Polite Dissent

The team in this week’s episode of House followed a more logical approach to the patient, but they were still hampered by bad medicine. But hey, an opossum!

Daryl is a 22 year-old college football player hoping to be spotted by pro scouts. In the middle of practice, he suddenly becomes uncontrollably violent. He grabs his opponent and drags him around by his helmet until it finally comes loose, and then he bashes himself in the face repeatedly with the helmet until he starts bleeding.

He is admitted to the hospital for evaluation, but has no memory of the incident. A head CT scan and a psychiatric evaluation — both obtained in the Emergency Room — were negative. House suspects Daryl’s symptoms are due to steroids, even though he tested clean in the Emergency Room. He believes he is on the “good stuff,” i.e. steroids that don’t show up on tests. The rest of the team suspects a pituitary adenoma (a tumor in the pituitary gland) caused by repeated head trauma. Tests for GnRH (gonadotropin releasing hormone, which controls the gonadotropins, which control the production of testosterone in men) are high, but a pituitary MRI is negative, which lends credence to House’s theory of steroid abuse. He tells the team to start Daryl on a somatostatin-analog (a medication which inhibits the pituitary gland) to block the effects of the elevated GnRH.

Daryl denies any use of steroids and begins to suffer a racing heart rate and chest pain. He has an episode of paroxysmal tachycardia (sudden onset of an abnormally fast heart rate) that requires cardioversion to return it to a normal rhythm (by definition “cardioversion” means returning the patient to a normal heart rhythm. This can be done chemically, such as with adenosine, or electrically). Taub reports that the cardiac symptoms do not fit the diagnosis of steroid abuse, so the team gives Daryl’s heart a further work-up including EKG and sestamibi scan (a test that looks at perfusion of the heart itself), but they are completely normal. The differential diagnosis now consists of a PFO (patent foramen ovale, a hole between the two sides of the heart) or hypertrophic cardiomyopathy (muscular thickening of the heart). House favors the latter and has the team put Daryl on a treadmill to stress him until he develops cardiac symptoms. Unfortunately (or fortunately, really), Daryl is in good enough shape that his heart rate never rises high enough to cause a problem. Going for “plan B”, House decides to chemically induce heart stress by injecting Daryl with a vasodilator (such as adenosine or dipyridamole — they mimic the effects of exercise on the heart). Before he injects the medication, however, he notices that the palms of Daryl’s hands are unusually white.

This new symptom causes the team to reassess their diagnosis. Taub thinks Daryl’s pale hands are due to Raynaud’s phenomenom (spasm of the smooth muscles around the small arteries of the fingers), which he thinks is caused by rheumatoid arthritis. Thirteen suspects that Daryl has plaques in his arteries, and these are breaking off and sending tiny clots blocking the arteries in his hands. Chase believes Daryl has Takayasu arteritis (inflammation of the aorta and other large arteries), and Foreman, ever the optimist, blames lymphoma. House likes the last two ideas the best, and tells Foreman to put Daryl on an ethanol drip. If he develops itchiness, it’s a sign of lymphoma, and if he loses his radial pulses, it’s a sign of Takayasu. Daryl develops itchiness while on the drip, so Foreman’s suspicion of lymphoma appears to be correct. Daryl is taken to surgery for a splenectomy, but during surgery Chase notices that his spleen is fine but his liver is inflamed.

Biopsies reveal no lymphoma and a non-specific liver inflammation. The new differential diagnosis includes polymyositis (a chronic inflammation of the muscles), Felty syndrome (rheumatoid arthritis + splenomegaly, which doesn’t fit at all), and viral hepatitis. Blood is drawn for further testing, but Foreman reports that the blood clotted almost immediately after being drawn. This suggests that Daryl has cryoglobulinemia (abnormal proteins in the blood that thicken with cold temperatures), brought on by football practice on cold days, and needs to be started on anticoagulants (blood thinners). This isn’t good enough for Daryl; he doesn’t want to miss his shot at the pros, so he leaves the hospital, promising to come back the next day. At the exhortation of Daryl’s mother, Foreman tags along to look after him — it was a good thing he did, too, as Daryl starts to experience shortness of breath and blurry vision. He is admitted back to the hospital. As the team begins to evaluate the new symptoms, Foreman admits that their really aren’t any new symptoms. He had dosed Daryl with nitrates (a class of blood pressure medication) to drop his blood pressure so he’d feel bad enough to want to come back to the hospital.

Looking over the chart, House notices that Daryl has only lost one pound during his stay in the hospital and he should have lost more. This lack-of-weight-loss could be due to steroid abuse, or paraneoplastic syndrome — only there’s been no evidence of cancer. The team performs blood test after blood test, and scan after scan, but can find no cancer. House then realizes that the cancer they are looking for is not inside the body, but outside. It turns out that Daryl has melanoma, a skin cancer hard to spot on African-Americans, and this cancer (or course) is causing paraneoplastic syndrome, which explains his symptoms.

(Here’s my take on what’s going on: you may have noticed during the episode that the team gave two different definitions of paraneoplastic syndrome. First, they described a situation where a cancer produces a hormone which can cause systemic effects: in this case, the melanoma is apparently producing GnRH which increased Daryl’s testosterone and gave the appearance and symptoms of steroid abuse including “roid rage,” weight gain, and probably the heart symptoms. Second, House describes paraneoplastic syndrome as a situation where the body is making antibodies against the cancer, and this produces the systemic effects. This would explain the kidney failure and liver inflammation. The apparent cryoglobulinemia may be an effect of the extra paraneoplastic antibodies, or cryoglobulinemia can occur with certain cancers. Both definitions of paraneoplastic syndrome are correct, but I’m not certain if a patient would ever experience both situations.)

I admit that I’m somewhat confused by House’s take on steroids. If Daryl was taking steroids, his GnRH should be suppressed — lower — not higher. Or is House suggesting that Daryl was receiving GnRH itself, or a synthetic substitute — and if that’s the case, the body generally downregulates GnRH receptors when GnRH levels are unusually high, actually leading to hypogonadism and less testosterone.

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

The clotting in cryoglobulinemia resolves at normal temperatures, so why would Daryl be clotting in the presumably warm hospital room. Did Princeton-Plainsboro not pay the electric bill?
Why didn’t he show abnormal clotting during surgery as most operating rooms are kept PDC (pretty damn cold).
Surely they drew blood before surgery, at least a blood type/transfusion panel, and should have notoiced the clotting then.
Blood thinners are not the recommended treatment for cryoglobulinemia.

Giving a patient enough of a nitrate to intentionally cause hypotension (low blood pressure) is dangerous. How did Foreman know he didn’t give too much? I’d also expect Daryl to develop a severe headache — the most common nitrate side effect – before any other symptoms.
I guess he learned it from House, who was trying to induce a cardiac event in a patient without even having him hooked up to any cardiac monitors.

Stress tests aren’t used to test for hypertophic cardiomyopathy, at least not as a first-, second-, or even third-line test. An EKG has already been obtained. A structural test, such as an echocardiogram or MRI is the next logical step. If needed, cardiac catheterization may also be performed.

Sorry Taub, steroid abuse can cause heart problems, including tachycardia.

Is there really a link between repeated trauma and pituitary adenoma, a type of cancer? I haven’t been able to find one, but then again, I’m not a neurologist or sports medicine specialist.
GnRH is released into the pituitary, not from it, so why would a pituitary cancer lead to “leaking” GnRH?

There is a condition known as the “lymphoma itch” that is a severe itching, primarily of the lower extremities. It is most commonly seen in Hodgkin’s lymphoma, but even then it only occurs in 10-25% of patients.
It is not associated with alcohol. A separate condition (severe aches and pains) can be worsened by alcohol intake in certain patients with lymphoma.

I don’t know it alcohol will really shut off blood flow in the radial arteries in patients with Takayasu’s arteritis, but who in the hell would thank that is a good idea. Personally, I like my hands to have full blood flow, thank you.

Return to full contact football a day after abdominal surgery, even a laparoscopic one? Nonsense.

Blood in the urine is really not a sign of kidney failure. It suggests that there is a problem with something farther along in the urinary system. This is especially true in patients on blood thinners, were urinary bleeding is more common – maybe from inserting the catheter in the first place.

Why would a melanoma secrete GnRH?

It is certainly possible to have rheumatoid disease with a negative rheumatoid factor.
Wasn’t Chase the one who shot down Taub’s suggestion of rheumatoid arthritis? So why would he later suggest Felty’s, which requires rheumatoid arthritis?

Paraneoplastic syndrome has become the lupus of this season.

I found the medical mystery interesting this week. Not great, but better than recent episodes. I give it a B+. The final solution clever (hidden melanoma in a black male), but too much of “Been there, got the T-Shirt” feeling (paraneoplastic, again, and a nearly impossible one at that). I give the solution a C-. Overall, the medicine was more driven this week, and followed a logical progression, but too much of it was questionable or downright wrong. Another C-. The soap opera was decent. I liked the Foreman and Foreman scenes, and the Wilson/House scenes were good, but I figures Lucas was the culprit fairly early on as Mark Michael Weston was listed as a guest star, but nowhere to be seen. I give the soap opera a B.

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Bunches of high scores this episode, thanks to this year’s ubiquitous diagnoses: paraneoplastic syndrome and “lymphoma.” TRad led this week with 18 points.

Overall, TRad and Noether increase their dominance, with 77 and 75 points, respectively. Theta Sigma stays in third with 57 points, and Corien retains fourth with 54 points. The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

This episode was better than last week’s pathos-fest, but it was still lacking in the medicine department.

Valerie is a 27 year-old ruthless business woman who experiences the sudden onset of severe bilateral ear pain. She is admitted to House’s team, even though he finds her case uninteresting, because she is “hot” and yet has an ugly husband. Chase suggests that due to a recent dietary change, Valerie may have a vitamin deficiency which is causing her symptoms. House thinks that her change in diet may have boosted her already elevated cholesterol, leading to blocked arteries, heart damage, and an arrhythmia (abnormal heart rhythm) which she experiences as ear pain. Testing shows no evidence of blocked arteries, but it does confirm an arrhythmia. The team plans to start her on unspecified “cardiac medications.”

An ex-coworker of Valerie’s appears in her room, drunk, and accuses her of having an affair with him and later poisoning him to cause him to lose his job. She denies these accusations and security escorts the man out. The male members of the team jump to her defense, but Thirteen thinks that Valerie is up to something. When the team discussed the situation with House, he suggests that she may have been poisoned with thyroid medication, which would rev-up her heart and cause the arrhythmia. House and Foreman want her started on beta-blockers (to block the effects of the thyroid medication), but Thirteen sneaks her off to the MRI suite. Her testing reveals that Valerie has no emotions and is by definition a psychopath. Confronted later, Valerie admits to everything Thirteen suspects. All that her co-worker said is true — she slept with him and then poisoned him. She also admits she only married her husband for his trust fund.

