Polite Dissent

A so-so mystery, but an interesting patient on this week’s episode of House.

James Sidas was a brilliant physics prodigy who quit the field twelve years ago and now works as a deliveryman. While he is delivering some books one day, he develops a hand tremor and some confusion. He is admitted to House’s team at Princeton-Plainsboro Hospital, with the presenting complaints of ataxia (loss of coordination), anemia, and a mild cough. A CT scan was negative, as was a screen for toxin screen. The team’s initial differential diagnosis consists of West Nile Virus, hyperbilirubinemia (high bilirubin levels in the blood), meningitis, sickle cell anemia, or TTP (thrombotic thrombocytopenic purpura). The last one seems the most likely so House has his team check a blood smear and AdamTS13 antibodies. The blood smear shows schistocytes (fragmented red blood cells), a sign of TTP, so they decide to begin treatment. Usually, plasmapheresis is treatment of choice, but James is allergic to one of the components of the procedure, so instead they perform a splenectomy — a removal of his spleen. The surgery goes well, but while Chase is examining him afterward, James begins to show symptoms of a stroke. He is rushed to the cath lab, where the clot in the brain is removed by a special catheter, “blood flow is restored,” and there is no permanent brain damage.

The fact that James suffered a stroke after his spleen was removed suggests that he did not have TTP. The differential now consists of CNS vasculitis (inflammation of the blood vessels in the brain), DIC (disseminated intravascular coagulation), acquired pancytopenia (low white cells, red cells, and platelets), or a toxin exposure. The team reasons that the basic toxin screen only tests for a few toxins, and they need to test for more. Chase and Taub are sent to search James’s apartment, while Thirteen and Foreman run an expanded toxicity screen. The apartment shows signs of mice (and Taub suggests James may have Leptospirosis), and a hidden bottle of booze.

The team now suspects that James has liver failure, probably due to alcohol abuse. When confronted, James admits to having a shot of vodka each day after work, but denies being an alcoholic. The team proceeds with a liver biopsy, which is normal. The liver function tests show a slightly elevated albumin, but are otherwise normal. Thirteen now deduces that James has renal (kidney) failure, not liver failure. The reasons for the kidney failure could be rhabdomyolysis (muscle damage), multiple myeloma (cancer of the blood forming cells), polycystic kidney disease, or Goodpasture’s Syndrome (an autoimmune disease that affects the kidneys and lungs). Goodpasture’s seems the most likely, so James is started on unnamed “immunosuppresant drugs” and dialysis. After a Eureka! moment in a conversation with Wilson, House realizes that James has been abusing dextromethorphan (DXM, also known as the DM in “Robitussin DM”). He has been taking it to suppress his intelligence, and taking the alcohol along with it to make it work better. The chronic abuse of the drug has caused his symptoms.

With an aggressive regimen, the drug is cleared from James’s system and his natural intelligence once again emerges. Due to his brilliance, he finds it impossible to relate to his wife anymore, and she herself realizes that he is no longer “the man she married.” While Foreman is trying to explain the situation to James’s wife, he begins to complain that he can’t feel his legs. Foreman evaluates and finds that James has no feeling in his legs at all. The team half-heartedly throws out some ideas including vitamin B12 deficiency, bone marrow malignancy (i.e. cancer of the bone marrow), and lupus, but none of them fit well. House talks to James who admits he had been abusing the dextromethorphan because, while he was intelligent, he was extremely unhappy. He tried to commit suicide once by jumping off of a tall building, but he survived, just busting some ribs. It was while he was in the hospital recovering from these injuries that he was given some narcotic pain medication, and he enjoyed the way it made him feel dumb. After discharge, he sought out the dextromethorphan because it made him feel the same way. Hearing about the history of broken ribs, House realizes that in the suicide attempt, James injured his spleen, causing it to split into multiple smaller (accessory) spleens. Chase thought he removed the spleen, but he removed only one and James still has several more. His ultimate diagnosis is the same one he started with: TTP. Once the rest of the spleens are removed, his TTP will be under better control. He decides to go back on the dextromethorphan though because he’d rather be dumb and happy than intelligent and alone.

For the second week in a row, There were no major errors that jumped out at me in tonight’s episode. The team did their usual combination overlooking certain findings and overtesting/undertesting (diagnosing renal failure without checking renal labs, for instance). Once again, that’s not to say I have no complaints…As usual, minor complaints are in blue, nit-picking ones in green:

Surely before Chase operated on James, he got an abdominal CT scan to double check the anatomy, and surely he would have seen at least one extra spleen (or unexplained mass) on the scan.

If James’s problem had been due to the DXM abuse, which they said caused brain damage, then clearing the drug from his system would not have returned him to his baseline but would have left behind some permanent damage.

Liver biopsy is not performed that early in someone with liver failure. There is much you can discover with labs and CTs/ultrasounds before you go plunging a needle into the liver of someone who is low on platelets.

Did James have accessory spleens or splenosis? It sounds more like the latter to me, but this is not my area of expertise.

The “Otis Campbell” mnemonic is for seizures, not strokes.

I’m not an expert on street drugs, as shown in my review a few weeks ago, but the affects of DMX that House and James describe don’t match what I see in the literature. Unless they’re saying that James went around high and tripping all the time, which you’d think somebody would notice.

What’s the House team going to do when they encounter someone who actually knows how to close a vent?

So James has Thrombotic Thrombocytopenic Purpura without the thrombocytopenia or the purpura? (OK, they implied a low platelet count late in the episode when they mentioned pancytopenia, but that was the only mention. Purpura? Never mentioned).

Schistocytes can be seen in other conditions besides TTP. DIC, for instance.

The team just gives up when James can’t feel his legs? And this is House’s All Star team?

Whatever happened to the ADAMTS13 testing from the beginning of the show? Might it have remained unmentioned because it would have given the final solution away too early?

Convenient how it was mentioned in the beginning that James’s CT was “clear”, but it was never mentioned what the CT was of…

A few brief words about the soap opera: while I enjoyed the way Cuddy tricked House, I found most of the Cuddy/House/Lucas scenes to be excruciating. On the other hand, I appreciated the fact that both Chase and Taub (especially Chase) were shown to be more devious than previously suspected.

The medical mystery was pretty good this week, but more due to the patient than the mystery itself. I give it a B. The final solution made a certain amount of sense. Spleens can “multiply” after trauma, and there have been cases where doctors removed the largest thinking it was the only one. I give in another B. Overall, the medicine was fairly strong, and earns yet another B. The soap opera had a few good parts, but was weighed down by the House/Cuddy/Lucas scene earning a meager C.

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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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An interesting premise initially on this week’s episode of House, but a slight episode over all. It was in many ways a rehash of House vs God, only not as clever

Jack Randall is the son of a billionaire. He has been sick for over a week with worsening abdominal pain, fever, dehydration, diarrhea, and weight loss. He has seen a variety of doctors, the last who prescribed intravenous antibiotics for a presumed case of Clostridium dificile (i.e. “C. diff” — a cause of severe antibiotic-related diarrhea). When it became clear that Jack did not have C. diff and was not improving, his father brought him to Princeton-Plainboro Hospital demanding that he be seen by House. Cuddy, as always, acquiesced (she has become the Neville Chamberlain of hospital administrators. Didn’t she used to have a backbone?)

House wants the team to start over from the beginning with the history and physical. While performing the physical exam, Cameron feels a left-sided abdominal mass. This is confirmed by an x-ray and revealed to be a fecal impaction (a big hard ball of poop) revealing that Jack is severely constipated. This is a new finding, as previous x-rays were normal. The team decides that this represents toxic megacolon due to Hirschprung’s Disease (a congenital condition caused by missing nerves in one section of the intestine). They want to perform a barium enema and colon biopsy to confirm. Jack feels much better after the procedure and disimpaction and is laughing and joking. Suddenly he begins staring straight ahead and then breaks into a convulsive seizure. Foreman gives him some diazepam (Valium — among its other uses, it is good at stopping seizures). An examination of the eyes reveals swollen optic discs, a sign of intracranial hypertension. Foreman orders furosemide (Lasix – a diuretic, i.e. “water pill”) and then orders more diazepam and then some phenytoin (Dilantin — another seizure medication). He is worried that Jack’s intracranial pressure will get so high the brain will herniate, so he rushes him into surgery where Chase drills burr holes in the skull to relieve the pressure.

