her calcium is elevated, and the initial concerns are hyperparathyroidism, cancer, and a “calcium-mediated neurotoxicity” — but apparently all those were ruled out in the ER. The next diagnoses considered include polyarteritis nodosa (a rare inflammation of blood vessels), Whipple’s disease (a rare type of bowel infection), a Strep infection, and vasoconstriction (a sudden narrowing of important arteries). The Strep test is negative, and when she is undergoing angiography, Kara suffers some sort of massive muscle contraction/seizure.

Meanwhile, Mikey’s oxygen levels suddenly drop. Chase listens to his lungs and diagnoses a collapsed lung (pneumothorax). He performs a needle thoracostomy and then acquires x-rays. He thinks the x-rays show a chemical pneumonitis (an inflammation of the lungs caused by an inhaled — or swallowed — irritant), but House disagrees and thinks the x-rays look like a bacterial pneumonia. He suggests placing Mikey on antibiotics and ECMO. Chase decides that House must be correct and starts the antibiotics and ECMO (extracorporeal membrane oxygenation — a big machine that oxygenates the blood and removes carbon dioxide).

In terms of Kara, the doctors are now considering a lithium toxicity and a myelogenous meningitis (a rare complication of leukemia where the cancer cells invade the lining of the brain). An MRI shows no brain tumor, but it does show a subarachnoid hemorrhage. It turns out that Kara has a bleeding disorder and her blood is not clotting as well as it should. Foreman’s search of Kara’s apartment turned up no lithium, but it did show a hidden bottle of vodka. When the team discovers that Kara is a former alcoholic, House suspects that she started drinking again and is now suffering from delirium tremens (a dangerous form of alcohol withdrawal). The liver damage from the alcohol would cause her bleeding problem (though they never seemed to run any liver tests). Foreman thinks it may be a conversion disorder, basically her body is having seizures to cope with the severe stress in her life. House overrules him and they place Kara in a phenobarbital coma to essentially sleep off her delirium tremens.

Kara’s feeling better when she awakens from her coma, and she is delighted to see her son (who appears fully recovered) and her husband. A short time later, House discovers her trying to suffocate Mikey. Chase resuscitates the baby and rushes him back to NICU. The team is now concerned that Kara has postpartum psychosis, especially after she admits that she hears voices telling her to kill her son. To ensure there is not some other neurological condition going on as well, they attempt to cause a seizure in her with sleep deprivation and strobe lights. Ultimately they succeed in setting off an atypical seizure that causes them to think that Kara is suffering from some sort of progressivedelirium. The possible diagnoses at this time includes Wernicke’s Encephalopathy (neurological disease caused by a severe thiamine deficiency – common in alcoholics), lithium toxicity, Whipple’s Disease, and pellagra (neurological disease caused by a severe niacin deficiency). Pellagra is the best fit, so they start her on niacin supplementation.

In the NICU, Mikey is not doing well. The lack of oxygen has severely damaged his kidneys and he has developed hyperkalemia (high potassium). Chase tries medication to bring the potassium level back to normal but it doesn’t work, and Mikey suffers a fatal arrhythmia (an abnormal heart rhythm — ventricular fibrillation in this case).

Kara is not improving despite the niacin, and complains of stomach pain shortly before vomiting blood. House has an idea but needs an intestinal biopsy. Because he suspects a disease that has a genetic component (and because Mikey has been breastfeeding and essentially eating the same food as mom), he can test the baby. A post-mortem examination of Mikey’s intestine reveals celiac disease, an autoimmune disease tied to eating food with gluten (wheat protein). This has caused malabsorption of vitamins (niacin, leading to pellagra and vitamin K, leading to a clotting disorder) as well as led to the development of a stomach cancer.

As the episode ends, both Kara and her husband are trying to come to terms with their son’s death — and having a hard time of it. Foreman is struggling to regain the skills he lost, and did I mention that Cuddy is looking for a sperm donor?

Kara’s medical care wasn’t that bad, but the pediatric medicine was sub-par. First, Chase is an adult intensivist, not a neonatologist, and the two are not interchangeable. Second, why did Mikey develop a pneumothorax? Infection (or pneumonitis) are not causes of a collapsed lung. Third, speaking of a collapsed lung, a needle thoracostomy is for treatment of a tension pneumothorax, not a spontaneous pneumothorax. The needle simply converts the tension pneumothorax into an open pneumothorax, which they neglected to treat. Fourth, I know ECMO machines look cool, but pneumonia is not an indication for using one (though bacterial sepsis can be an indication).