Taking both the heart and brain symptoms into account, the new differential diagnosis consists tertiary syphilis (late stage syphilis where mental symptoms are common), Wilson’s disease (a disease of copper metabolism), and Hashimoto’s thyroiditis (autoimmune inflammation of the thyroid gland). The first seems the most likely, so they start Valerie on penicillin. There is a heated discussion between Valerie and Thirteen, and when Thirteen reaches to turn over Valerie’s arm, she breaks it. Further testing reveals elevated BUN (blood urea nitrogen) and creatinine levels which suggest kidney failure, which would explain the brittle and easily-broken bones.

House now feels that the Valerie’s psychopathy is something she was born with, and not a symptom of her condition. Focusing on the heart and kidney symptoms, Foreman suggests that she has paraneoplastic syndrome, likely from a lymphoma. House orders full body radiation therapy. Thirteen wants to run some tests first, but Foreman shoots her down.

There are more confrontations between Valerie and Thirteen, with Thirteen’s “innocent” questions lead Valerie’s husband to realize she’s was having an affair, and Valerie reporting her to the medical board. Eventually, Thirteen is removed from direct patient contact with Valerie, but Cuddy explains is it because Thirteen does not deserve to have Valerie inflicted upon her.

Valerie starts bleeding heavily from her mouth due to esophageal varices (enlarged, bleeding esophageal veins related to liver disease). She is taken to the operating room for a TIPS procedure (transjugular intrahepatic portosystemic shunt) — placement of a stent which bypasses the liver, relieving the elevated blood pressure in the liver which lead to the varices. This new symptom causes the team to reevaluate their diagnosis, and this time they consider and discard amyloidosis and alpha-1 antitrypsin deficiency before settling on primary hepatic fibrosis (fibrosis of the liver not due to another disease). She is started on steroids and a search begins for a liver donor for transplant. Thirteen talks to Valerie’s sister and learns that she wasn’t always a psychopath — that started during her teen years. This suggests that the psychopathy is a symptom of her condition, and not something that can be overlooked. Thirteen and House realize that she must have Wilson’s disease, which is confirmed by looking at her fingernails which are blue. She is started on chelation therapy to remove the excess copper. By the end of the episode it seems to be working

Those of you who read comic books will know what I mean when I say that the medicine of this episode was the television equivalent of a Mark Millar comic: a bunch of dramatic set pieces connected by sketchy plotting and poor logic. Sudden ear pain (hand waving) It’s her heart! (hand waving) Oh no, kidney failure! (hand waving) It’s cancer! (hand waving) Now it’s liver failure (hand waving) Wilson’s disease and presto! Iit’s cured, and now the world is safe for democracy.

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

You do not treat a patient for cancer — be it radiation therapy or chemotherapy — without knowing what sort of cancer it is first. Different cancers have different treatments. Even if it is a B-Cell Lymphoma, there are over a dozen different cancers of that type, and only some are treated with radiation therapy. This seems to be a recurrent mistake this year.

Her kidney failure is so bad that her bones break that easily and she’s stopped producing urine and nobody noticed?
There’s no way it took that long before they checked her BUN/Creatinine. They would have been checked before running any cardiac artery testing to make sure her kidney could handle the dye.
Similar arguments for no one noticing her chronic liver disease bad enough to cause bleeding varices.

Wilson’s disease should have shown up on the MRI. You know, the one they used to dismiss the diagnosis of amyloidosis.

She sure improved from her fifteen years of Wilson’s disease improbably fast, especially her psychiatric symptoms.

A paraphrase:
Thirteen: If she has Wilson’s, why doesn’t she have Kayser-Fleischer rings?
House: Notice how I avoid answering — or even acknowledging — your question by distracting you with another symptom. Aren’t I (and by extension, the writers) clever?
(House could have just said that KF rings only occur in 2/3 of the patients with Wilson’s. Blue nails [azure lunula] are certainly seen in Wilson’s, but less commonly than KF rings).

Technically, Broca’s area is only on one side of the brain, it is not bilateral.

I suspect the fingernail polish under the pulse-ox (oxygen monitor) had already been wiped off – the monitors work a lot better that way.

The team never “ruled out” Wilson’s, they just focused on the tertiary syphilis instead.

The medical mystery was modestly interesting, but quickly forgotten and ear-pain was never again mentioned after the seven minute mark. It deserves a B. The final solution was a bit of a stretch, but actually fit fairly well (especially if you ignore the whole “chronic” aspect of the disease). It also earns a B. Overall, the medicine was spotty, with the team missing things an intern would have noticed. I give it a B-. The soap opera was light, but generally well done. I thought Olivia Wilde held up her end better than expected, but I’m surprised House never ran any sort of background check on his classmate. I give the soap opera a B.

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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.

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.

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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 nice turn by Thulsa Doom, full of many layers of moral dilemmas. Plus, if you ignore the scenes dealing with the heart, the medicine was pretty good.

Dibala, a brutal African dictator suspected of genocide, is in the United States to address the UN when he suddenly starts coughing up blood (or vomiting blood — it’s not entirely clear). He is admitted to House’s Foreman’s team at Princeton-Plainsboro for evaluation. The team’s initial differential diagnosis includes hemorrhagic ulcers of the lung, an assassination attempt using polonium (suggested by the dictator), and acid reflux. Foreman notices a bug bite on the patient’s hand and thinks he had has malaria. House, on the other hand, thinks the bump is not a bug bite but instead chloracne indicating dioxin poisoning (probably from an assassination attempt). Foreman goes with House’s idea and starts Dibala on Olestra (the same “fake fat” once used in no-fat potato chips. It is thought to increase fecal excretion of dioxin — i.e. it makes you poop more).

Dibala suffers a heart attack. He is started on oxygen, heparin (a blood thinner), and streptokinase (a “clot buster”). He survives, but since the heart is now involved and he has also developed a low grade fever, the team revisits their differential diagnosis. They now focus mostly on infectious causes including Lassa fever, Ebola, Marburg, and trypanosomiasis (African Sleeping Sickness). Once again, Foreman goes with House’s suggestion and starts the patient on ribavirin to treat Lassa fever. Dibala’s staff bring in an expatriate who has survived Lassa fever. They want to use her blood to help treat Dibala (they will presumably inject her antibodies — which would include antibodies against Lassa — into Dibala, providing him with passive immunity). Cuddy agrees over Cameron’s dissent.

Meanwhile, an opponent of Dibala has sneaked into the hospital and attempted to assassinate the dictator. The shots miss, but while evaluating Dibala, Chase notices a right eye hemorrhage. Further evaluation shows that an enlarged lymph node has blocked the retinal vein, leading to the bleeding into the eye. With lymph node involvement, the differential changes again and now consists of sarcoidosis, a Staph infection, and lymphoma. The lymphoma seems the most likely, so a biopsy is checked, but turns out to be completely normal. When Chase and Cameron tell Dibala the results of the test, it becomes clear that he is having problems with his short term memory. House suspects scleroderma is the cause, but Foreman suggests blastomycosis, a fungal infection (the argument here seems confusing to me: Chase says he agrees with Foreman, but then says he doesn’t think it is fungal). This time, Foreman sticks with his choice and starts Dibala on Amphotericin B, an antifungal medication. Cameron begins to have second thoughts that maybe it was scleroderma after all. Some blood tests are run which show that Dibala is positive for anticentromere antibodies (a test for scleroderma). As Foreman points out, it’s not a perfect test, but it does strongly suggest that scleroderma is the cause. Taking this into account, Foreman stops the Amphotericin and starts steroids to treat the scleroderma.

The next time we see Dibala, he is bleeding copiously from his mouth and nose. Chase is using a bronchoscope to look down into his lungs to find the source of the bleeding. He is able to cauterize one bleeding area, but another appears, and then another and another. It is too much for Dibala and his heart stops and he flatlines. Foreman calls for the paddles and the patient is shocked and shocked and shocked and shocked — all the while blood is pouring from his mouth and nose. It’s no use though, Dibala is dead.

After it’s all over, Foreman is mulling over the case and can’t decide what mistake he made. Was he too stubborn, or not stubborn enough? He wants to recheck some tests, but Dibala’s body is locked in the morgue. He discovers Chase visited the morgue earlier in the day and realizes that the blood tests for scleroderma did not come from Dibala at all, but from an elderly patient who died of the condition. Chase had purposefully misled Foreman so that Dibala would get the wrong treatment and die.

The medicine, for the most part (i.e. ignoring the cardiac scenes) was fairly sound. But, oh, those heart scenes dragged it down.As usual, major complaints are in red, minor in blue, nit-picking in green:

I’ve discussed shocking flat lines many times before — and I’m going to do it again — but with a twist: Dibali’s problem isn’t that his heart has stopped, it’s that’s he’s losing massive amounts of blood — which in turn is leading to the heart stopping. No amount of shocking (or anything) is going to restart the heart until the bleeding is stopped and blood replaced. It probably would not have been a bad idea to try some other maneuvers before declaring him dead (epinephrine or atropine, or CPR), but as I mentioned above, it wouldn’t have made a difference unless they stopped the hemorrhage first.

A recent bleeding problem (i.e. in the last six weeks) is a relative contraindication to the use of thrombolytic (clot busting) therapy. In another words, while not an absolute no-no, think twice before doing it. Dibala had some significant bleeding in his lungs just a day or two before — is using streptokinase really a good idea?
Regardless, you don’t give heparin with streptokinase (other thrombolytics, yes, just not streptokinase).
You’d think they’d use a newer thrombolytic at a cutting edge hospital like Princeton-Plainsboro.

You don’t give Amphotericin IV push — it’s too dangerous. Quoting the FDA: “rapid intravenous infusion has been associated with hypotension, hypokalemia, arrhythmias, and shock.”

The incubation period of malaria is at least seven days, usually longer. The mosquito bite mark should have gone away by then.
To be fair to Foreman, it’s quite a stretch for House to consider a single bump on the hand chloracne.

Anticentromere antibodies tend to occur in the more limited, milder forms of scleroderma. This should have given Foreman more reason for pause.

The mirror box is a relatively new technique for phantom limb pain, and while it does show promise, it doesn’t work that fast (it takes multiple treatments) or that completely.

The medical mystery was good this week — lots of unexplained bleeding usually is — though not terribly original. It earns a B+. The final solution generally fit the symptoms, and had a nice twist, so earns another B+. I have mixed feelings about the medicine overall. Most of it was quite good, but two scenes were particularly bad. I wish I could split the score, but I can’t (well, it is my site, so I guess I could — but I won’t), so I give the medicine a weak C. The soap opera was very good. There was House/Wilson, House/Neighbor, House/Foreman, Foreman/Thirteen, Chase/Cameron, Chase/Dibali, Cameron/Dibali, and of course, Foreman/Chase. It deserves an A.

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A perfectly serviceable episode of House – for the middle of the season, anyway. As a season finale, it was a bit of a let down (until the last five minutes, that is).

Scott is a 20 year-old who has undergone surgery that cut his corpus callosum (the part of the brain that allows the left and right sides of the brain to communicate) to treat a seizure disorder. The seizures have resolved since the surgery, but he has subsequently developed Alien Hand Syndrome, where he has no control at all over his left hand and it seems to have a mind of its own. He is at a restaurant on a date, complaining of bland food, when his left hand starts throwing rolls at an obnoxious diner at another table. A fight ensues, and before the melee even starts, we notice blood dripping from his eye.