Jack is looking a little better after the operation, but the team notices that he is building up fluid in his brain and abdomen again. Closely examining the head CT, Foreman notices an irregularity in the way the fluid is building up and finds this suspicious for early brain cancer. House concurs. A biopsy is taken, but it is negative. Now House suspects that Jack has adenocarcinoma (cancer) of the stomach, and this is what is causing his symptoms. Jack has another bad seizure, but this time with a normal intracranial pressure. The team gives him some diazepam to stop the seizure and proceeds with the scope — but there is no sign of gastrointestinal cancer either. In the meantime, Jack has fallen into a coma. Chase suggests the cause may be infection caused by an antibiotic resistant germ, but all the cultures have been negative. Cameron suggests that Jack may be having abdominal epilepsy — in other words, he has seizures, but they show up as severe stomach pain, and this then in turn led to his other symptoms. House agrees and Jack is started on gabapentin (Neurontin, an anti-seizure drug). An EEG (brainwave) evaluation is started but reveals no seizure like activity. However, Cameron notices that Jack has developed a rash all over (and I mean all over) his body.

The differential diagnosis of Jack’s condition now includes an allergic reaction to his medications, autoimmune disease (lupus and vasculitis), or polyarteritis nodosa (another type of autoimmune disease). House considers starting Jack on Prednisone to treat the polyarteritis, but when Cameron tells him that the rash is also on the genitals, he deduces that Jack has Degos disease, an incurable terminal disease caused by inflammation and blockage of small and medium sized blood vessels. House breaks the news to Jack’s father and lets him know that Jack has less than a day left to live. Jack’s father decides to invest all his assets in extremely risky ventures, knowing he will lose everything. He has decided that by doing so well in business, he has tempted fate and his family is suffering. Therefore, if he is ruined financially, his karma will even out and Jack will improve. House mocks him, but doesn’t stop him (and apparently makes some money on it). As the financial papers are signed, Jack has a cardiac arrest and flatlines. The team is able to resuscitate him, but it’s touch and go. Talking with Wilson a short time later, House has one of his patented aha! moments and realizes that Jack does not have Degos, but has Primary Antiphospholipid Syndrome. They give him some heparin and immunoglobulin and he miraculously recovers.

The medicine had some problems this week. As usual, major complaints are in red, minor in blue, nit-picking in green:

I’m no neurosurgeon, but I don’t think you just whip out your trusty Ryobi cordless and drill a burr hole like that.
At the very least, clean the skin first — I don’t want any nasty skin bacteria pushed into brain which is what you are drilling into.
Also, a sudden drop in an increased intracranial pressure is likely to cause a brain herniation — the very thing they were trying to avoid.

This is the second episode of the season (and we’re only four episodes into the season) where the misdiagnosis of the patient was made by biopsy.

While writing the script for the classic film noir The Big Sleep, the screenwriters couldn’t figure out who murdered the chauffer. They called up Raymond Chandler, who wrote the original book, and ultimately he admitted the plot was so complex that he didn’t know either. I think this happens in House a lot when the writers get lost in their own plot. Case in point — the seizures: First they suggest the increased intracranial pressure is causing the seizures (could happen). Then they suggest electrolyte imbalances could cause the seizures (could happen) — but if the latter is the case, then what caused the increased intracranial pressure in the first place?
The team kept referring to the abdominal fluid returning or recurring. What did they do to remove it in the first place?

Furosemide is, at best, a second-line agent for treating increased intracranial pressure. If you’re going to use a diuretic, acetazolamide is the best choice. Mannitol is a good choice as well.
Cameron’s suggestion of intubation and hyperventilation was another good option.

Phenytoin 500MG is not an unreasonable dose to break a seizure in patient who weighs 60-80 pounds.
I notice Cameron only ended up giving 50MG. Was this a continuity error in the script, or willful disobedience on her part? And 50MG would be an appropriate dose for an 6-10 pound child, way too little for this kid.

If your patient with C.diff is a previously healthy kid, with no recent antibiotic use, and no record of C.diff exposure, and he requires oxygen, then your C.diff case does not have C.diff.

I defy anyone to get a good fundoscopic exam on a seizing patient in the middle of a brightly lit room. Can’t be done.

You’d think after six years, Jennifer Morrison would know how to pronounce ascites.

Labs don’t run extra blood tests without an order. Especially tests that require prep, like fasting before a cholesterol test.
Here is another example of the writer’s trying to have it both ways. If the lab ran the tests, then there would be a computer file with results, not just a single piece of paper. But if Chase ran the test himself so there was not a full computer record, then who ran the extra tests?

I thought the medical mystery was interesting this week and deserves a B. The final solution fit fairly well, though I think Degos fit better. I give it another B. The medicine overall was average, though there were some positive signs — like the team actually performing a history and physical. I give it a C+. The soap opera was okay. Nothing great, but nothing out of character either. It earns a C.

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A mystery with potential, an interesting patient (in an annoying sort of way), and good soap opera all marred by very sloppy medicine (but at least they got the defibrillation right this time).

Doug is an environmental activist who starts the episode chained to a giant bulldozer. After being forced to leave, he stumbles around and discovers that he is unable to walk or even stand up. He sees a variety of specialists, but no one can cure him, so he is transferred to Princeton Plainsboro and admitted to House’s team.

Cameron tells the team that the “tox screen” is negative, and that there are no neurological, muscular, or cardiovascular abnormalities. House has Cameron perform a vestibular caloric test (irrigating cold water in the ear canal and monitoring any resulting nystagmus — eye twitching) to test his inner ear — the test is normal. Foreman suggests that Doug may have carotid atherosclerosis (hardening and narrowing of the carotid artery, leaving Doug at risk for stroke) worsened by stress. House orders a Holter monitor and a carotid doppler, both of which are normal. While performing the procedure, Cameron discovers that Doug has a serious case of the hiccups, and has had them on and off for a week. She realizes that his hiccups are somehow tied in to his condition. She suggests that he may have organophosphate poisoning from spending time protesting at commercial agricultural warehouses (organophosphates are commonly found in commercial insecticides). Taub counters that multiple sclerosis is a more likely diagnosis. House agrees and orders a lumbar puncture to test for the disease.

Cameron is having difficulty performing the spinal tap on Doug because he keeps moving when he hiccups. She gives him some chlorpromazine (better known as Thorazine, a potent antipsychotic which can be used to treat intractable hiccups). Then Foreman notices some swelling in his neck. At first, Cameron thinks it is torticollis (a severe muscle spasm) caused by the chlorpromazine, but House points out the neck is not just stiff but swollen. It also crunches when he touches it, a sign of crepitus, or air in the subcutaneous tissue. In this case, it comes from an “air leak between the lungs.” Sarcoidosis is suggested, but so is scleroderma, and House chooses to go with the latter, starting Doug on intravenous steroids.

Doug is lying in bed, wheezing (and this wheezing is never really mentioned or even addressed), when he develops a sudden excruciating pain in his left leg. The team decides it is likely osteomyelitis (infection of the bone) after deciding it is not a tumor, aneurysm, or metabolic bone disease. He is started on intravenous antibiotics and x-rays of the left leg are obtained. Surprise, surprise — the x-ray shows a fracture of his left femur. Cameron suggests it may be due to osteogenesis imperfecta (an inherited bone disease), but House is convinced it’s cancer. He wants to start Doug on chemotherapy. Meanwhile, Chase is surgically repairing the broken leg (because he’s an orthopedic surgeon this week), and Foreman asks him to obtain a bone biopsy at the same time. The biopsy is clear, showing no cancer. Unfortunately, Doug has bleeding problems after the surgery, with bleeding from the leg wound and purpura (a skin discoloration that is commonly seen in platelet disorders, vasculitis, and coagulation disorders) showing up on the other leg. Foreman orders 2 units of FFP (Fresh Frozen Plasma).

House is still convinced Doug has cancer and wants to proceed with total body irradiation. Instead Taub suggest that they give Doug Insulin-like Growth Factor, which should make the cancer grow larger, and thus they’ll be able to find exactly where it is. It should really come as no surprise that House agrees with this dangerous and unethical plan. About this time, Doug goes into pulseless ventricular tachycardia and needs several shocks to resuscitate him (and defibrillation is the right idea in this situation). An echocardiogram is normal, as is the troponin level (a blood test that is elevated after a heart attack). House and the team are stumped, stymied, and stuck. They have no idea what is happening to Doug. House decides to implant a defibrillator while they try and deduce what is going on. Then he his has his weekly Eureka! moment talking to Wilson. Despite being fervently anti-commercial-florist, Doug broke down once and bought his wife some roses after missing their anniversary. He caught sporotrichosis (a fungal infection) from those roses, and that’s what’s caused his problems.