In terms of Kara’s treatment, isn’t it ironic that she was found to have a cancer after we were told in the beginning that the ER had categorically ruled out cancers? For Foreman, I’m glad to see he’s recovering, albeit slowly, but why is everyone convinced it was the biopsy alone that caused his problems. Meningitis takes at least a month of convalescence (which does not include going to a stressful job) before a person is anywhere near recovered. Finally, shame on House and Wilson (especially Wilson, as an oncologist he should know better). Tumor markers can be used to follow an established cancer or to check for a recurrence, but have no use in screening for tumors (except maybe the PSA — prostate specific antigen — in men, and even that’s open for debate).

The mystery was interesting and gets a B and the solution logically followed, earning a B+. However, the medicine and in particular the pediatric medicine was bad enough that I can’t give a higher grade than a C-. The soap opera component, particularly the Wilson/Cuddy “date”, had potential and deserves a B+.

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No sex this week, just a very sick six year-old and the memories of a sick seventy-three year-old. Be warned, there are spoilers aplenty for this week’s episode of House ahead

Ian, a six-year old with bloody diarrhea and ataxia (loss of coordination) is admitted to the hospital. Cuddy thinks it is a case of gastroenteritis (food poisoning or a “stomach flu”), but House suspects it is something more. Twelve years before, a patient of his was admitted with the same symptoms and ended up dying within twenty four hours. That patient — a 73 year-old woman named Esther — developed kidney failure, pituitary failure, liver failure, and respiratory failure before she died. House believed she had a rare condition known as Erdheim-Chester Disease, but he was never able to prove it. With Ian, he sees a chance to redeem himself.

While House believes it is Erdheim-Chester, the rest of the team is not convinced. They also want to consider Listeria infection, leukemia, asthma, or even diabetes. A colonoscopy is performed but shows no evidence of Erdheim-Chester. Just when the team is starting to think that it may only be a case of gastroenteritis after all, Ian develops kidney failure.

The differential diagnosis now includes infection with the bacteria E. coli 0157:H7 (which Chase incorrectly calls HO157) leading to hemolytic uremic syndrome, Goodpasture’s Syndrome (an autoimmune disease that attacks the kidneys and lungs), heavy metal toxicity, and lymphoma. Blood tests for lymphoma are normal, but an MRI of the brain shows a pituitary mass. House starts Ian on a variety of medications in an attempt to ward off liver failure. They seem to work at first, though soon Ian’s platelet count drops and he has trouble breathing, ultimately requiring intubation and mechanical ventilation.

The team is now concerned with sarcoidosis, juvenile rheumatoid arthritis, an autoimmune disease, or Kawasaki Disease. An echocardiogram shows no evidence of the aneurysms normally seen in Kawasaki, but it does show a mass in the heart. House biopsies the heart mass, but the procedure causes a cardiac arrest. Ian is successfully resuscitated, but it takes eight minutes so he may have suffered some brain damage from the lack of oxygen during that time.

Knowing they only have a small biopsy sample to use to save Ian’s life, the team has to decide which three tests they can run because the sample is only large enough for three tests. They are considering histiocytosis (an abnormal increase in the number of histocytes, one of the cells of the immune system), tuberous scelerosis (a genetic disease), leukemia, sarcoidosis, neurofibromatosis, chondrocytoma (a tumor of cartilage tissue), or sarcoma (a muscle tumor). The tests for histiocytosis and tuberous sclerosis are negative. With only one biopsy sample left, House decides he must have been right all along and runs the test for Erdheim-Chester — which of course is positive. The diagnosis has been made, treatment is started, and the ghosts of old failures are exorcised.

An interesting episode with a good mystery. However, the ultimate solution really is not that good a fit for either Ian or Esther. Erdheim-Chester Disease is a rare form of histiocytosis that affects the long bones of the skeleton. Bone pain is one of the first signs, and it has a very distinct appearance on x-ray — something they should have looked for right away. It is most commonly seen in middle aged individuals, and while it has a high mortality, it takes years to run its course, not hours. It can cause kidney, liver, heart, pituitary and lung problems, but it has not been shown to affect the colon or cause bloody diarrhea.

The writers were unusually sloppy about medical terminology this episode. Erdheim-Chester is a type of histiocytosis, but Chase had already run a test to rule out “histiocytosis” — they were probably referring to Langerhans Cell Histiocytosis (”Histiocytosis X“), the most common kind, but it was still sloppy. Cameron mentions “connective tissue diseases” though the team had already ruled out “autoimmune diseases” and the two phrases are synonyms. Of course, that didn’t stop them from mentioning Goodpasture’s Syndrome and Juvenile Rheumatoid Arthritis — two specific kinds of autoimmune disease.