Scott is admitted to House’s service for evaluation of his bloody tears and loss of his sense of taste. The initial differential diagnosis includes autoimmune disease, nasolacrimal tumor, infection, or the common cold. House has Taub and Thirteen search Scott’s apartment and they find mold growing on the ceiling in his bathroom. They decide this is the cause of his symptoms and start him on anti-fungal medication. About this time, Scott has a fight with his girlfriend, his left hand slapping her, and she storms out. He tries to follow her out but finds that he cannot walk. The differential now consists of dehydration or a meningioma (the most common tumor of the central nervous system) — only it’s a special meningioma that is allowing the two sides of the brain to communicate again. Instead of running an MRI or CT scan to look for the tumor, they run a test to see if there is communication between the left and right brain. The test is negative, but House notices that Scott is shivering. He also detects an ammonia scent to his breath and sees a caput medusae on physical exam, all signs of liver failure. House suspects the liver failure is due to sarcoidosis and has the team perform a liver biopsy. While performing the biopsy, Thirteen sees splinter hemorrhages (a sign of trauma or tiny blood clots) under Scott’s fingernails. He then takes a sudden turn for the worse, vomiting blood while his oxygen saturation and blood pressure drop.

The team now decides that Scott has a clotting issue, and start him on heparin (a blood thinner). An echocardiogram is normal, so the heart isn’t the source of the clots. They’ve also run tests for Factor V Leiden, Protein C, and Protein S (all things that can cause a clotting disorder), but they’re also negative. Thirteen now recalls his mention of always being sweaty and wonders if that might be a symptom of whatever disease he has. Cancer is thought to be the most likely, particularly lymphoma or pancreatic cancer. House strongly suspects the latter, even when an MRI of the pancreas is normal. He has Chase perform a new test where scorpion toxin and infrared dye is painted on the pancreas and will light up any cancer cells. There isn’t any sign of cancer, but once again Scott starts to develop a dangerously low blood pressure. House now realizes that the clotting problem is caused by his heart throwing off clots, but only when he slips into an arrhythmia, which he does under stress (like surgery or a biopsy), or every now and then. Sure enough, Chase checks a transesophageal echocardiogram and finds an abnormal rhythm and clots in the left atrial appendage. The heart throwing clots explains most of Scott’s symptoms, but what explains the heart condition? The new differential includes rhabdomyolysis (muscle disease), Graves disease (an autoimmune disease that causes too much thyroid hormone to be produced), and Cushing’s Syndrome (a condition where the body makes too much cortisol, a steroid). The Cushing’s seems the most likely, and a dexamethasone suppression test is ordered. About this time, Scott’s girlfriend returns and points out that his left hand only seemed to get “agitated” when Scott’s deodorant was involved. It turns out to be a special deodorant that Scott has to special order. Taub checks on it, and sure enough, one of the ingredients has been shown in one case to cause a heart condition and therefore this is decided to be the cause of Scott’s problem. End of case. Taub also notes ironically that the chemical has been implicated in seizure disorders, and maybe Scott had not needed the surgery in the first place.

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

Patient has neurological signs (loss of his sense of taste, inability to walk) and they even suspect a brain tumor, yet they never check a CT or MRI of the brain?

The liver failure, particularly the varices and caput medusae, developed way too quickly — or else they’ve been there for a while and the team did a piss-poor physical exam.

It caught my attention when the script was vague about propylene glycol causing “heart problems.” From what I can find, it can cause arrhythmia, particularly bradyarrhthmias (abnormally slow heart rates) and QRS abnormalities. I don’t see any connection between it and atrial fibrillation, the arrhythmia that would cause Scott’s symptoms (again, left unnamed in the script).

The patient is crashing in the OR and no one thinks to look at the cardiac monitors?

I was surprised how quickly the team accepted that propylene glycol caused his problems and just stopped there, other more likely causes left untested for.

While giving blood thinners to someone with a clotting disorder is a good idea, they might want to think twice about giving it to someone with bleeding esophageal varices (at least I assume he has them, that’s the only thing that fits and can explain the vomiting blood).

Chlorotoxin-based (scorpion venom) tumor paint has been used in animal models, but I’m not sure it’s been tested in humans yet. It seems like an extreme step to take though. One of the first things I was taught (and taught loudly) on my surgical rotation was “don’t mess with pancreas” — though the language was more colorful.

So a clot to the brain caused the lack of taste , but what caused the bloody tears?
And don’t tell me “subconjunctival hemorrhage,” that was an embarrassingly bad suggestion of Taub’s.

I like that the writers finally acknowledge that storylines are often built on single case reports (not that there’s necessarily anything wrong with that).

The medical mystery was mediocre, and they never explained one of the opening symptoms. His underlying condition (Alien Hand Syndrome) was more interesting that the mystery: C. The final diagnosis fit the symptoms, or at least the main ones, it just seemed the team accepted that the deodorant caused it too easily. I give it a B. The medicine overall was superficial and rushed, but not horrible. I give it a weak B. The soap opera was the highlight of the show, particularly the end scenes with Cuddy and Wilson and earns the show an A in this regard (though shouldn’t Cuddy have been mad that House lied to the clinic about sleeping with her, and not just yelled at him for discussing her sex-life?).

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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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An enjoyable episode of House; one of the better of the season. A good mystery, and the medicine was generally decent. Some nice battle of wits soap opera as well.

Emmy, a thirty year-old fitness instruction, is filming an infomercial when she experiences sudden difficulty breathing and collapses, breaking her ankle in the fall. She is admitted to House’s service for evaluation and all the initial tests were normal. Taub suspects her of steroid use, Kutner mentions environmental allergies, and Cuddy suspects exercise induced asthma. The last seems the most likely, so the team sets about to recreate Emmy’s episode, the best they can with her broken ankle. Sure enough, while in the middle of exercising, she once again collapses and is found to be pulseless.

Kutner suggests she may have Carcinoid syndrome. A CT is obtained which shows no carcinoid tumor, but does reveal that she has had gastric bypass surgery in the past. This catches the team by surprise, and has them rethinking their differential diagnosis: now diabetic neuropathy (nerve damage caused by diabetes) and sleep apnea are added. Thirteen suggests gastrointestinal malabsorption leading to a low potassium, but Kutner takes it one step further and thinks Emmy may have SIBO (small intestine bacterial overgrowth) in a blind loop of bowel, and that these bacteria are making their way into her blood stream causing her symptoms. They test her stool, but there is no evidence for bacterial overgrowth or fat malabsorption.

House decides to rethink sleep apnea, and has Kutner and Taub run a sleep study. During the test she sneaks out, and the pair find her exercising on a treadmill, her ankle still in a splint. They also notice she is bleeding from the ankle and never noticed — she has lost sensation in her foot. The differential now includes multiple sclerosis, Parkinson’s Disease, and transverse myelitis (a crosswise inflammation of the spinal cord). House orders a nerve conduction velocity test (NCV), but while setting it up, Taub realizes that she is losing muscle strength in her arms. This again changes the differential, and the team considers myasthenia gravis, botulinum toxin exposure, other toxins, or heavy metal poisoning. House has them start her on chelation to treat her suspected heavy metal toxicity, but there is no change in her condition. The latest differential consists of a corornary-cardiac fistula (an abnormal connection between the coronary arteries — which supply blood to the heart muscle — and the interior of the heart), Austrian syndrome (meningitis, pneumonia and endocarditis caused by the Pneumococcus bacteria), or Guillain-Barre Syndrome (an autoimmune disease of the peripheral nervous system). The latter fits the symptoms the best, so she is started on the treatment for Guillain-Barre, plasmaphersis.

When Emmy starts hallucinating, the team realizes that the Guillain-Barre diagnosis is wrong as well. Thirteen favors a diagnosis of CNS lymphoma, but Taub is suspicious she has a prion disease (a rare type of disease caused by infectious protein particles. The best known example is probably mad cow disease). House wants a brain biopsy, but Cuddy won’t let him until they’ve ruled out other brain tumors by non-invasive means. The initial tests come back negative and House decides to perform the brain biopsy himself. However, when he and Taub enters the room, they find Emmy up and about, feeling good. Taub informs House that there have not been any new drugs, but that she did eat a piece of chocolate cake from the cafeteria. House now realizes the cause of her condition — she has hereditary coproporphyria. This is an inherited disease that House tells her can be controlled by a high carbohydrate diet. When she was fat, she ate that type of food all the time, so suffered no ill effects, but now that she is slender and eating healthy, the symptoms have caught up with her. He recommends resuming the high carbohydrate diet, but she chooses to continue her low calorie diet and take medication to control her symptoms.

Major complaints are in red, minor in blue, nit-picking in green. Overall, not too many big errors this week, but many of the diagnoses were quite a stretch.

You don’t test for SIBO with a stool study. You need an aspiration of fluid from the small intestine to evaluate or a hydrogen breath test. Plus, if she has a blind loop of bowel, how are the bacteria from it going to end up in the stool to be tested?

She was pulseless, but they never specifically said what her rhythm was. If it was asystole or PEA, then defibrillation was wrong. Otherwise, it was probably right. (And I’m still not too clear on why she coded in the first place).

The time course was off again, but in different way than usual. Emmy must have been several years out from her surgery — she had the weight to lose, the muscles to tone, the fitness guru-ness to obtain, and the informercials to produce and distribute — and only now does she start to have symptoms?
And she never had symptoms with a low carb diet while trying to lose weight before her surgery.

Diet alone is not the best treatment for severe CHP attacks. A drug known as Hemitin also helps.
A high carbohydrate diet is recommended by some physicians. Most doctors recommend a healthy balanced diet with high carbs only during acutre attacks.
Abdominal pain is a key symptom of coproporphyria.

Several episodes this season where diagnoses are made by looking at the urine color and they miss the classic purple urine in this one?

The medical mystery was good this week and deserves an A. The final solution was fairly clever, though a bit of a stretch, and earns a B. The medicine, though again quite a stretch at points, was good overall and also earns a B. The soap opera was well done, both in terms of House/Cuddy and Thirteen. I give it an A, with extra credit for Cuddy’s comment about House’s balls.

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

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

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

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

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

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

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

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

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

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

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

Why did Stewart need a jugular line?

Surgery is not first line for partial small bowel obstruction.

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

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

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

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The fifth season starts with an enjoyable episode with a mostly-satisfying conclusion, though the writers played a little fast with the clues tonight.

Lou, a thirty seven year old female, is admitted to House’s service for what at first appear to be psychiatric symptoms. She works as the assistant to a high profile feminist activist and travels around the world at her boss’s side. In the middle of a meeting, Lou suddenly began to hallucinate ants crawling all over her body. Other admitting symptoms convinced the team that her problem was not psychiatric; she was also found to have abdominal pain, anemia, bradycardia (an abnormally slow heart rate), and some memory loss. Various diagnoses were suggested: an infection she obtained while traveling (but she didn’t have a fever), amphetamine abuse (drug screen was negative), vitamin B12 deficiency, and an insulinoma (an insulin secreting tumor). House felt that the labs were most consistent with B12 deficiency and ordered a B12 injection for Lou.