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

There are hundreds, if not thousands, of different kinds of cancer. Different types of cancer require different types of chemotherapy. What works for one cancer may not work for other cancers. There is no generic “chemotherapy” that treats every cancer — you need to know what type of cancer you are treating.

Similarly, total body irradiation only works on certain cancers — the blood and lymphatic cancers, primarily.

How exactly did the sporotrichosis make Doug unable to walk and start this entire situation? Are they suggesting he had a sportrichosis-related meningitis (a known, albeit rare, possibility), that didn’t have any affect on his mental status? They probably should have gone ahead with the lumbar puncture.

Cameron announces that Doug is free from cardiovascular disease, yet is quickly testing for carotid atherosclerosis — a cardiovascular disease.

A Holter monitor is a portable heart monitor that patients wear so that their heart rhythm can be recorded while they go about their normal daily business. It would be redundant in the hospital where all of House’s patients are already hooked up to heart monitors.

If Doug is bleeding out so much that he’s weak and fainting, a transfusion of blood might be a good idea in addition to the fresh frozen plasma.

Pulmonary sporotrichosis (from inhaled fungus) is a distinctly different form of the disease than cutaneous sporotrichosis (from superficial penetrating trauma), which is what House is describing.

His femur is broken, but everyone is focusing on and looking at his calf.

I’m suspicious that defibrillating ventricular tachycardia would be enough to raise the troponin level, at least a little bit. (From what I can find, the jury is still out on this: studies suggest defibrillating atrial arrhythmias doesn’t do much to the troponin, but multiple shocks in ventricular tachycardias do affect it).

The medical mystery itself was good again this week and deserves a B+. The final solution almost fit, but should not have been as significant a puzzle as House’s team made it, I give it a B-. The medicine was very sloppy, and even the smallest amount of research would have shown that “generic” chemotherapy was wrong. The medicine earns a D, and that’s probably generous. The soap opera was good, with Cuddy, Wilson, and Cameron/Chase all having their moments. I give it a B+.

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I thought this would be a good episode of House — the last couple have been pretty good — but I was mistaken. It was surprisingly boring and the medicine was hap-hazard and illogical as well.

Morgan, a thirty-five year-old nursing home nurse comes to see House in the hospital clinic complaining of frequent colds and feeling rundown. As she is asking for some tests to be run, she suffers a tonic-clonic seizure and becomes incontinent of green urine. House decides to admit her.

The team’s initial differential diagnosis consists of infection (especially Pseudomonas) or toxin exposure. House sends Taub and Kutner to search Morgan’s office where they find a bottle of methylthionium chloride (better known as “methylene blue“), a medication that can cause green urine. Taub suspects that she has Munchausen’s Syndrome and has been faking her symptoms. Rather than admit that Taub was right, House sends him off on a fool’s errand.

House now goes to see the Morgan and pretends to induce a photosensitivite seizure. He catches her faking a seizure and she realizes it. She admits that her symptoms were fake, but insists that she is really sick. She knows that she is sick because Debbie the nursing home cat came to sleep beside her. Debbie has a reputation for only sleeping next to people who are dying, so now Morgan is certain that she is at death’s door. House is unimpressed, but then she collapses outside his office, wheezing. Foreman declares that she has bronchospasm, which both House and Foreman agree cannot be faked.

The differential now consists of bronchitis, emphysema, or visceral larva migrans (infection with intestinal worms from the cat). House suspects the latter and has the team perform a bronchoscopy (looking down the lungs with a flexible fiberoptic camera) to find any worms. The test is negative, and so now the team considers acid reflux, allergic asthma, or a panic attack. House thinks the allergy idea is the most likely, so orders a methacholine challenge (a test which provokes asthma is the patient is asthmatic). The challenge test is negative, so Cuddy tells House the he has to discharge Morgan. He takes her out to the smoking area to talk about the dissolution of her marriage and death of her step-son. While there, he notices a rash and she begins to wheeze again. He has another nearby doctor diagnose her with bronchospasm then wheels her back into the hospital. He thinks she has Churg-Strauss Syndrome (a type of vasculitis more common in people with asthma) so starts her on steroids. Morgan now develops brown urine, but there is no evidence of kidney failure, liver failure, an intestinal fistula (an abnormal connection between the intestine and bladder), or blood in the urine. Foreman suggests that the urine only looks brown because it still has traces of green dye and something is making it purple, and purple + green = brown. House thinks this means she may have a Strep bovis infection from colon cancer (about 15% of colon cancers have a concurrent S. bovis infection. The exact relationship between the two is unclear). The team reminds him that her colonoscopy was normal. He orders a pill-cam (capsule endoscopy), which is also negative for cancer.

Kutner suggest that Morgan may have a skin cancer which has spread to her colon. House has him check her over for melanomas. He finds no skin cancers, but does find prominent spider veins on her back which weren’t there before. House now determines that she has Cushing’s Syndrome (Cushing’s is caused by elevated levels of cortisol in the body. This is most commonly caused by high levels of ACTH, a chemical that tells the body to make more cortisol. ACTH-secreting tumors can most commonly be found in the pituitary gland — part of the brain — or the adrenal glands near the kidneys. House is trying to determine which is the source of the ACTH.) An MRI is negative for a tumor in the adrenals or brain, and blood levels of ACTH are equivocal, so House wants Chase to sample the blood from within her brain to see if there are high levels of ACTH there. The surgery is completed, and Morgan is found to have slightly elevated levels of ACTH in her brain. Incidentally, she also suffered a cardiac arrest while in the operating room. House decides that the cause of her Cushing’s Syndrome is an ACTH secreting tumor in the pituitary. The symptoms can be controlled with medication, but surgery can correct the problem permanently. Chase tries to dissuade her from the surgery, but she decides to have it anyway.

About this time, House has his Eureka! moment of the week when the cat comes in to his office and plops down on his laptop. He realizes that Debbie likes warm places to sleep, so she lay down with patient with fever or those on a heating blanket. She chose to sleep next to Morgan because she was giving off heat due to a carcinoid tumor hiding in her appendix. House is able to stop the brain surgery in time — and presumably Morgan has her appendix and tumor removed.

A very blah episode of House. Basically a weak copy of the themes of House versus God, with much less exciting medicine. The best part was Taub’s side story, and that — like a car crash — was painful to watch but you couldn’t look away. Poor guy.

This episode did inspire me to develop Scott’s Sign: If the cardiac arrest occurs off-camera, it’s not going to be a good show.

Their really weren’t any huge medical errors this week, but there was a great deal of confusing medicine, leaps of logic, and poorly explained reasoning. Since I didn’t have any major complaints this week, I’ll just go with minor complaints in blue and nit-picking in green:

It always amuses me when House, a show about a physician which prides itself on finding the most obscure presentation of a particular disease, limits itself to only looking for the most common causes a condition knowing it must be one of them (in this case, it was Cushing’s Syndrome having to be from an ACTH-secreting tumor in either the brain or adrenals. Sure, they’re the most common, but many other more obscure causes are known and this show thrives on obscure.)

All her MRIs and CT scans and no one ordered a scan of the abdomen, which would have found the tumor.

The purple urine/Strep bovis infection is quite a stretch. Strep bovis is one of the possible culprits in PUBS (Purple Urine Bag Syndrome — a condition seen in catheterized patients), but the evidence is far from convincing.

House seemed to be saying the Cushing’s explained the brown urine (which, incidentally, I can find no information on), but the team also told him they tested for every cause of brown urine, which would presumably include Cushing’s. So did they test or not?

Labyrinthitis is only very rarely treated with antibiotics. It is not treated with the Dix-Halpike maneuver either — Benign Positional Paroxysmal Vertigo is (though, admittedly, they do have similar presentations)

The medical mystery wasn’t given a chance to be interesting, so only earns a B-. The final solution was slightly clever, but relies on too many missed opportunities earlier, so earns a B. While there was nothing hair-rendingly bad about the medicine this week, there was nothing remotely commendable either, and so it is awarded a strictly average C. The soap opera was disappointing as well. The Taub scenes were painfully good, but the rest was just goofy. I give it another B-.