The rest of the medicine was pretty good, though I have a few quibbles about the lab tests (the results were amazing quick, and I’m astonished that their hospital has all the reagents to run these very rare and very expensive tests and doesn’t have to send them out to a specialty lab like the rest of us have to).

In terms of the non-medical content, the poker tournament was a clever set-up and fun to watch. The interactions between House (in person or on the phone), Wilson, and Cuddy were well done. However, this was at least the third or fourth time this season that a random comment from someone (Wilson this time) suddenly makes House realize what the solution to the mystery du jour is. I realize that’s a common cliché in detective fiction, but I find it distracting in a medical show.

The mystery gets a strong B+, but the solution earns a meager C because it really doesn’t fit. This drags the overall medical score down to a high B-. The non-medical content was enjoyable and earns an A as well.

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A rising black politician has just finished giving a speech when he suddenly collapses. He blames it on being overworked and under the weather for the past few weeks. A physical exam turns up some neurological abnormalities and a lumbar puncture and brain MRI are performed. The MRI shows a suspicious lesion that is ultimately determined (after brain biopsy) to be toxoplasmosis. Dr. House and team suspect that this means the politician has AIDS, because that is by far the most common cause of disseminated toxoplasmosis. The politician swears he does not have AIDS, and while a first HIV test is positive, a second test is negative. Discarding the AIDS diagnosis, the doctors concentrate on cancers that could be causing his symptoms such as hairy cell leukemia. Ultimately, House diagnoses the patient with Combined Variable Immune Deficiency (CVID) based on the combination of a seizure medication and common infection the patient had as a child. Some immunoglobulin shots and the patient is good to go.

AIDS is a logical thought when severe toxoplasmosis is found. The idea of repeating the HIV test doesn;t make much sense as most HIV tests are already a double test – an ELISA followed by a Western Blot if the ELISA is positive (to check for false positives, such as was the case in this episode). The seizure medication phenytoin (brand name Dilantin) has been associated with CVID, as has Epstein-Barr Virus. However, it’s not the double whammy of the two together that can cause CVID as House suggests; instead it appears that that either one alone can cause it (though genetics seems to be a more common cause of CVID). I also find it suspicious that the patient’s CVID had remained quiet for thirty years before suddenly showing up as two serious (and dramatic) fungal infections in a matter of days. A more realsitic scenario would have the politician suffering recurrent common infections for years before developing a more serious infection such as toxoplasmosis or PCP.

The soap opera was good again this week, but not quite as tense as the previous episode. I get the feeling that the writers are setting us up for something big. The writers also seem confused about Vogler’s motivation. He wants to get rid of House becuase he’s costing the hospital money, but also chooses him to speak on his newest drug because he’s a well-known and well-respected physician. Anyone who’s well-respected enough to introduce a new cardiac drug — if they’re not a cardiologist — would be well-known enough to bring a great deal of money into the hospital. The writers are trying to have it both ways: House is famous enough to for Vogler to pull his little stunt, but not famous enough for Vogler to want to keep him around. Puzzling. And don’t get me started on Vogler’s conflicts of interest…

The mystery gets a B+ with the ultimate solution getting a B- (the timing is just a little too coincidental). The medicine earns an A-. The soap opera earns a B.

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When Dr. House announces that the patient has AIDS, my wife looks at the clock then looks back at me.
“He can’t have AIDS,” she says. “We’re only fifteen minutes into the episode.”
And she was absolutely correct. The show’s writers really need to make this a little less predictable.

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The Good News: House has been renewed for a second season.
The Bad News: Because of this, Hugh Laurie will not be able to play Perry White in the upcoming Superman movie. Instead Frank Langella will. I’m not sure I see that.

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Reviews of past House episodes.

The second issue of M.D. is a lot darker than the first issue. Only one of the four stories can really be considered to have a traditional happy ending. The art continues in the intricate style E.C. comics were known for, and the lettering has the familiar blocky look.

The cover shows two doctors assisting a victim at a car crash, a scene that never appears in the comic. M.D. #2 is dated June-July 1955 and had the cover price of 10?.

The first story, “The Balance”, is about Bobby, a young boy who develops leukemia. Since the story was written before chemotherapy was available, treatment options were limited. Bobby is admitted to the hospital and given injections of cortisone to suppress the white blood cells and transfusions to build up his number of red blood cells. He does well at first, but then his symptoms return and worsen. He slips in and out of a coma and eventually dies. When the doctor tells his parents the sad news, his pregnant mother panics and runs down the hall, slipping and injuring herself. She is taken for an immediate c-section, and ultimately delivers a healthy set of twins. Looking at his new children, Bobby’s father remarks: “It’s strange, isn’t it doc…how things work out? Twins! A boy…to take the place of the one we…we lost…and the girl we’ve wanted for so long.”