While Thirteen was administering the shot, Lou complained of fecal incontinence, but Thirteen discovered that she had instead passed a large amount of blood. Upper and lower endoscopies were normal and no source of bleeding could be found. Her pregnancy test came back positive, but when Kuttner performed a uterine ultrasound, he was unable to find a fetus. The team now considered the diagnoses of choriocarcinoma (a tumor that secretes βHCG, the “pregnancy hormone”), immunoglobulin A deficiency, and βHCG injections (injections of the “pregnancy hormone” would give a false positive pregnancy test). House disagrees with all three possibilities and reveals that the patient has an ectopic pregnancy (a pregnancy outside of the uterus). It has implanted in the intestine, and this is causing her bleeding and other symptoms. The fetus cannot survive where it is, and is a threat to Lou’s life, so Chase has to surgically terminate the pregnancy.

Lou continues to have a slow heart rate after the surgery and also develops new neurological signs, such as constant blinking. Her heart rate continues to drop, and in fact drops so low that she slips into cardiac arrest, but the team is able to implant pacer wires and revive her. Anxiety, stroke, and Tourette’s Syndrome are suggested for her neurological symptoms, but Taub points out that they wouldn’t explain her low heart rate. Thirteen suspects multiple sclerosis, and the patient is started on interferon. There is no improvement on the treatment — in fact, she develops a fever. Thirteen now suspects Lou somehow became infected during the surgery. On reviewing the surgical tapes, the team notices a small nodule in the intestine that they think might possibly be a ganglioma (a tumor composed of ganglion cells) which might possibly have caused her symptoms. They want Chase to perform another surgery to biopsy it, but he refuses, pointing out that the patient barely survived the first surgery. Instead, they decide on a do it yourself biopsy procedure involving an endoscope, a light, and a scalpel — and no anesthesia. Ultimately, and painfully, the biopsy is obtained. Under the microscope, it shows no ganglioma, and is suggestive of amyloidosis. To treat the amyloidosis, Taub states that they need to discover what caused it, and the team considers rheumatoid arthritis, familial Mediterranean fever, and lymphoma as possible causes of the disorder. Wilson looks at the biopsy and decides that while it doesn’t necessarily look like lymphoma, it doesn’t not look like it either, and that’s good enough for Foreman to start Lou on chemotherapy. She does show improvement on the chemo, so lymphoma seems to have been the cause of her problems. But then House appears — and pointing to the previously unmentioned bruises on her legs — points out that she has diffuse lepromatous leprosy and this is what has been the cause of all her problems. Some antibiotics and Predisone, and she’ll be cured.

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

The team should not have missed an ectopic pregnancy, that’s a first-year medical student mistake. A positive pregnancy test, abdominal pain, and abnormal bleeding — that’s an ectopic pregnancy until proven otherwise.
You don’t start chemotherapy for lymphoma by thinking it kind of looks like it. For one thing, it helps to know what kind of lymphoma you’re going to be treating.
Not mentioning the bruises until the very end was kind of cheating, don’t you think?

Apparently the team immediately knew that Lou had secondary amyloidosis (amyloidosis caused by another condition or infection) as opposed to primary amyloidosis — which is what it’s been every other time amyloidosis been mentioned on the show.
It takes more than a single injection of B12 to correct a deficiency.
Lou may have been too unstable for general anesthesia, but there’s no reason they couldn’t have used IV sedation, local anesthesia, or at least painkillers.
Maybe when Lou spiked a fever, they should have remembered that they only ruled out travel related infection initially because she didn’t have a fever.

There’s a bit of a paradox in today’s final answer. The (ectopic) pregnancy caused her symptoms which then caused her ectopic pregnancy. According to Thirteen, the pregnancy caused Lou to develop nodular leprosy, which caused her symptoms — including the scarring of the fallopian tubes. But it was these scarred fallopian tubes which led her pregnancy to become ectopic. The tubes didn’t suddenly become scarred the instant she conceived, they must have been scarred for some time before that. But according to Thirteen, they didn’t become scarred until she became pregnant…
Kudos: the surgical team all wore eye protection this time, a definite improvement over previous episodes. Now if only they’d carry that over into the other procedures as well.

So how did I grade episode one? The medical mystery was interesting, though the writers were too stingy with the clues, so it scores a solid B. The final solution was a stretch, but clever, and also earns a B. The medicine was pretty weak, and the team overlooking the ectopic pregnancy was a big miss, so only deserves a C-. The soap opera was very good, if more melancholy than usual, and earns a B+.

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House lands the prime post-Super Bowl slot, and it was a strong episode overall. The medical mystery was intriguing, as were the logistical difficulties involved in solving it. There were some strong character moments, and a surprise reveal at the end that I did not see coming.

The medicine? Eh, it was OK. The rest of the show was good though.

Cate is a psychiatrist working at the South Pole on a psychological research project, as well as serving as the physician for the team stationed there. Just after treating another staffer with an injured femoral artery, she develops sudden intense right-sided flank pain, vomiting, and begins gasping for breath. No other physicians are available at the South Pole and evacuation is not an option. Since Cate is an adjunct faculty member at Princeton-Plainsboro Hospital, the Psychiatry Department asks House to treat her. Given her location, all the diagnosis and treatment must be done over webcam, and the medical supplies and tests available at the South Pole are minimal.

The initial differential diagnosis includes appendicitis, gallstone, or kidney stone. House in particular feels she has a struvite kidney stone due to recurrent urinary tract infections (large and jagged kidney stones that form due to urinary infections). She denies any history of urinary tract infections. Her Chem 7 (also known as a Basic Metabolic Panel, or BMP) shows declining kidney function, which House believes proves the existence of a kidney stone. He wants her to take a dose of intravenous Cefuroxime (a broad spectrum antibiotic) to cover any infection. She declines, telling House that there are other people who may need their limited supply more. Her kidney function continues to decline. House continues to believe this is a kidney stone, but she believes it is because of dehydration from the vomiting (and dehydration can certainly alter kidney function tests, though it usually has a very specific pattern); she wants to repeat the test after she’s rehydrated. In the middle of the conversation, she becomes tachypneic (rapid breathing) and develops chest pain. House notices that her trachea is deviated to the left which means that she has a tension pneumothorax, a life threatening emergency. Under his direction, she is able to relieve the tension by performing a needle thoracostomy (basically inserting a needle into her chest to relieve the pressure and allow the lung to re-inflate).

The differential now includes tuberculosis — but her PPD was negative, as was everyone else’s at the South Pole — and cancer in the kidney or lungs. An x-ray of her body shows an enlarged mediastinal node which could be a sign of lymphoma. Unfortunately, it is too deep for anything but a surgical biopsy, and that’s not an option. No other lymph nodes show up on x-ray (but then, x-rays aren’t very good at showing lymph nodes), so House has her perform a detailed physical exam on herself to look for other nodes, closer to the surface. She finds an enlarged node just above the belly button. Under Wilson’s direction, Cate plunges a syringe into it and withdraws about 2cc of a straw-colored fluid. No cancer cells show up in the fluid, but there are signs of inflammation. Unfortunately, Cate now begins having severe left flank pain, identical to what she had earlier on the right.

House suspects an autoimmune disease such as SLE (lupus) or vasculitis. He wants to start her on Prednisone, but she doesn’t want to use the medication unless she knows for sure that it’s an autoimmune condition. Foreman states that the normal test, an ANA, is not available, nor is an older test looking at C3. They can perform an improvised LE Prep (Lupus Erythematosus Cell Preparation). The test result is negative, arguing against an autoimmune condition, but House is still suspicious. Reluctantly, he agrees to Foreman’s plan to have Cate go outside, on the theory that the extreme cold will reduce the inflammation of the autoimmune disease and reduce her symptoms. She is about to comply when she passes out and then slips into a coma.

House, Foreman, and Wilson are now dealing with the station mechanic, as Cate is in a coma. They have him taste her urine to see whether it is concentrated (suggesting a kidney problem) or dilute (suggesting a brain problem). The urine is watery, so the cause of Cate’s coma is likely in her brain, they suspect an elevated intracranial pressure (ICP) or a hypothalamic problem. Under the team’s instructions, the mechanic drills a burr hole into Cate’s skull. This is to relieve any increased ICP. Sure enough, she comes out of her coma shortly after the hole is drilled.

House’s team now considers what condition could cause kidney problems, lung problems, and increased intracranial pressure. The differential includes tumor (already ruled out), bacterial endocarditis, deep vein clots, atherosclerotic emboli or fat emboli. House is intrigued by this last suggestion. Cate was cold during the exam and had left her socks on. When they are removed a broken toe is revealed. This broken bone has been throwing off clots of fat to the kidney, lungs, and heart, causing her problems. The bone is reset and splinted and she should be fine.

Fat emboli can definitely cause lung problems in the form of pulmonary embolism (clots to the lungs), but I don’t see any way it cause a tension pneumothorax. In terms of the treatment of Cate’s tension pneumothorax, the needle thoracostomy relieves the tension aspect of the pneumothorax, but a simple pneumothorax still remains. Cate needs a chest tube (or if it’s small enough, 100% oxygen — all the time, not just an occasional breath).

That’s not how a percutaneous needle biopsy is performed, and that’s an incredible amount of fluid to get back — it’s a solid tissue structure they’re biopsying, not a cyst. PLus, I find it hard to believe the medical kit wouldn’t contain a local anesthetic such as Lidocaine.

Sending someone with an autoimmune disease or vasculitis out in the cold is not a clever idea. It may reduce their symptoms, possibly, if the moon is right. Or it could cause a bad case of Raynaud’s Disease (a cold-induced spasm of the blood vessels in the fingers and toes. It is common in people with autoimmune diseases and vasculitis).

I can see how a fat embolism in the brain could cause a coma (from causing a stroke), but I don’t know that it would increase the intracranial pressure and cause a coma that way.

How did fat embolism lead to enlarged lymph nodes?

It’s fractures of the long bones (femur, most commonly) that lead to fat emboli. I don’t think there’s enough fat in a toe bone to cause a fat embolism.

I give the medical mystery an A because it was the best mystery they’ve had in a while. The limitations imposed by the patient being at the South Pole were well done. The final solution fit the big picture (lung, kidney, and brain damage), but missed the specifics (how did clots do all that? And from the toe?) so gets a merely mediocre C-. The medicine was for the most part appropriate, especially given the limitations already mentioned. The final answer is where the medicine fell apart. Still, I’ll give it a B- overall. The Three Musketeers didn’t add much this week, but Wilson and special guest patient Cate more than made up for them. That Wilson-is-dating-who? ending is worth some points as well. A for the soap opera.

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Another episode of House that focuses more on the applicants (or hirelings, if you prefer) and soap opera rather than the medicine. That’s not necessarily a bad thing, and it was an enjoyable episode soap opera wise. I just wish it had better medicine. Spoilers below!

The main patient tonight is Stark, a 37 y/o man with Spinal Muscular Atrophy, an incurable and progressive neurological disease that weakens muscles. He is wheelchair bound and assisted by his dog Hoover. While crossing the street, Stark faints without warning and is nearly hit by a car. He is admitted to the hospital to find out why he had the fainting spell.