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The scores for this week’s House Challenge have been posted

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Once again, you do not shock a flatline.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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This was not so much an episode of House as it was a parody of an episode of House — and a parody which seemed to be written by someone who’s heard about the show, but never actually seen it.

Apple, a young high school math teacher, is one of six patients who received transplanted organs from the same donor. In the past eight months, four of these patients have died suddenly and one is hovering near death — though all from different causes. Apple is the only one still alive. She is admitted to the hospital so the common cause of these deaths can be found, and in Apple’s case, prevented.

A donor infection that slipped by screening is suggested, but discarded. Autoimmune disease, vasculitis (specifically Henoch-Schönlein Purpura) and cancer are also suggested as possible diagnoses. House focuses on the cancer diagnosis. However, when he goes to talk with Apple, she starts to hallucinate.

This neurological symptom makes him wonder if the common cause of the deaths might be a neurological disease instead of cancer. One of the dead patients was a mixed martial artist, and House suspects that he was showing neurological symptoms (a temporal lobe seizure) right before he died. This would lend credence to his neurological-cause theory. A brain biopsy would give the best information, but brain biopsies are risky, so therefore House decides it would be best to biopsy Frank — the nearly dead patient. In the midst of trying to obtain consent from his wife, Frank suffers a respiratory arrest, then a cardiac arrest, and dies. A brain biopsy performed at autopsy is negative, so House goes back to his cancer diagnosis.

Kutner counters with some nonsensical suggestion that it might be an “intestinal perforation.” He postulates that normal intestinal bacteria got into the bloodstream though an abnormal blood vessel in the intestine. Then, once into the bloodstream, these bacteria would affect other organs, and this is what caused the problems in all the patients. It sounds at first as if he is suggesting a blood borne infection that slipped by screening, but if that’s the case, it wouldn’t explain the Apple since (as Thirteen pointed out earlier in the show), the corneal transplant was bloodless (and corneas have no blood vessels). Then there’s a suggestion this intestinal flaw is hereditary, and the team goes as far as giving the organ donor’s illegitimate four-year old daughter a colonoscopy (which is negative). Even if it is hereditary, how does it affect the transplant patients? Did their transplants somehow affect their intestines? This entire train of thought and how it was handled was — well — ludicrous is far too kind a word.

Apple now develops a rapid heart rate, difficulty breathing, but her colonoscopy(!) remains normal. Multiple sclerosis is suggested but then quickly discarded. House is back to thinking it’s cancer, so he starts her on chemotherapy. Apple starts to improve; her heart and lungs return to normal (as do her previously unmentioned amylase and lipase, two pancreatic enzymes). But now House is back to thinking it isn’t cancer because he has discovered that Frank was on methrotrexate, a drug that is used to treat some cancers. Since Frank died anyway, House decides it must not be cancer.

House tries to talk with Wilson so he can have one of his usual last minute epiphanies, but Wilson slams the door in his face. Commiserating afterward with the private eye he hired to spy on Wilson, he finally has his flash of insight. He decides that the organ donor had cancer stem cells. These spread out from the transplanted organs through the transplant patients’ bloodstreams and then differentiated into abnormal cells in various organs. Not cancer cells, per se, but non-functioning cells so that the affected organs became weakened and suddenly failed. He believes that Apple has these cells in her brain and wants to perform brain surgery on her. (House believes the cells are in her brain because even though she had a corneal transplant, she still thinks the world look ugly. House suspects that her eye are seeing correctly, but the brain is interpreting the results wrong.) Cuddy says no, but House is able –with the help of his new private eye assistant — to make it look as though Apple is sicker than she is and brain surgery is her only hope. The surgery is carried out, and sure enough, House is right. The abnormal brain tissue is removed and Apple is once again healthy and able to see well.

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

Kutner’s whole intestinal perforation theory just makes no sense (not to mention there is no actual intestinal perforation involved in it). Maybe it’s just me and I’m missing something, but the whole concept was an impossible dead end from the very beginning.

There is no “general” chemotherapy for that covers all cancers. There are many different types of cancer, and they require different types of chemotherapy. You need to know which type of cancer to select the right chemo. This is the second week in a row with this same mistake.
Speaking of chemotherapy, it shouldn’t kick in that fast, or wear off that dramatically.

You don’t shock a flatline! (In this case, Frank’s lungs had failed, and this is what led to the cardiac arrest. You won’t be able to correct the heart rhythm until you correct the underlying lung problem.)

Cancer stem cells don’t work quite the way House describes. Cancer stem cells may grow into different types of cells, but one of their hallmarks is that they form tumors, which should show up at autopsy or on a CT scan. And once again we’re back to the cornea, which is bloodless, so hematogenous spread wouldn’t get the cancer stem cells to the cornea (or from the cornea to the brain, for that matter).

Why no anesthesia for the poor kid? The “so we know when it hurts” is pure evil BS. Colonoscopies are scary and uncomfortable and the kid is 4 and her mom’s not with her, so it’s all going to hurt.

Why go straight to the tracheotomy? There was no reason not to attempt an intubation rather than go straight for the knife (and all the inherent risks) so quickly.

Methotrexate is not an “off label” arthritis drug. It is a classic and long-prescribed (and on-label) drug for autoimmune arthritides such as rheumatoid arthritis.

No eye protection during the brain surgery. And they did so well last week.

I know he didn’t get any other screen time, but since when is Chase a neurosurgeon?
And why is Taub — a plastic surgeon — doing the brain biopsy? If any of them has the necessary experience, it would be Foreman, the neurologist.

The medical mystery was very interesting and had great potential so deserves an A. The final solution was weak, and didn’t explain the main character so only gets a measly C-. The medicine, especially the “intestinal perforation”, was abysmal. I give it a D, and that may be generous. The soap opera was average, at best. There wasn’t much, and what there was focused on the new private eye character Lucas, who I alternately liked and disliked. I give the soap opera a C.

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A second episode of House in a row that felt shallow and superficial. There were two potentially great concepts in this episode: House kidnapping a soap opera star, and the hospital’s accreditation inspection, but both were essentially squandered in this disjointed episode.

House is convinced that Evan Greer, the star of his favorite soap opera, has brain cancer. House has noticed that Evan’s line readings are slower and he is pausing more which leads him to believe that Evan has bad peripheral vision from an occipital lobe brain tumor. So House does what any other self-respecting doctor would do: he kidnaps his patient by pretending to be a chauffeur.

Arriving at the hospital, House convinces Evan to let him run one test on him — a test of his visual fields to look for blind spots. House informs him that the test showed upper right quadrant blind spot and that he’ll need an MRI. Foreman picks this moment to show up and point out that House is lying and the test is normal. Frustrated, Greer leaves the room; House pauses a minute to grab something from Pyxis, then follows Greer onto the elevator. While having a conversation with Wilson, House reaches over and injects Greer with a sedative, knocking him out, so that the MRI can be performed. Surprisingly (to House at least), the MRI is normal and shows no tumor. Greer wakes up at the end of the test and is furious. He storms off to find Cuddy to complain when his right foot suddenly goes completely numb and he finds himself unable to walk. He is admitted to the hospital — officially, this time.

At this point the differential diagnosis consists of vitamin deficiency or a toxic exposure. Cameron suggests that Greer may have injured a nerve in his foot when he fell after House knocked him out and suggests an EMG. House order Kutner to pretend to perform the EMG (Electromyogram — a test that checks the conductivity of muscles and nerves), but Kutner decides to go ahead and runs the test for real. Meanwhile, House has the rest of the team watching old episodes of the soap opera for subtle diagnostic clues. Taub and Foreman think that there might be some slight neurological symptoms and suggest myxedema or demyelination. The EMG is negative, and Kutner adds atherosclerosis (hardening of the arteries) to the possible diagnoses.

House checks out Greer’s dressing room and talks to his female costar. He learns that even though Greer’s character likes his gin and tonics, Greer himself does not drink — in fact, he’s kind of a health nut. Housee also learns enough to suspect that Greer may be suffering from erectile dysfunction. House suggests that Greer has B6 toxicity and the resultant autonomic dysregulation from eating too many sunflower seeds. The team decides to test whether the impotence is physical or psychological by testing heart rate, blood pressure, and tumescence after giving Greer some pornography. He is able to have an erection, but he also develops a dangerously rapid heart rate that requires defibrillation.