The type of leukemia Bobby has is never stated, but is most likely Acute Lymphocytic Leukemia (ALL). It is a cancer of precursor white blood cells, which grow so dramatically that they choke out all the other blood cells. The treatment of leukemia has dramatically improved in the past fifty years, and the diagnosis is no longer the death sentence it once was. Hospital conditions and policies have improved as well. Family is considered important, and Bobby would not have had to die all alone.

This story does show a fair amount of sexism with the mother repeatedly referred to as “frail” based on nothing more than the fact she was female and pregnant. The father’s last line and the thought repeated by the doctor that a dead child can be “replaced” is misguided and strikes me personally as somewhat repugnant.

Herbie, a child with cerebral palsy, is the focus of the second story “Different”. Feeling that his family would be better off without him, Herbie runs away. He knows his mother will miss him, but he doubts his brothers will even notice he is gone because they always make fun of him. His father mostly ignores him, and just the other day forbade him from going outside so the neighbors wouldn’t know he had an “idiot child.” Herbie is found by a kindly policeman and taken to a wise family doctor. The parents are brought in to see the physician who lectures them sternly about Herbie: “If Herbie were an idiot, he wouldn’t have been hurt by the things you said about him and did to him! Your son, Mr. Struthers, is a bright, sensitive, intelligent boy!” Chagrinned, the parents ask for help. The doctor informs them that there is no surgery or medicine that can cure Herbie, but with intensive therapy, he can lead a more normal life. The parents agree and Herbie starts therapy, improving a little each day.

This story is a good narrative about cerebral palsy, both then and now. The treatment remains essentially the same today, and the prejudice faced by people with cerebral palsy continues.

In “A Case for the Books”, the third story, the elderly cabinetmaker Gustaff suddenly loses most of the vison in his right eye. He goes to see the local Family Doctor, who sends him on to an eye specialist in the city. The specialist tells Gustaff that he has ocular hypertension and that the high pressure in his eye is damaging the optic nerve and could lead to permanent blindness. An operation is required to reduce the pressure. Gustaff agrees, and a small hole is drilled in his eye to reduce the pressure. The operation is successful and Gustaff regains his vision. Instead of money, the doctor asks for a handmade bookshelf in payment.

The term ocular hypertension fell out of favor in the 1970s because it was vague and meant different things to different people. Today it refers to someone who has elevated eye pressure but no other symptoms. Gustaff had progressed beyond this to a severe case of glaucoma. Caught early enough, glaucoma can be treated with eye drops. If it progresses too far, an operation is required. Modern glaucoma operations are similar to the one Gustaff had, though lasers are used.

In the final story, “Even For a While”, Augie has constant severe headaches, nausea, and visual changes. The local doctor suspects he had a brain tumor, and sends him to a specialist at the hospital. The specialist runs a battery of tests and confirms that Augie has a tumor. An operation is performed, and the cancer removed successfully. After recovering from his surgery, Augie thanks everyone for caring so much about him, especially considering the fact that he is a murderer set to die in the electric chair in a few weeks.

Our diagnostic tests are better today, so the several days of tests Augie went through would not be required. The ethical issue raised by this story is left up to you.

In addition to the four stories, there are also two text pieces in the comic. The first one, “Fever Fighter”, tells of an American army physician named William Gorgas who served during the Spanish-American War and while the Panama Canal was being constructed. Gorgas was the first to realize that yellow fever was spread by mosquitoes. He was one of the first to realize that malaria was also spread by mosquitoes. He was ultimately named Surgeon General of the Army.

The second text piece tells of Edward Jenner and how he discovered smallpox vaccination. This story has always fascinated me, not just because the eradication of smallpox is one our greatest accomplishments, but because of some of the ethical issues involved in Jenner’s original experiment. His subject was an eight-year old boy who was first injected with cowpox, then smallpox. How ethical is it to experiment on a child? Did they, and could they, give consent? What if Jenner had been wrong?

The stories in this issue are not nearly as wordy as those in the first issue were. In fact, the story on leukemia and the one on ocular hypertension could have used more explanations. The mix of medical conditions this issue is good because it shows that no matter how much medicine changes over the years (leukemia, glaucoma), much of it stays the same (cerebral palsy).