House divides the ten remaining applicants into two teams of five each: boys versus girls. The team that diagnoses Stark correctly wins and gets to remain. The losing team is fired. Everybody’s favorite alpha-female Amber wants to join the men’s team but they rebuff her.

Both teams initially consider that Stark may have picked up a bacterial infection from his dog Hoover, but discard the idea. The women’s team now decides that he must have become infected with Strongyloides (threadworm) on his recent trip to Thailand. They treat him with Ivermectin, an antihelminthic drug (i.e. an anti-worm drug). The men have no working diagnosis and want to run a full battery of tests on Stark’s hair, blood, and stool. During this conversation, it is revealed that Stark is also incredibly constipated. Amber manages to finagle her way onto the men’s team by convincing them to try xenodiagnosis — basically, have a bug bite the patient, and test the bug for any parasites that the patient may have (of course, this would only test for blood-borne parasites, not ones in the intestines or other organs). In the middle of the test, Stark starts choking and coughing.

The next morning, House reveals that the patient has suffered an aspiration, but is improving on oxygen and chest PT (though the patient is shown receiving a nebulizer. Aspiration pneumonia, a nasty type of pneumonia, would be a concern in this patient). House seems intrigued by the women’s diagnosis of Strongyloides and dismayed that the men have only managed to run test after test. He places the men’s team in the “penalty box” — making them sit in his office and not talk about the case while the women go about proving theirs. Their plan is to perform a tilt table test on Stark and try to induce a fainting spell. If the test is negative and there is no fainting, then their diagnosis and treatment must be right (but not necessarily, the tilt table test only reproduces certain types of syncope — and not the type the patient has — and/or he might be getting better for other reasons beside their treatment).

Amber and the guys have not given up. They want to know whether Stark’s choking is dysphagia (difficulty swallowing) or achalasia (an esophageal motility disorder). The old guy suggests paraganglioma — a tumor in the neck that presses against the vagal nerve, thus causing fainting, whenever the patient eats. The tilt table test is negative, seeming to confirm the women’s diagnosis and treatment, but Amber runs a CT on Stark anyway. No tumor is revealed, but she believes the results are consistent with scleroderma, a type of connective tissue disease that commonly affects the skin and esophagus. House disagrees and fires the men and Amber. She’s not done though, she talks Chase into running labs on the patient for her. She wants to run an anti-centromere antibody test, a blood test that is sensitive for scleroderma. When she draws the patient’s blood, it turns out to be green.

With this finding, House “rehires” the men’s team and Amber because the diagnosis he thought was right clearly is not. The plastic surgeon deduces that the blood is green because the contrast for the CT the patient had the day before has not been filtered out by the kidneys meaning that Stark has kidney failure. (Who runs a contrast CT on a hospitalized patient without checking kidney function first? That’s very sloppy medicine by Amber, even if she did run the test herself).

The differential is now a gram negative bacterial infection from his indwelling catheter versus scleroderma. House orders Stark to be started on Ampicillin and Gentamicin, two potent antibiotics, for the possible infection; he also orders skin and lymph node biopsies to look for scleroderma. Shortly, the team reveal that the antibiotics are having no effect (though it seems mighty quick to make that judgment) and the biopsies are negative. Or are they? House notices some black specks in the cervical lymph node biopsy and suspects that Stark has melanoma of the eye that has spread throughout the body He wants to remove the eye and manages to talk Cuddy into agreeing with the surgery. Before surgery, the applicants are performing a thoracentesis (draining the fluid from around Stark’s lungs) to make his breathing easier when they notice the fluid is clear. This is not consistent with fluid from a cancer, which tends to be cloudy and bloody. Stepping in after House’s injury (discussed below), Wilson and the team decide that Stark has Eosinophilic Pneumonia, and he is started on corticosteroids and cyclophosphamide (a potent immune suppressant and chemotherapy drug, that has been used for certain types Eosinophilc Pneumonia). The medication doesn’t help and Stark dies quickly and quietly, his faithful dog by his side. When the dog is revealed to be dead a few minutes later, House realizes that Hoover took the patient’s Invermectin (which is fatal to that breed of dog) instead of the patient. Thus, the women were right and the patient had Strongyloides all along, and died of an overwhelming threadworm infection.

Medically, the episode was rather limited — which is to be expected in a story with six patients and more than a dozen doctors. The ultimate solution was interesting and not expected. I’m not sure exactly how the Strongyloides led to fainting, unless it was a severe case of disseminated Strongyloides, and even then it’s a stretch. The women never confirmed, or even tested for, the diagnosis of Strongyloides. Stool samples are the most common test, but it can take up to seven, but there is a good blood test for the infection. Most experts recommend at least two doses of Ivermectin, if not more. The disease progressed remarkably rapidly, but then Stark was in a debilitated condition, and given immunosuppressants, which are a bad idea with disseminated Strongyloides. It’s not generally the physician’s responsibility to make sure the patient takes the medication (I’m not sure whose it is — at some point, you just have to assume the patient wants to get better and trust that he will take the medication). I’m also unclear why the dog ended up with medication. Did he eat it of his own accord (his name “Hoover” suggests this may be a possibility), or did Stark feed it to the dog? If it’s the former, why wouldn’t Stark tell someone that he didn’t get his medication?

Just because a tilt table test was negative does not prove the diagnosis of Strongyloides. Tilt tables are best for certain kinds of fainting — for instance, orthostatic hypotension that occurs when people stand up suddenly. When was the last time Stark stood up? It’s a poor choice of tests to begin with, and did they have a positive test before treatment to compare it to? It’s basically a post hoc ergo propter hoc error.

Finally, where did House get the idea that the suspected cancer cells must come from the eye because the eye is the only thing that drains to that lymph node? Lymph node drainage is a lot more complex than that. An eye may indeed drain to one lymph node, but it is not the only part of the body that drains there.

As for the clinic patient — I am not an electrician — but wouldn’t you need to complete the circuit, that is have metal in both parts of the socket, for the electricity to flow (assuming the hospital is grounded correctly)?

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Tomorrow night I’ll be taking a look at the new ABC show Private Practice (Last week’s review can be found here)

Tonight’s episode of House was primarily a character episode for Foreman, and other than some good House/Wilson (and sometimes Cuddy) moments, was a spectacularly lackluster show. Even the return of Charles Dutton as Foreman’s father couldn’t help. This week’s House medical review, chock full of spoilers, follows…

A 28 year-old inner city girl is playing a game of three-card monte when she suddenly suffers from abulia (a loss of will, shown as the inability to make a decision) and collapses. She is admitted to the hospital and Dr. Foreman explains that she has had a TIA (transient ischemic attack). He suspects the TIA was caused by drug use or toxin exposure, but the patient denies both and her drug screen comes back negative. Cameron suspects a clot from the heart and wants to do a bubble study (House told Cameron to do the bubble study, but it seems to have gotten lost in shuffle, which is a shame because it would have shown the correct diagnosis). Foreman still suspects drugs or contaminated drugs, and when he and Chase search her apartment they find a crack pipe. She insists the pipe was a boyfriend’s. The pipe shows evidence of arsenic, so her hair is tested but only shows a trace amount — not enough for arsenic poisoning.

While talking with Foreman, the patient develops a nasty cough which proceeds to a bloody cough. A CT scan of the lungs shows a large mass. The initial diagnosis is (wait for it…) autoimmune disease , including giant cell arteritis or lupus vasculitis. Foreman starts her on steroids. When he examines her eyes a short time later, he notes scleral icterus (the whites of the eyes are yellow), a sign of jaundice. He diagnoses her with liver failure (presumably he ran some other tests first). Foreman now suspects that her problem is not autoimmune, but instead a rare cancer: lymphomatoid granulomatosis. He recommends whole body radiation for treatment and manages to talk House into agreeing with him. In fact, House volunteers to get informed consent from the patient (because he wants to meet the patient who dislikes Foreman so much).

While House is obtaining informed consent, the patient has another episode of abulia then loses consciousness. House schedules her for the radiation anyway. When Foreman is examining her after the radiation therapy, he hears a new heart murmur. At the same time, the patient begins to scream in pain from the pressure from the blood pressure cuff. These two symptoms together tell the team that the patient has developed sepsis (an overwhelming bacterial infection of the body). At this point, the team decides that there is nothing that they can do for her. Foreman explains the situation to the patient and admits that his decision to give total body radiation wiped out her immune system and essentially killed her. She gets mad at him (understandably), but eventually they have a heart to heart and he sits by her side as she dies. In the end, House performs an autopsy and determines that she died of a Staph infection from a skin scratch caused by her bra clasp.

• A TIA (sometime called a “mini-stroke”) is abnormal is a 28 year-old and they should have performed a more intensive work-up, at least a head CT, carotid doppler, and echocardiogram to look for treatable causes. Actually, they did perform the echocardiogram (as part of Cameron’s bubble study), but never saw fit to mention it again. This would have shown that something wrong with the heart valves from the beginning*.
• The jump from autoimmune to rare cancer was unintuitive, and I doubt that any radiation oncologist would give radiation treatments without a definitive diagnosis, or at the very least a signed informed consent form.
• My reading on lymphomatoid granulomatosis shows that there is no clear best treatment. Steroids can work (and the patient was already on steroids), and a recent strategy has been to use antiviral drugs. Radiation can be used for localized disease — which means that it would be very specifically aimed radiation, very different from the total body radiation the script described.
• The timing of the rest of the show was off. The radiation knocked out her immune system far faster than it should (I would expect several days), and then the infection flared up very quickly as well.
• An increased heart murmur can be a sign of infection (endocarditis), but linking the pain from the blood pressure cuff to sepsis was a stretch.
• More importantly, I don’t know why they wouldn’t at least start her on some antibiotics to treat the infection. Immune suppressed patients have survived infections — even sepsis — before and antibiotics played an important role. They throw antibiotics at patients at the drop of a hat, and now when they have an actual infection, they don’t?

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The first of nine new House episodes in a row, tonight’s show featured a Iraq veteran suffering from Gulf War Syndrome, though little attention was actually paid to the controversial diagnosis. Medically, an above average episode, though it felt fairly light otherwise.

House is asked by Cuddy to see a patient who just happens to be the nephew of one of the hospital’s benefactors. Strangely, House has just had a dream about the patient, and is sure that he has seen his face somewhere before (he probably recognized him as Riley from Buffy the Vampire Slayer). John is a thirty-four year-old sergeant in the Marine Corps who recently returned from a two-year tour of duty in Iraq. John believes that he has Gulf War Syndrome and complains of chronic fatigue, intermittent rashes, joint pain, and frequent sore throats. While Chase seems predisposed to believe that it might be Gulf War Syndrome, the rest of the team suspect that he must have another diagnosis because there has never been any definitive medical proof of Gulf War Syndrome — in fact, there is medical evidence against it. House orders a blood work-up including tests for HIV, Hepatitis C, Malaria, schistosomiasis (a parasitic infection acquired from contaminated fresh water. Schistosomiasis does not occur naturally in the US, but does in Irag), and Acinetobater baumannii (a bacteria that can cause health-care related infections and has been seen with some frequency in soldiers who have served in the Middle East).