The differential now includes sepsis, paraneoplastic syndrome, and Graves Disease (an autoimmune disease which leads to too much thyroid hormone), with the latter being the most likely. House wants to “nuke” Greer’s thyroid to stop the Graves, but the rest of the team actually wants to test for Graves first by performing a radioactive iodine uptake test. The test shows that his thyroid is normal, but that he is starting to develop kidney failure. Autoimmune diseases are now added to the differential. A short time later, House is talking to Greer and he finds him repeating old lines from the show and discovers that he actually believes himself to be his soap opera character. He is also running an extremely high temperature and has slipped into delirium.

The team now suspects that Greer is septic, in other words he has an overwhelming infection. They are just not sure what infection it is. Pneumococcus, Tetanus, Lyme Disease are suggested, as are fungal infections. House also mentions rat bite fever and listeria. Greer is started on broad spectrum antibiotics, but is not improving.

While helping Wilson shop for a bed, House had an epiphany. Greer is not septic, instead he a rare type of allergic reaction known as allergic vasculitis and he is allergic to the chrysanthemums in his dressing room. House wants to start him on high dose steroids, but Foreman points out that high dose steroids would kill him if her were septic. Cuddy eventually steps in and allows House to start the steroids, but runs some confirmatory allergy tests. After these tests are complete she informs House of the results — negative: Greer has no floral allergies. They return to the patient’s room ready to restart the antibiotics only to find that Greer has greatly improved; the steroids worked. Later, House realized that Greer is allergic to quinine, the chemical in the tonic water his soap opera character drinks.

I can understand why House thought Greer had a brain tumor — that makes at least a little sense (though I think a frontal lobe tumor would fit the suspected symptoms better than an occipital lobe tumor). The rest of the medicine in tonight’s episode barely made sense, and the team basically haphazardly stumbled from one unsupported diagnosis to another to another. Here’s what caught my eye tonight:

The final solution of allergic vasculitis doesn’t really fit the case well. The symptoms Greer had are rarely, if ever, seen in allergic vasculitis and he was missing the common symptoms such as the distinctive rash. I would also like to point out that the team dismissed an autoimmune cause because he had a fever, but no one batted an eye at a fever being caused by allergic vasculitis — another type of overly aggressive immune response (in truth, both autoimmune diseases and allergic vasculitis can cause fever. Just give me a little consistency in logic, please). And why was House convinced that chrysanthemums were the cause — where did that come from? On a daily basis, people are exposed to hundreds if not thousands of allergens, it could have been any of them.

B6 toxicity doesn’t match his symptoms either. It can cause nerve toxicity, but not like Greer had. Sunflower seeds do contain a large amount of B6, but he would have to eat a hell of a lot of them to develop toxicity. An ounce of sunflower seeds contains 0.23mg B6. Toxic doses start around 500mg/day, or over 2000 ounces of seeds per day.

Giving someone porn and then watching them to see if they get an erection is not the way to differentiate physical from psychological causes. That situation is enough to cause psychological impotence in anyone.

Graves disease is an autoimmune disease. An ANA is not the definitive test for autoimmune — there really isn’t any one single test. ESR (”sed rate”) is probably one of the most common, but if the team had run that, they would have figured out the vasculitis much sooner.

100mg of IV methylprednisolone (”Solu-Medrol”) is not that uncommon a dose. When high doses are needed, it’s generally an emergency (acute asthma attack, for instance) and having to wait for Cuddy to sign off on it is a delay in treatment and a lawsuit waiting to happen. And you’d think the pharmacist would learn to lock his door by now.

Ampicillin is not an appropriate drug for sepsis, particularly sepsis of an unknown cause.

Accreditation inspections involve a team of inspectors, not just one, and are not usually carried out on an annual basis unless there is a known problem.

I give the medical mystery a B+ because it was a clever idea: House deducing something is wrong just by watching an actor on television. Unfortunately, neither the final solution nor the medicine leading up to it were all that good; I give them both a C-. The soap opera was fairly average. There were a couple brief glimmers of cleverness, but nothing really memorable, so it deserves no more than a C.

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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.

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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.

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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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Tags: television medicine house kidney stone cancer autoimmune

A relative weak episode of House, medically. Foreman returned, and it was good, but the mind-reading/mimicking patient blew my suspension of disbelief.
All in all, while Mirror Mirror was one of the best Star Trek episodes, the same cannot be said of House (it’s not an awful episode , just mediocre). Anyway, spoilers below!!

A man walking down the street is mugged and starts coughing and wheezing during the attack. As he falls to his knees in respiratory distress, one of the muggers feels bad enough to call for an ambulance (but not bad enough to return his wallet). The patient, who identifies himself as Martin Harris, is admitted to House’s team for evaluation of his respiratory collapse.

The initial differential diagnosis includes asthma (not supported by the x-ray), food allergy (no skin findings), and pulmonary embolism (a blood clot in the lungs — but radiology studies were normal). Foreman suggests laryngospasm (a sudden tightening of the vocal cords) as a diagnosis. Though he is not happy about Foreman being present, he recognizes that his suggestion has merit and orders a methacholine challenge. The test is negative, though now the patient complains of numbness in his extremities and abdominal pain. The differential diagnosis now consists of dissecting aortic aneurysm, a spinal cord lesion, or multiple marantic emboli (clots from growths on the heart valves). None of them seem to fit the symptoms well, but the team is interrupted mid-discussion with the news that the patient has had a syncopal episode and collapsed.

As they are evaluating Martin, Foreman begins to suspect Munchausen’s Syndrome because the patient “borrowed” the name of one of the paramedics and his new symptoms match the exact symptoms of his neighbors. House, instead, suspects Giovanni’s Giovannini’s Mirror Syndrome, where a patient who has lost his memory mimics those he sees around him. House brings Martin into the operating room where Wilson is performing a procedure. Sure enough, Martin begins to mimic Wilson, confirming the Mirror Syndrome diagnosis.

A short time later, House and the team notice that Martin has a lace-like rash over his arms and legs (livedo reticularis), which House decides is due to cold agglutinins (antibodies that clot in the cold, blocking capillaries and blood flow) caused by infection. Blood cultures are ordered as well as an ultrasound. House sends Dr. 13 and Big Love to search for the patient’s car to find out who he really is. A solid liver lesion turns up on the ultrasound — the thought is either an abscess or a vascular hemangioma (a clump of dilated capillaries). Frat Guy performs a needle aspiration and gets a dark substance he believes is pus. He suggests that Martin has a tropical fungal infection and the patient is started on Amphotericin. The livedo reticularis returns and Martin is placed in a heated whirlpool. The Amphotericin does not help and what was felt to be pus ends up just being coagulated blood. The differential remains infection, but most likely viral or some rare bacteria. Because the patient has no memory, they can’t get a good history, but House suggests they run antibody tests on Martin’s blood and cerebrospinal fluid (CSF) because this will give them some idea what diseases he’s been exposed to in the past and a general idea of where he is from and where he’s been. His antibodies are high for histoplasmosis (common in the Ohio River Valley) and weak for coccidiomycosis (found in the San Joaquin Valley) and Chagas Disease (common in Mexico and Central and South America).

The livedo reticularis has returned despite aggressive hot water baths. House starts Martin on lipopolysaccharide (a toxin found on the cell wall of certain infectious bacteria) to induce a fever to raise his temperature and keep his blood flowing. While in the tub, Martin goes into cardiac arrest. Kumar defibrillates Martin before he is completely dry. This returns Martin to a normal heart rhythm, but also knocks Kumar out.

House orders a re-check of the blood cultures and Foreman recommends a heart biopsy. As Dr. 13 completes the heart biopsy, Kumar drops a hint to House that Martin regained some of his old memories while in the hot tub. Taking the items found in the patient’s car by Big Love and Dr. 13, House pretends to be Robert Elliot (the patient’s real name) in an attempt to jog the patient’s memory. With the help of vaporub, he succeeds and discovers that Robert/Martin is a traveling farm equipment salesman and has developed an Eperythrozoon infection from pig feces (a type of bacteria found in certain animals, including pigs and ruminants. It has been known to infection humans on occasion, though I can find no listing of serious infections).

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There was too much bad reasoning in this episode for the medicine to be very good. Everything magically clicked into place when it shouldn’t have. Sure, methacholine can be used to detect laryngospasm, but it is better for inducing asthma – also on the differential diagnosis list. Sure, infection can cause cold agglutination, but so can many, many other things including vasculitis, autoimmune diseases (Lupus!), cancer, and tuberculosis, just to name a few.

I don’t have much to say about Giovannini’s Mirror Syndrome, because I can’t find any information about it. Whether it exists or not (and I suspect it does in some manner), the way it was presented was too unbelievable. A patient would take on characteristics of those around him, but not be magically able to see deep into their psyche; they wouldn’t become omniscient. And if patients with Mirror Syndrome do mimic the strongest personality about them, why would he copy Wilson in the ER and not House, who is clearly the dominant personality. Why did he pick one name and stay with it? Wouldn’t he pick a new name every time he encountered someone dominant? Shouldn’t he be Gregory House?

The temperature of cold agglutination does not increase as the patient becomes sicker, certainly not to over 100 degrees. Anyway, giving someone a bacterial endotoxin to cause a fever is not a good idea because it causes other serious effects besides just fever.

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Funniest Line (intentional):

House (to Cuddy): I know when my Vicodin isn’t Vicodin. Do you know when your birth control pills aren’t birth control pills?

Funniest Line (unintentional):

House: He’s got Mirror Syndrome.
Foreman: Giovannini’s?
House: Do you know another Mirror Syndrome?

(um, how about Maternal Mirror Syndrome from last season?)

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The medical mystery was interesting, though the symptoms were stretching incredulity — I give it a B. The medical aspect forgot the whole idea of differential diagnosis, and chose certain causes without reason. It wasn’t wrong, per se, as incompletely thought out. The Giovanni’s Mirror Syndrome seemed a little too convenient, too. It earns a C. The solution was yet another strange zoonotic disease, but not one really considered as dangerous as the show suggested; I give it a B-. The soap opera with Foreman and House and Cuddy was good (as was Chase running a betting pool), but Martin reading everyone’s mind was too much of a stretch: B.

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Tags: television medicine house mirror syndrome livedo reticularis cold agglutinins eperythrozoon

An enoyable and quick-mving episode of House, albeit one without much medicine in it. The mystery was intriguing, the solution logical, and the soap opera progressed well. Spoilers below!

Irene is a 24 year old Ukrainian immigrant who works as a funeral home cosmetologist. At work one night, she hallucinates that she is attacked and raped by two dead men. She starts screaming and her boss rushes in to find her in a full tonic-clonic seizure on the floor. She is admitted to the hospital and House and his team take over the case.

The initial differential diagnosis includes a temporal lobe tumor (but the CT was normal), toxic chemical exposure, or STD (which was dropped and never mentioned again). House sends part of his team to investigate the funeral home and Irene’s apartment; the rest he has run an MRI, EEG, LP (lumbar puncture, i.e. spinal tap), and a generic “blood panel.” The studies are all negative. The search of Irene’s apartment reveals little besides a plethora of organic foods. The funeral home search turns up no smoking guns, but Mormon Guy is suspicious of ethanol toxicity from the embalming fluid (which was already ruled out in the ER), and Old Guy points out that a recent cadaver at the funeral home died of something that sounds suspiciously like Mad Cow Disease (which they identify as Creutzfeldt-Jakob Disease). House sends the team to disinter the body of the suspicious cadaver and run tests on its brain — tests that end up being negative.

Irene is insistent on going home and the team is ready to release her when they realize that she has been carrying on a conversation with her dead mother. Old Guy points out that this is both a hallucination (talking to someone who isn’t there) and a delusion (believing her mother is alive when she died 20 years before). Plastic Surgeon suggests carbon monoxide poisoning while Old Guy believes that she may have an inherited disease of some sort. Irene’s mother died young, at age 25, and he suspects Irene may have the same disease, whatever it may have been. House tells the team to run tests for every hereditary disease, starting with Amyloidosis and continuing through to “Zamyloidosis.”

Around this time, Dr. 13 and Amber discover that Irene is seeing not just her mother, but other dead people as well, including a wheelchair bound man with a dead dog (Stark? From the previous episode?). When House talks to Irene, she tells him she sees his grandfather Walter. After hearing this, House leaves the room in a hurry, but he confesses to Wilson that it was all a ploy to make Irene think he believed her –– House actually has no grandfather Walter. He returns to the room and — through Irene — elicits some history from her mother to narrow down the cause of her premature death. Her mother was tired, unsteady on her feet, had a tremor, and walked bent over. From these symptoms House deduces that Irene’s mother died of Parkinson’s Disease. It matches Irene’s symptoms as well, so he starts her on L-dopa and Bromocriptine.

Irene now hallucinates that Dr. 13 and Kumar are stabbing her. When Dr. 13 tells her it was a dream, Irene points out that her arm is bleeding as if she had been stabbed. These new symptoms lead the team to consider retinal vasculitis and acute intermittent porphyria. Tests for both are run while she is started on corticosteroids, the treatment for vasculitis. While undergoing a retinal test, Irene starts complaining of abdominal pain and begins to vomit blood. The next thing we know she is in surgery with Chase (and since when was he a surgeon?) who finds an enlarged spleen and a necrotic liver. Old Guy still believes she has a vascular disease of some sort, so a visceral angiogram is ordered. As the test is proceeding, Irene begins to grope Mormon Guy and has convulsions, delirium, and hypersalivation. During this discussion, House continues to poke fun at Mormon Guy who finally has enough, and punches him. One of House’s comments rings a bell with Amber and she realizes that Irene is suffering from Ergot poisoning. Ergotism is caused by Claviceps purpurea, a mold which grows on rye grain (Irene’s organic food). Its symptoms include hallucinations, seizures, constriction of blood vessels, headaches, nausea, vomiting, and dry gangrene. It is thought by some to be the underlying cause of the infamous Salem Witch Trials. After treatment, Irene’s symptoms resolve and she bids a tearful farewell to her dead (again) mother.

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The medicine, although there wasn’t much of it, was decent this episode. Not much time was spent on preliminaries and the obscure diagnoses came quickly. The writers were stretching on quite a few of the ergot-related symptoms (like the almost-stigmata, where did those come from?) and ergotism usually has a distinctly different presentation than Irene, but when has anything on House presented normally? Irene’s normal MRI, EEG, LP, and blood tests rule out most of the other causes besides a toxin of some sort — just what it ended up to be.

Also, Mad Cow is new variant Creutzfeldt-Jakob Disease, not classic CJD.

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The medical mystery was interesting, though most of the symptoms were vague and added as afterthoughts (”By the way, she has focal weakness and urinary retention, we just didn’t feel like mentioning it earlier.”) — I give it a B+. The medicine was a little more focused than recent episodes, but still seemed more show than substance — it earns a B-. The solution was logical and actually fit most of the symptoms and earns an A-. The soap opera could have used more Wilson, but otherwise was strong, especially the last Cuddy and Foreman bit. It also earns a B+.

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Tags: television medicine house hallucination parkison’s disease vasculitis porphyria ergotism

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.

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Medically, this episode wasn’t horrible, but wasn’t great either. The medicine on the show always seems to suffer when they have a “special guest star” or a “character episode”, and this was no exception.

• 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 medical mystery was started out good (abulia), but went downhill with each revelation and earns a C+. The solution was something that should have been caught in the first place, by a test they ran! This gets a C-. The medicine was haphazard and — more than usual — clearly just served to get the plot from point A to point B. It wasn’t horrible, just maddeningly average, which is not what I expect from House. It earns a meagerC. The soap opera was enjoyable, particularly the House/Wilson and Wilson/Cuddy scenes. The Foreman scenes felt like they were trying too hard. Still, the soap opera earns a B+.

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Tags: television medicine house lymphomatoid granulomatosis tia sepsis

House returns with a well done episode with some of the best medicine yet. There is a high “ick-factor” this week, so consider yourself warned when you watch the episode or when you read this week’s House medical review.

Tracy and Jeremy, a young married couple, are eating in a diner when two gunman try to rob the restaurant. Tracy is held hostage, but Jeremy manages to rescue her. After subduing the gunman, he turns around to finder her gasping for breath in anaphylactic shock.

House’s team picks up the case four days later. In addition to the swelling of her throat, Tracy is also experiencing abdominal pain. She has been on steroids and antihistamines the four days she has been in the hospital and has shown some improvement. Allergy tests were negative and a laparoscopy has already been performed and was also negative. The initial differential diagnosis is pregnancy and allergies, both of which are ruled out by testing. Her urine drug screen did show evidence of marijuana and the team speculates that she could have been exposed to Salmonella through contaminated marijuana. She is started on a fluoroquinolone (an antibiotic such as Cipro, Levaquin, or Floxin) to treat the suspected Salmonella.