John’s physical exam is normal. He describes a frequent rash of black dots on his palms and soles, but he doesn’t have the rash currently. He also mentions a cough and sore throat, as well as chronic joint pain and tingling in his legs. Nothing shows up on exam. His routine blood work is also normal, except for his potassium which is a little low. Chase suspects John may be suffering from the after-effects of chemical warfare medication, military pre-deployment vaccinations, or toxins encountered in Iraq. He also mentions that John could be suffering from radiation poisoning from depleted uranium (depleted uranium is used in artillery and tank shells because it is extremely dense and has very good penetration). He wants to order a special urine test from England No one else agrees with his suspicions and House orders a polysomnogram (sleep study) figuring that poor sleep may be at the root of John’s problem.

The polysomnogram is normal, but John starts to complain of a foul smell. Foreman discovers that John has a nasty oral infection that is causing the odor. The team describes it as “bacterial vaginosis of the mouth.” (Bacterial vaginosis is an overgrowth of normally occurring vaginal anaerobic bacteria. It is a common cause of vaginal infections and is not usually considered to be sexually transmitted.) John is started on antibiotics for the infection (metronidazole is the most common). His HIV test is negative and there is no evidence of diabetes or other endocrine problems. Cameron suspects an autoimmune disease such as Sjogren’s Syndrome, but Foreman rules that out (but you’ll notice that he doesn’t rule out any other autoimmune diseases). Foreman suspects lymphoma, a cancer of the lymphatic system. House agrees that it is cancer, but suspects it is a parotid tumor (the parotid gland is the large salivary gland on the side of the jaw). He criticizes Chase for not sending John’s urine to England for the uranium test. Wilson performs a parotid biopsy, but the results are inconclusive. He next performs a sialogram (a test to look for blockages or obstructions in the salivary ducts), but it is normal. During the test, John suddenly becomes deaf. Wilson obtains a head CT which shows 6 tumors in the brain.

House is having problems of his own. He has been unable to urinate for three days — a side effect of the Vicodin — and has painful bladder distention. He tries some alfuzosin (brand name: Uroxatral) ( a drug that relaxes the prostatic and bladder muscles), but it doesn’t help. There is a funny scene in the clinic with a patient with diabetes insipidus (a condition where the kidneys are unable to concentrate the urine correctly, and thus the patient is urinating frequently and always thirsty).

A brain biopsy is scheduled, but just as Foreman is about to cut (or drill) into John’s skull, he realizes that the tumors aren’t showing up anymore on the scanner — they’ve disappeared. Looking over the symptoms, the team now considers the diagnoses of infection or infection plus cancer. Chase arrives with the tests from England showing that John does have evidence of depleted uranium in his urine. Since House no longer suspects cancer, he is not interested in the urine results. He tells the team to continue John on the antibiotics and monitor his symptoms. He goes home to catheterize himself and sleep. While House is gone, the Young Guns decide to go ahead and treat John for presumptive uranium poisoning, but the treatment does no good and may actually have worsened the situation. John now complains of paralysis to the abdomen (though the show confuses paralysis and lack of sensation, which are two different conditions).

When House arrives the next morning, he’s cracked the case thanks to another dream about John. He is aware that John is showing a lowered blood pressure and a lower hematocrit (signs of blood loss) and House announces that John has Hereditary Hemorrhagic Telangiectasia (also known as Osler-Weber-Rendu Syndrome). This condition can lead to AVMs (arteriovenous malformations) which cause frequent bleeding. Epistaxis (nosebleeds) are one of the earliest symptoms. House states that an AVM in the spine led to John’s neurological symptoms, and one is his lungs led to the joint pain as well as the mouth and brain infection.

I give the medical mystery a B and the ultimate solution a B+. The medicine was above average, but I’m deducting for “bad blood”: C+. The soap opera/non-medical content, despite Cameron and Chase’s best efforts, only struck me as so-so and deserves another C+ .

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A story from medical school involving a urinary catheter

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).

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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Much better medicine this week on House, as well as some fun character moments. Not a great episode, but certainly not a bad one. It’s a perfectly enjoyable middle of the road episode, which still makes it better than much of TV. House medical review and spoilers follow.

A ten year-old severely autistic boy is admitted to House’s service because he won’t stop screaming (though I noticed that he didn’t really scream much for the rest of the episode). Initial medical concerns include heart problems, allergies, and toxins. House orders stool studies, an ANA (to check for lupus, of course), blood cultures, and a lung ventilation scan (which looks for a pulmonary embolus — a clot in the blood vessels of the lungs).

The initial studies are all normal, though they can’t obtain the stool studies because Adam is constipated. When Foreman goes in to get the study, Adam starts gagging and spits up a large amount of fluid. He is diagnosed with a pleural effusion (a build-up of fluid around the lung). The effusion could be caused by heart failure so an echocardiogram is obtained to assess the heart. Foreman notes that the echo shows an abnormal heart rhythm and an EKG confirms it. Still, this isn’t heart failure and does not explain the pleural effusion. The team is now convinced Adam might have cancer — Non-Hodgkin’s Lymphoma, to be precise — and corrals Wilson into performing a lymph node biopsy. The biopsy shows no cancer, but it does show liver cells in the lymph node.

The differential diagnosis still includes cancer, but now also has liver failure and cirrhosis added. A liver biopsy is normal. Meanwhile, Adam goes into ventricular fibrillation and needs to be shocked back into a normal rhythm. He ends up with first degree AV block.

Looking at the high mineral content in Adam’s stool sample, House determines that Adam has pica (the ingestion of non-nutritive substances such as paint chips, ice, dirt, or sand). He could have gotten lead poisoning (from eating paint chips) or arsenic poisoning (from snacking on treated lumber). Foreman cases Adam’s house and yard and manages to find some Jimson Weed. Could this be the cause of the problem? House attempts to question Adam but in the midst of questioning, Adam’s eye rolls back into the socket. The differential now includes multiple sclerosis, stroke, or almost microscopic microtumors of the heart, liver, and eye. Foreman wants to locate these tumors even if he has to remove Adam’s eye to find them. In the end House determines that Adam does not have microtumors, but instead is infected with Raccoon Roundworms. He was infected when he ate sand from his sandbox that raccoons had used as a bathroom. These worms have invaded his heart, lungs, liver, and eyes causing his wide array of symptoms. Antiparasitic medication and laser therapy for the eye should take care of the infection.

The medicine was better this week. The authors still managed to confuse pleural effusion and pleural edema (fluid is coughed up in pleural edema, not pleural effusion), though not to the extent they did last week. I was pleased to see that they discussed the make-up of the pleural fluid and whether it was an exudate or not. It’s an important distinction because it helps a clinician distinguish between the various causes of the effusion (though they didn’t show the needle in the back to obtain the fluid this week — and it would have been the right procedure this time). Most of my complaints are of the more nit-picky variety this week. Such as, if Adam was eating so much sand, why didn’t a great deal of silicon show up in his stool sample? If the liver cells that ended up in the lymph node were “damaged” why did no one notice the damage when they were looking under the microscope (and why weren’t any lymphatic cells present)? What’s the connection between the ventricular fibrillation and the first degree AV block — two very different heart rhythms? If the liver was infected by the worms, it should have been enlarged, and why didn’t the damage show up on a liver screen? The ultimate solution was clever, particularly the way House discovered it through Adam’ drawings. Still, it’s a stretch to say the worms could cause all those symptoms without being noticed; they’re pretty big worms.

There were some clever character moments in this episode. I loved it when House barged into the wrong operation (I sure hope they scrubbed up again, starting with the main surgeon who pulled his mask down with his sterile glove). I also liked when House was quoting Casablanca to his stalker and she was buying every minute of it (and as for Coccidioides immitis, it causes coccidioidomycosis which leads to respiratory and sinus problems, but not the personality changes House mentions – well , at least not without causing a dangerous meningitis first).

I give the medical mystery a B and the ultimate solution a B-, it was clever, but too much of a stretch. The medicine was better this week and most of my complaints were minor so I award it a low B. The soap opera/non-medical content earns an A this week for the carpet, the zen garden, the mouse toy, the wrong OR, and Casablanca.

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Despite Joel Grey in a guest starring role, this was another sub-standard episode of House. Frankly, some of the worst medicine in the series yet. Medical explanations and spoilers follow.

Ezra Powell, a famous researcher, is in his lab dissecting some rats. A subtle tremor of his right hand can be seen and he is coughing as he is examining the rats. His breathing becomes worse and he starts gasping for breath before falling unconscious to the floor.

Powell is admitted to the hospital and House and his team take over the case. They are unsure if the breathing problems are due to the heart or to the lungs. They mention such diagnoses as amyloidosis (a condition where an abnormal proten builds up in certain organs leading) and long term exposure to toxic chemicals, but both the EKG and chest x-ray are reportedly normal (which is strange as they repeatedly refer to fluid in the lungs — pulmonary edema — which does show up on x-ray).

House orders an exercise stress EKG. This is the first big mistake of the night because that’s entirely the wrong test. The team is concerned with heart failure — that the heart is not beating as strong as it should and fluid is backing up in the lungs. An exercise stress test doesn’t evaluate this; instead it shows how the electrical system of the heart reacts to stress. While it is a valuable tool for picking up ischemic heart disease (narrowed arteries) or irregular rhythms, it tells nothing about how strong the heart is beating. They need an echocardiogram for that — like the one they ordered in last week’s episode.

Anyway, Powell is too frail to walk on the treadmill, so the test is stopped. Cameron tells House that there’s too much fluid in Powell’s lungs, so House tells her to get rid of it. Chase performs a thoracentesis and drains some fluid. And this is the second big mistake. Thoracentesis drains fluid from the area around the lungs (pulmonary effusion), not from within the lungs themselves (pulmonary edema). It simply wouldn’t have worked (according to my notes, this isn’t the first time the writers have confused pulmonary effusion and edema. They also did it in the first season). Regardless, they stress Powell again, this time having him use his arms. When this doesn’t raise the heart rate enough, House injects some epinephrine (adrenalin) into Powell’s IV. This gets the heart racing enough for the test, which unsurpsingly is normal (because it’s the wrong test!). Powell takes this opportunity to inform the team that he knows he is dying and would like them to help him die.

House is now more suspicious that the cause of the shortness of breath has to do with the lungs. He considers Strep pneumoniae (a common bacterial cause of pneumonia) and mycoplasma (a less common cause of pneumonia). Powell refuses any more tests. He informs House plainly that he wants to die and would like House’s assistance. House strikes a bargain: if he can’t make the diagnosis in twenty-four hours, he will help Powell die.

The team needs to make the most of the twenty-four hours. They run a variety of tests including amylase (looks for pancreatitis and some lung cancers), d-dimer (looks for clotting disorders), C Reactive Protein (measure the amount of inflammation), urine tests, and a bone marrow biopsy. He has Cameron search Powell’s lab for clues. The blood tests are all normal and Foreman reports that no bacteria grew in the blood cultures (but this can take up to 48 hours, even if you “spin them down.” Bacteria can only grow so fast). The bone marrow biopsy showed abnormally few cells, but showed no obvious source of the problem. An MRI of the brain is ordered when House suspects Powell might be having memory problems, but it too is normal.

With the twenty-four hours up, the team returns to Powell’s room. House tries to bluff and tell Powell that he has multiple myeloma (a cancer of the blood forming cells in the bone marrow), but Powell quickly realizes House is lying and tells House that he expects him to keep his word and help him die. Later, House returns to the patient’s room with a syringe of morphine. Cameron and Foreman protest and then leave the room, but Chase just shuts the door and closes the blinds. House injects the morphine into the patient who quickly goes into pulmonary arrest and codes. As soon as this happens, House grabs the rescue gear and intubates the patient, placing him on a ventilator. Now House can continue his tests without Powell’s “whining.”

Taking another look at the MRI, House notices that it went low enough to reveal that the top of the lungs show scarring. An autoimmune disease — it could be lupus — is suspected and Powell is started on immunoglobulin and a colonoscopy is ordered. The colonoscopy is normal and the immunoglobulin makes things worse. A diagnosis of Idiopathic Pulmonary Fibrosis is now considered and a lung biopsy is performed — which is also normal (but while pulmonary fibrosis would cause shortness of breath, it wouldn’t cause fluid to build up in the lungs). Powell now develops a right pneumothorax (a collapsed or “dropped” lung) and a chest tube is placed to reinflate the lung. As he is stitching the chest tube into place, House notices that Powell has no sensation on his right hand. The team wakes Powell up, who is understandably angry, and he refuses any more tests. Through some sleight of hand, House is able to confirm a lack of sensation to the left leg, right arm, and abdomen. The differential diagnosis now consists of Kawasaki’s Disease (”Which would explain the kidney failure,” Chase says. What kidney failure? When was this mentioned?), lymphoma, and sarcoidosis. A skin biopsy is obtained by Cameron and tests negative for all three (but of those three, only sarcoidosis shows up in the skin, and not in random biopsies). However, when exposed to a Congo Red (a special red dye), it fluoresces, showing that the patient has amyloidosis (and that Chase was right all along, for once). Unfortunately Powell has the most severe form of amyloidosis and it is terminal (though it is not quite as immediately fatal as suggested — but then, it’s not clear how long Poweel has had the disease). He dies later that night under what can be called suspicious circumstances.

The soap opera aspect was better this week. The issues raised are intriguing, and we spent several hours discussing them in medical school. Under what circumstance, if any, is physician assisted suicide acceptable? How can you make sure that depression, common in severely ill patients, is not influencing the patient’s desire to die? Is there an ethical difference between withdrawing support and letting the patient die, and taking a more active role? All good questions, and all addressed to some extent during this show. No firm answers were provided — which is as it should be — but the show did an excellent idea raising the correct questions.

This episode earns a B for the mystery, but only a C for the solution because the final answer seemed too random (a red thong!) and really should have been found sooner — but the medicine overall earns an even-worse-than-last-week D-. The soap opera/non-medical aspect were very good and deserve an A.

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There’s a big nasty spoiler in this week’s review of the season finale of House, so do not read this if you haven’t watched the episode. No really, I’m serious — turn on your VCR or Tivo and watch it before reading any more. And that means you, Jessica.

House and his team are discussing the case of a patient with a swollen tongue and a fever of 103° when a man comes in looking for House. As soon as he finds out which physician House is, he shoots him in the abdomen and then the head.

House wakes up in the intensive care unit. By the growth of his beard, he assumes he has been unconscious for two days. Cameron informs him that the first bullet went through his stomach and bowel before lodging in a rib. The second bullet entered his neck and nicked his jugular vein.

The tests on the patient with the swollen tongue are negative. A tongue biopsy showed no cancer or abnormal cells and all blood tests were negative. The patient’s intracranial pressure is high, which means it is dangerous to perform a lumbar puncture because the brain might herniate. House suggests that the team perform a biopsy of the lymph node under the patient’s jaw.

The man who shot House is placed in the ICU in a bed next to House. It turns out that his wife was a patient of House’s. House cured her problem, but in the course of her treatment, House discovered that her husband had been unfaithful and relayed this information to the patient. She later committed suicide and this man now holds House responsible (or at least partially responsible) for his wife’s death. Anyway, as House is ambling around the hospital, he notices that his leg is feeling better. He begins to wonder if this may be because the surgeon screwed up and somehow injured his peripheral nervous system.

Meanwhile, the patient’s tongue has swollen so much that it makes it difficult for him to breathe and a tracheostomy is performed. Foreman notes that the patient has been on broad spectrum antibiotics but it has made no difference in his symptoms. House tells them to go ahead and perform the lumbar puncture even though the pressure is high. The lumbar puncture results are completely normal and there is no elevated pressure. However, after the procedure is over, when Chase and Foreman flip the patient over, they discover that he is bleeding behind his left eye, and bleeding with enough pressure to enucleate the eyeball (pop it right out).

During the procedure, House has been talking to the patient’s wife, but he has somehow ripped his stitches open and started bleeding again. He collapses onto the floor.

The team’s diagnosis of the patient now includes a bleeding disorder, a sinus mass from Wegener’s Granulomatosis, or something wrong with the blood-brain barrier. The team elects to biopsy the blood-brain barrier and to start the patient on mebendazole (a anti-worm medication), and levofloxacin (brand name Levaquin), and azithromycin (brand name Zithromax) — both fairly broad spectrum antibiotics.

When House realizes that the patient does not have a wife and no one else saw the woman he was talking to, he realizes he has been hallucinating. He obtains his operative report and is puzzled to discover that the surgeon used ketamine on him instead on standard anesthesia (Ketamine causes a dissociative state The patient can still experience pain, but cannot react to it, or really react to much of anything at all; it’s as if the mind and body are separate. Ketamine is commonly used as in veterinary surgery and as a date rape drug). When he confronts Cuddy about this, she tells him that research from Germany has suggested that chronic pain can be treated by inducing a coma and she decided that House was a good candidate for this.

The blood-brain barrier biopsy is negative and the patient continues to run a high fever. The team wonders if the patient may have some sort of foreign object lodged inside his body somewhere. Chase is helping the patient to the bathroom when the patient’s scrotum becomes so full of blood it explodes. The group is now concerned that patient might have testicular cancer.

House continues to have hallucinations, this time involving and argument with Wilson and Cuddy and a fight with Wilson.

The patient does not have testicular cancer. A cystoscopy is also negative. House now considers the diagnoses of bacterial prostatitis or prostate lymphoma. All the prostate tests come back negative. Now House wants to perform another surgical biopsy on the patient, this time using some sort of advanced robot as a surgery aid.

House continues to notice hallucinations and memory lapses. He starts to suspect that everything has been a hallucination, even when he wasn’t hallucinating. He confronts his team as they are performing the surgery and purposefully botches the procedure, killing the patient. This jolts him out of his hallucination and he wakes up as he is being wheeled to the emergency room just after suffering two gunshot wounds.

Notice the green text in the above description. Those were the only parts that were real. All the black text in between was a hallucination. Because it was all a hallucination, it doesn’t matter if the medicine was bad (which much of it was — ridiculously bad) since that was likely the intention of the writers. I would say that most of the individual bits of medicine were fine on their own, but they didn’t come together to make a coherent whole.

I can’t really give the medicine or the soap opera a grade, since it was all a hallucination. I did like the mystery of the swollen tongue, but I would have liked a real answer, not just an imaginary one (and they didn’t find an imaginary one). I applaud the writers for trying something different, but I think last year’s episode Three Stories was a better example outside the box storytelling — and for some reason imaginary stories always make me feel cheated.

Two final thoughts:

1. I don’t think it was mentioned on the show itself (except in the closed captioning) but it was mentioned at various places on the web. The patient who shot House was named Moriarty — another nod to Sherlock Holmes.
2. If this was House’s hallucination and it was showing things that he didn’t want to face consciously, does that mean that he does want to undress Cameron?

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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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A clever mystery, and some interesting ethical debates made this a good episode of House. There are some major spoilers for this week’s episode of House below, so read at your own risk.

Hannah, a twenty-five year old woman, can’t sleep. She has not been able to sleep for ten days. She tells her girlfriend Max that she’s going to get a glass of wine and will be right back. When her girlfriend wakes up in the morning, Hannah’s not in bed; instead, she finds Hannah banging her head against the wall after taking an entire bottle of sleeping pills and still being unable to sleep. Hannah is brought to the hospital and assigned to House’s team.

The doctors’ first thought is infection, schizophrenia, or drugs – but they are all ruled out rather quickly (and frankly, not rather well. A single blood count doesn’t rule out a hidden or low grade infection, and there is no simple test to rule out a mental disorder). Next they wonder if it might be a visual perception issue, so they take a look at Hannah’s retinas and optic nerves. While performing the test, Foreman and Cameron notice that Hannah is sleeping, just in little 10 to thirty second intervals that she’s not even aware of.

A CT of the head shows no tumor, clots, or seizure disorders (which is impressive, as CTs don’t show seizure disorders) and the eye studies are normal. House’s plan now is to purposefully keep Hannah awake and see if they can provoke more symptoms. It His plan works too well: they quickly notice bright red rectal bleeding. With these symptoms, the concern becomes a clotting disorder or a tumor in the colon. Chase performs a colonoscopy but it is essentially normal. (Given that House wants to keep Hannah awake, I can see why they would not sedate her during the procedure, but there’s still no reason they couldn’t give her some pain medication). During the procedure, Hannah develops a copious nose bleed. She is transfused with 2 units whole blood (most physicians would have used packed red blood cells instead of whole blood, but whole blood is a theoretically better for people with clotting disorders and that might be why they chose to use it). An examination of the rectal blood reveals nasal epithelial cells, suggesting that the blood came from the nose (Generally, upper bleeding that comes through the gastrointestinal tract ends up dark maroon, black, or coffee ground in appearance due to the digestive process. Bright red blood like this patient had suggests a lower gastrointestinal tract bleed).

The differential now includes a toxin or a coagulopathy (another name for a clotting disorder). Some more history comes to light: shortly before she began having sleeping problems, Hannah had a rash diagnosed as poison ivy, and was given a dog by Max as a gift. The rash resolved on a dose of steroids, and the dog was returned because Hannah was allergic. House begins to suspect Wegener’s Granulomatosis. As Cameron is performing an upper airway biopsy to look for Wegener’s, she notices that Hannah appears to be in REM sleep, but with her eyes open while sitting up (these symptoms never seemed to be fully explained). To House, this suggests a movement disorder of some kind. Foreman thinks rabies, though Chase is concerned about allergies. While an allergy test is being administered (ever notice how many of House’s patients only develop problems during testing? My recommendation: never undergo testing by one of House’s team.), large bruising on the abdomen is seen correlating with severe internal bleeding. Foreman reports that blood tests show that Hannah is in acute liver failure, and without a transplant, she’ll be dead within hours. (In terms of the bruising and bleeding, the liver makes blood clotting proteins, so as the liver fails, it stops making these proteins any more and bleeding occurs).

Hannah’s partner Max volunteers donate part of her liver to her since they have the same blood type. House figures that the transplant will give them another thirty-six hours to figure out what’s wrong with Hannah. Thoughts include viral hepatitis, cancer (splenic or ovarian), non-Hodgkin’s Lymphoma, Wilson’s disease, or poisonous mushrooms. Multiple tests are performed to look for these conditions.