She develops a rash from an allergic reaction to the antibiotic (an allergy that happened way too fast, by the way). The team now discusses allergies as a cause again, but House suspects exercise induced anaphylaxis. Tracy is placed on a treadmill. She has some abdominal pain, but the test is negative. On the other hand, her husband develops severe chest pain and abdominal pain and finds himself admitted to House’s service. His initial work-up is negative — no heart attack or aortic dissection — and the team thinks it might be psychosomatic or a panic attack.

Then the team makes the assumption that both Tracy’s and Jeremy’s conditions are related and share a common cause. It seems like quite a stretch in logic to me at this point, but it’s not my show. A search of their apartment turns up a box of condoms so Chase and House suspect the cause is Gonorrhea, but all STD tests are negative.

Tracy’s pain is worsening. She goes into acute delirium and hallucinates about Jeremy’s father. She then slips into a coma. An MRI shows some generalized swelling as well as some suspicious spots in the brain stem, but it doesn’t give enough information for a firm diagnosis. House is concerned about sarcoidosis, though he also mentions plaques (multiple scelerosis, Alzheimer’s) and tumors. He starts the pair on methotrexate to treat the presumptive sarcoidosis, but he also wants a biopsy of Tracy’s brain. This sets up an ethical dilemma. Jeremy would normally be able to make medical decisions for Tracy when she is incapacitated, but since the decision will also affect his health, there is a conflict of interest. Another guardian must be declared, but that will take time. House ignores this and sends the team to talk to Jeremy, but he refuses to let them biopsy her brain. House wants to browbeat him into agreeing, so he uses naloxone to counteract Jeremy’s pain medicine. Despite House’s ploy, he still refuses.

Jeremy is not showing any brain symptoms, but he starts showing an elevated lactic acid, which can be a sign of an ischemic bowel (intestines that are not getting enough blood supply. This can proceed to death or infection of the intestines.). The team is concerned that his bowel is dying, so they operate expecting to have to remove some bad bowel. Surprisingly, they find no dead bowel, just swelling of the intestines. House now wonders if maybe it is two separate diseases: Tracy has small cell vasculitis, while Jeremy has porphyria. He then makes one of his patented logical leaps and realizes that they both have a rare genetic disorder called Hereditary Angioedema that leads to the swelling of body tissues, particularly in times of stress. He then takes it one step farther and realizes that Tracy and Jeremy share the same father and are in fact half-siblings, this giving us our ick-factor of the episode.

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Overall, the medicine was sound. I have a few complaints, most of which I mentioned above, but no deal breakers this week. Most of the mistakes were jumping to conclusions too quickly without any real evidence, but that’s par for the course on this show. The team also went to surgery too quickly, both on Tracy’s laparoscopy (though that was the previous team), and on Jeremy’s bowel surgery. (And why didn’t they see edema during Tracy’s surgery?). I feel I should point out that the Young Guns did not perform any unrealistic testing themselves this week (the treadmill was a test I would expect them to run); since I always criticize them in this area, I will compliment them for getting it right this week. Additionally, lupus was not mentioned this week, nor was “autoimmune disease.”

Some nice soap opera this week. All three of the Young Guns, particularly Foreman, are standing up to House more. There is a clever sub-plot involving Wilson and a pediatric nurse, as well as House’s continues insistence that Cuddy is pregnant. David Morse also appears as a taciturn and disgruntled patient of House. He lodges a complaint, but House rebuffs him. In the final scene, House is speeding down the street on his motorcycle when he is pulled over by a cop — one that just happens to be Morse. House ends up arrested for possession of narcotics (this scene would have had a lot more punch if FOX hadn’t spoiled it by showing it in every preview for the past month).

I give this episode a B for the mystery, but an A for the solution because it was clever and supported by the signs and symptoms of the patients. Surprisingly, I award the medicine an A — a weak A, but an A nonetheless. The soap opera/non-medical aspect was good and deserve a B+.

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Tags: television medicine house sarcoidosis angioedema.

The season premiere of the third season of House. Medical reviews and spoilers below!!

It’s Houses first day back at work since he was shot several months before. In the meantime, he has undergone the Ketamine treatment mentioned in last year’s season finale and no longer has pain or weakness in his leg. He arrives at the office to find that he has 3 patients to chose from. He scolds Wilson for trying to give him an easy case, and then chooses to take both of the two remaining cases.

The first patient was a young woman who was standing on her head performing yoga, when she heard something snap and found herself paralyzed. An x-ray showed no evidence of a broken neck or spinal trauma.

The initial diagnoses of Chase and Foreman were multiple sclerosis or transverse myelitis, but House finds flaws with both those suggestions. He ordered an EMG (Electromyogram — a test that checks the conductivity of muscles and nerves) but the patient flinched when the needle was inserted, suggesting that she was not paralyzed and could in fact move her legs. By holding a lighter to her foot, House showed she could feel heat as well. He discharged her suspecting she was faking. However, before she could be discharged, she developed a sudden shortness of breath. The Young Guns think she has a pleural effusion (a fluid build up around the lungs which compresses them and does not allow them to expand fully), but House noticed her distended jugular veins and realizes she had a cardiac tamponade. This is a life threatening condition that occurs when fluid builds up in the pericardium, the membranous sac that surrounds the heart. If too much fluid builds up, the heart can no longer expand properly, the volume of blood being pumped drops precipitously, and the patient goes into shock. To treat the tamponade, House plunges a needle through her chest into the sac around the heart and withdraws blood, relieving her tamponade. The differential now includes tuberculosis and vasculitis. House has a different idea: he thinks the patient has the delusion that she is paralyzed and he believes that she has a vascular tumor on her spine causing this delusion as well as her other symptoms. As she is being readied for exploratory spinal surgery, he notices that she has bled into her toenail and uses this to diagnose scurvy –- a deficiency in Vitamin C, in this case brought on by a protein heavy diet that was deficient in fruits and vegetables. This deficiency leads to a weakness in collagen which leads to spontaneous bleeding — such as into the pericardial sac and nails. Scurvy can sometimes cause a pseudoparalysis as well, so score one for House.

The second patient is a man who is eight years out from brain surgery and radiation treatment for an astrocytoma (a brain tumor). The surgery has left him just a shadow of his former self. He is essentially non-communicative, and his life consists of little more than sitting around in a motorized wheelchair. At a get together in his backyard, he drives his wheelchair purposefully into the pool and nearly drowns.

House takes the case to prove he can handle difficult cases — not difficult from the medical point of view, but difficult in terms of human interaction. By the end, he has started to view it as one of his typical challenges and tries to find what other doctors have missed over the years. After a sudden revelation while running, House decides that the patient has hypothalamic dysregulation brought about by scar tissue from his brain surgery. The hypothalamus controls the thyroid gland, adrenal glands, ovaries and testes, and a malfunctioning hypothalamus can lead to a whole host of problems including difficulties with appetite, growth, and body temperature. House suspects the patient drove into the pool because it was the only means he had to cool himself off from the persistent high temperature caused by his hypothalamic dysfunction. Furthermore, House suspects the patient’s main problem is that because of the malfunctioning hypothalamus, his adrenal glands are no longer producing enough of the hormone cortisol. This is known as Addison’s Disease, and House believes it is the underlying cause of many of the patient’s problems. He wants to give the patient a shot of cortisol to see if he’ll improve, but Cuddy vetoes the idea. After some soul searching, House accepts her reasoning. Cuddy, however, decides to see it House is right and injects the patient with cortisol. Within a few minutes he miraculously improves. Cuddy wants to tell House the results, but Wilson tells her not to, noting that House was just guessing and got lucky and the next time he might kill someone with one of his guesses. Score two for House.