The surgeries are successful (though none of the surgical teams are wearing eye protection, a major safety infraction). All the tests come back normal. House decides that Hannah’s immunosuppressant medicine is hiding the underlying condition, so he stops them all (immunosuppressants are used after transplant to prevent rejection of the new organ). Soon Hannah has severe a severe rejection syndrome with a high fever. Her white count is normal, when it was expected to be low, so this tells the team that she has an infection of some sort. The differential includes tularemia, leptospirosis, typhoid, and relapsing fever (typhus). House suspects that the infection is somehow related to the dog, and when he realizes the dog came from the southwest, he examines the patient and quickly finds a buboe (a swollen lymph node infected with the bacteria Yersinia pestis), confirming the diagnosis of bubonic plague. Plague is transmitted by fleas, so House hypothesizes that the plague-carrying fleas which normally affect prairie dogs infested Hannah’s dog, and then jumped to Hannah. With time and strong antibiotics, she’ll be better.

The medicine was fair. No big mistakes — other than the lack of protective eyewear and the bright red blood — but a number of medium-sized errors. No story breakers this week.

The non-medical soap opera content was the highlight of the episode. This week, it all dealt with ethics. First, there was the disagreement between Foreman and Cameron over the ethics of publication. Cameron had prepared a paper on one of their patients and given it to House to review. Foreman also wrote a paper on the same patient well after Cameron did, managed to get House to review it quicker, and got it published first. This incensed Cameron and she accused Foreman of stealing her work, or at least her idea. At the end, she apologizes to Foreman, but he refuses to apologize to her, telling her that he had done nothing he needed to apologize for, and furthermore, they were not friends, only colleagues. Second, there was the ethics of love between Hannah and Max. Hannah is planning on leaving Max, but there was concern that if Max were to find out, she wouldn’t donate part of her liver to Hannah. Cameron wants to tell Max the truth, but House doesn’t want her to. In the end, it turns out that Max knew all along, and is using the guilt of the liver donation to keep Hannah in the relationship. I liked the way that there were no clear winners or right answers in the ethical debates. Nobody was right.

The mystery gets a solid B+, and the solution earns a B+ as well. This overall medical score gets a straightforward B. The non-medical content was the best part of the episode and earns an A.

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Still want more great medical reading? This week’s Grand Rounds are being held over at Fat Doctor. It’s an especially good Grand Rounds this week, and not just because I have an article in there. Make sure you take a look around Fat Doctor’s while you’re there, she’s one of the best of the more recent medical bloggers.

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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Still want more great medical reading? This week’s Grand Rounds are being held over at Anxiety, Addiction, and Depression Treatments.

Sex and marriage and sex after marriage, and maybe some extra-marital sex. Yes, it’s another episode of House. But be warned, there are spoilers below!!

Before I began I just want to make sure that everyone realizes that the part of the patient Henry was played by none other than Dr. Johnny Fever (Howard Hesseman) of WKRP in Cincinnati fame.

Anyway, it was an interesting episode that dealt more with ethics than medicine.

While talking to his daughter during a game of bridge, Henry suffers an absence seizure (basically a prolonged non-responsive staring spell). While at the hospital to evaluate this seizure, Henry tells Dr. Foreman that he also has a swollen right testicle. An MRI of the brain shows a tiny smudge — it might be a micro-abscess, or it might be nothing. The team’s initial differential diagnosis is testicular cancer, lymphoma, or a sexually treated transmitted disease (STD) such as syphilis. A needle biopsy of the testicle reveals no cancer and House decides to start the patient on antibiotics for a suspected STD.

As House is injecting him with medication, Henry starts to cough up frothy bloody sputum. This is consistent with Flash pulmonary edema, othe sudden build up of fluid in the lungs An echocardiogram reveals infected growths along his mitral valve. These growths are known as vegetations and are caused by some kind of infection in the bloodstream. The team considers psittacosis and Strep viridans as possibilities, but neither completely fits the situation. House remembers Henry mentioning attending a wine and cheese party and deduces that Henry has caught brucellosis from unpasteurized sheep cheese. This infection led to the growths on his mitral valve which caused a small embolic stroke, causing the seizure. Unfortunately, Henry suffers a massive heart attack when one of these growths breaks off and plugs an artery supplying blood to the heart. His heart suffers so much damage that he is only days to live.

House goes to the transplant committee, but they turn him down because Henry is too old. So House decides to procure a heart for Henry himself. A female school teacher has been killed in a car accident and House decides that she would make a perfect candidate. She is turned down as an official donor because of concerns about possible Hepatitis C because she had a recent fever and elevated liver enzymes. After convincing her husband to donate her heart to Henry (a painful and extremely ethically questionable situation), House elects to treat the cause of the woman’s liver problems so that her heart can be given to Henry. An MRI of her gallbladder and liver shows no gallstones, but does show a cyst in the liver. A presumptive diagnosis of amebiasis (infection by amebas) is made and she is started on high dose antiparasitic medications. Unfortunately, these medicines have a nasty effect on her heart so they have to be stopped. House considers other causes of liver disease, particularly toxins or infections. No toxins are found in her house or school room, but he becomes suspicious that she might have had an affair. She tests positive for gonorrhea and House begins treating her with ceftriaxone.

Not a moment too soon! Henry’s heart gives out completely and both patients are rushed into surgery. The transplant goes well, and Henry soon regains consciousness, daughter and ex-wife at his bedside.

Not as much medical mystery in this one as usual — basically two mini-mysteries — but as I mentioned earlier this episode was mostly about ethics and marriages (and, apparently, cows).

Just a few significant medical concerns:

• Henry is well outside the normal age range for testicular cancer (it’s primarily a disease of younger men), so that wouldn’t be as high on my list of possible diagnoses. If it were on my list, I certainly wouldn’t do a needle biopsy. There are certain cancers where needle biopsies are not performed for fear that the cancer will track — spread up the needle’s path. Testicular cancer is one of these cancers. If it is suspected and confirmed by scrotal ultrasound, then the testes is removed. No biopsy except in rare cases, and then a special surgical biopsy is performed. Never a needle biopsy.
• I realize that heart transplants do not require as careful a match between donor and recipient as other transplants, but tissue compatibility is still important. Was this even mentioned? How about blood type compatibility?
• An ultrasound or CT is a better choice in looking for gallstones than an MRI.
• I’m not a transplant surgeon, but the cavalier way the heart was transported between patients seemed a little sloppy to me.

The soap opera dealt with marriages and sex: Henry and his ex-wife, the organ donor and her husband, and Dr. Wilson and his wife…and maybe an affair.

This episode earns a B for the mystery, another B for the solution, and a B+ for the medicine overall (extra points for including Johnny Fever). The soap opera also earns a B+.

• The previous House review
• A list of all prior House reviews

This medical review of House contains a whole bunch of spoilers, so don’t say I didn’t warn you…

House finds himself accosted outside his home by Kalvin, a young man with AIDS who wants House to figure out why he is having increasing shortness of breath and fever. House tells Kalvin that he simply has one of the common infections that occur in AIDS patients and to leave him alone. When Kalvin refuses to leave, House gives him a gentle shove. The patient falls, hitting his chest against a nearby car and going into anaphylactic shock — a sudden and life-threatening allergic reaction.

Kalvin is admitted to the hospital, but House is still sure that he must have an opportunistic infection such as herpes simplex, pneumocystis, or tuberculosis. Kalvin’s tests are all negative and his T-cell count is over 200. T-cells are the infection-fighting cells that are the targeted by HIV; a high T-cell count makes it unlikely that Kalvin has an opportunistic infection.

Kalvin’s drug screen is positive for methamphetamine and ecstasy, and when Cameron confronts him about this, he develops a sudden hemoptysis — a bloody cough — and some of his blood ends up in Cameron’s eye and mouth. Realizing she has been exposed to HIV, Cameron talks to the hospital infection control officer who starts her on some anti-viral drugs. She must wait six weeks before being tested because the AIDS test looks for antibodies against HIV, not HIV itself, and these antibodies take several weeks to show up.

Cameron wonders if Kalvin’s symptoms may have been caused by contaminated drugs so she and Chase search his apartment. They don’t find any drugs, but they do discover some old photographic equipment and speculate that Kalvin may be suffering from beryllium poisoning, since that was a chemical used in old flash bulbs. A subsequent lung biopsy is negative for beryllium damage.

Kalvin becomes suddenly short of breath and his distended neck veins suggest cardiac tamponade. Tamponade occurs when the pericardium, the sack that surrounds the heart, fills with so much fluid that the heart cannot expand properly. The treatment is to drain the fluid through a long needle inserted through the chest wall into the pericardium. Most tamponades are caused by blood, but when a clear liquid is withdrawn instead of blood the team suspects Kalvin must have a cancer of the heart. A CT scan confirms a tumor mass in the heart and some smaller ones in the lung. Non-Hodgkin’s Lymphoma is the diagnosis and surgery is scheduled.

Meanwhile, Kalvin’s father has come from Montana. He and Kalvin don’t get along because they both blame Kalvin for his mother’s death. When House notices the father profusely sweating, he deduces that Kalvin does not have lymphoma, but instead a parasitic infection known as echinococcus. Kalvin and his father both caught this disease years ago while hunting foxes in Montana, and it had laid dormant until recently. In Kalvin, it masqueraded as heart and lung cancer, while in his father it masqueraded as cirrhosis — a liver disease most commonly caused by heavy drinking. It was the fever that gave it away, because cirrhosis does not cause fever. When these parasitic cysts would break open, such as when Kalvin fell against the car, the body would develop an immediate allergic reaction against the parasites causing anaphylactic shock. Two quick surgeries later and Kalvin and his father are healing, both physically and mentally.

The medicine was reasonable. House’s behaviors, such as purposefully inducing anaphylactic shock in the father, were unethical and quite likely illegal, but the science behind them was sound. I do wonder what sort of radiologist could mistake a hollow cyst for a solid tumor on a CT scan, or confuse cirrhosis with a cyst.

The highlight of the show was the soap opera. Using the notes he stole last week from Stacy’s therapist, House begins to worm his way back into her life. He tries to show her that he can do all the things her incapacitated husband can’t — such as cleaning the dishes and catching the rat terrorizing her apartment. He also continues his subtle and not-so subtle jibes at her husband, like leaving the toilet seat up so that he’d know Stacy had had a male visitor. By the end of the episode Stacy realizes that House had read her file and kicks him out of her office, and possibly her life entirely.

Meanwhile, Cameron is not coping particularly well with her HIV exposure. She puts on a brave front, but is clearly scared. She samples some of Kalvin’s drugs and seduces Chase while she’s high. A very dumb move on her part, but a monumentally stupid one on his. Not only does Chase sleep with an intoxicated co-worker, but one who may be HIV positive as well. Only time (and a few more episodes) will tell.

This episode earns a C+ for the mystery, a B+ for the solution, and another B+ for the medicine overall. The soap opera, especially the Cameron and Chase subplot, earns a solid A.

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