For the most part, the medicine was clever and appropriate this episode. I’ll make my usual comments about the Young Guns performing tests they’re not trained to do, but at least they weren’t performing the surgery this week. I have two small complaints regarding the first patient. The first is that the team was a little too quick in assigning her shortness of breath to a pleural effusion (I suspect this was to give House a chance to have a needle in his hand) — a pulmonary embolism (a clot in the lungs) would have fit the scenario better and would have been my first suspicion. My second complaint is that House was a little too cavalier about plunging a needle in the patient’s chest. That’s not an area you want to be messing around with unnecessarily. Too deep (which it looked to me like he was) and you’ll draw blood from within the heart chamber, and not the pericardial sac. A little bit off on either side and you’re in the heart tissue — never healthy for the patient. I did think it was clever that he noticed the distended jugular veins. As soon as I saw them, I started yelling “She has a cardiac tamponade” at the TV. I think that was about the time my wife decided to move down to the other end of the couch.

I have little to say about the last patient. It was just so much of a shot in the dark that happened to be right. The patient’s symptoms and tests really did not match the diagnosis much — House just had a hunch that happened to be right. Of course, that was the whole point of the scenario, so I’m fine with it. OK, I have to make one complaint: the patient got better way too quickly and was standing incredibly well for someone who hasn’t used their legs in eight years and just had tendon surgery done.

The soap opera aspects were good, though I think the writers are still trying to feel out the new status quo. Everybody seemed to be acting a little tentatively. It also seems that while House was out for the summer, everybody had time to find a backbone — except Chase, that is.

I give this episode a B+ for the mysteries with an A- for the solutions and B+ for the medicine overall — a solid episode medically. The soap opera earns only a B because it seems the characters are still finding their way in this new season.

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UPDATE: One last nit-pick. At the end of episode, House sneaks into Wilson’s office and writes himself a prescription for Vicodin, forging Wilson’s signature. I wasn’t able to get a good look at the script, but Brent was kind enough to send me a vidcap. It shows that House has written a prescription for “Vicodin ES 5-500″. Now the standard dose of Vicodin is 5MG Hydrocodone + 500MG Acetaminophen, but Vicodin ES is 7.5/750, so there is no “Vicodin ES 5-500″. As Brent points out, House of all people should know better.

Tags: television medicine house tamponade addison’s disease

This medical review of a rather blah House contains a few spoilers, so don’t say I didn’t warn you…

Adam, a 16 year-old boy, is riding an ATV when he loses control and it crashes, catching fire. He is severely burned and brought to the hospital for treatment. House’s team is consulted when the patient demonstrates tachycardia (an elevated heart rate) and low potassium despite standard burn therapy.

Due to a lack of skin on his chest, the team cannot run an electrocardiogram (also known as an EKG or ECG) to check heart rhythm, instead they have to use an old fashioned instrument, a galvanometer. The heart reading appears normal, but the patient suffers a seizure while they are administering the test.

The team is concerned that Adam may have a brain infection or multiple sclerosis. Because of his condition is unstable, they are unable to move him to radiology for a CT scan or MRI (though they seem to have no trouble moving him into a hyperbaric chamber, not to mention flipping him on his side later). Because of concern about infection, a lumbar puncture (also known as a spinal tap) cannot be performed either. The doctors ultimately perform “transcranial Doppler sonography,” in other words they are looking at the blood flow in the patient’s brain by ultrasound (though in real life this doesn’t work nearly as well as it does here). They see no evidence of infection or multiple sclerosis, but they do find a subarachnoid bleed.

Later, while Adam is in the hyperbaric chamber, the team notices that the patient is having an orgasm. There is thought that his brain might be misinterpreting sensations (i.e. feeling pain as pleasure), but there is still concern about infection or vasculitis. Cameron is concerned that the burns may be infected and this is overwhelming is brain, but somehow a single treatment with maggots proves that there is no infection.

House declares that they must perform a lumbar puncture, only they must do it in the neck where there are no burns. Of course, the neck is the cervical spine as opposed to the lumbar spine of the lower back, so this would be a cervical puncture instead of a lumbar puncture and any doctor — especially a neurologist like Foreman — would know this. Anyway, the spinal fluid shows no evidence of infection or multiple sclerosis.

House wakes Adam up, who despite being in tremendous pain (and one would suspect groggy and very confused) is able to tell House precisely that he felt no tingling in his legs before the accident, but did lose bladder control and pass out before the crash. House deduces that the patient had a seizure before the accident and decides that antidepressants must be causing Adam’s seizures.

Adam’s parents deny that their son was depressed, but House doesn’t believe them. He plans on waking up Adam again to ask about antidepressant use when he notices a cigarette burn on his wrist and nicotine stains on his fingers (so much for doing a thorough exam on admission). He realizes that Adam was using antidepressants to help him stop smoking and this caused his seizures (and other symptoms too, presumably).

Meanwhile, House’s nemesis from early in his training is giving a lecture at the hospital on his new treatment for migraine headaches. House injects himself with this doctor’s “miracle cure” and then induces a migraine in himself with nitroglycerin. He is pleased when the other doctor’ cure fails to work, but now he’s stuck with a migraine. In the end, the drug company pulls funding from this doctor after House e-mails them about the failure of the drug.

This was a very unimpressive episode of House, and frankly the worst in recent memory. It’s true that that the final solution was correct, but only to a point. Certain antidepressants do raise the risk of seizure. This is particularly true of bupropion (better known as Welbutrin or Zyban), the antidepressant prescribed to help people quit smoking. However, this has nothing to do with ordering shady drugs over the internet; it’s a known risk of a commonly prescribed drug. Also note that this is an entirely different class of antidepressants than those associated with serotonin syndrome (or “serotonin storm”, as they called it in the episode) — which is what Adam’s other symptoms were blamed on. And for the record, antidepressants are not the most common drugs used for smoking cessation; that would be nicotine, as in “nicotine replacement” (patches and gum), particularly because it can be obtained without a prescription.

Overall, the plot was cluttered and the complications contrived. Concepts were advanced that had little to do with the story (Ooo…maggots!), and stupid mistakes were made. The side plot, Dr. House getting revenge on an old rival, could have been fun but ended up being less exciting than the rest of the uninspired storyline (like a pharmaceutical company would stop studying a drug it spent millions of dollars to develop because it didn’t work a single patient? Get real!)

This episode gets a C for the mystery and another C for the solution. The medicine earns a D, because I’m feeling generous. The soap opera aspects earn a C-.

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Tags: television medicine house migraine seizure.

This episode of House, “Damned If You Do,” is a repeat of one of the early episodes from last season. My review at the time was fairly brief. I stand by it, but I thought I’d take a second look at the episode, particularly the medicine. As usual, there are some significant spoilers in the review…

House’s final clinic patient of the day is Sister Augustine, a nun complaining of a rash on her hands. He diagnoses her with contact dermatitis and recommends an over-the-counter antihistamine and a topical steroid cream. Shortly after taking the antihistamine, Sister Augustine develops severe wheezing. House gives her a shot of epinephrine; it restores her breathing, but unfortunately it knocks her into cardiac arrest. Epinephrine is the medical name for the hormone adrenalin. Sister Augustine is successfully resuscitated and admitted to the hospital.

The team considers the diagnoses of cellulitis and vasculitis, particularly Churg-Straus Syndrome. Cellulitis is a type of skin infection and vasculitis is an inflammation of the blood vessels. Labs are drawn and Sister Augustine is started on high dose steroid therapy. The tests come back normal but Sister Augustine develops olfactory hallucinations, religious visions, and seizures — signs of brain injury. She is subsequently diagnosed with herpetic encephalitis, an infection of the brain caused by the herpes virus (though the diagnosis is forgotten halfway through the show).

The team next suspects that Sister Augustine has Mixed Connective Tissue Disorder. The usual treatment for this condition is steroids, but since they will also worsen her encephalitis, the steroids cannot be used. Steroids work by dampening the immune system. This is good for connective tissue diseases when the body is under attack by its own immune system; however, slowing down the immune system is bad idea during infections. House suggests placing Sister Augustine in a hyperbaric oxygen chamber. Foreman believes the idea is dangerous and complains to Cuddy, who takes House off the case.

Cuddy takes over and, frankly, does a horrible job. She focuses only on symptoms and doesn’t even bother to look at causes. She’s dangerous too, putting the patient on a NSAID (a Non-Steroidal Anti-Inflammatory Drug — the same class of drugs as Motrin, Advil and Aleve) despite the fact that the patient is in kidney failure and liver failure — which this class of drug can cause or worsen.

After talking to the Mother Superior, House learns that Sister Augustine lived a fairly wild life before becoming a nun. He also realizes that she’s been drinking figwort tea. According to him, combining figwort tea and epinephrine will lead to a cardiac arrest (though I can find no evidence or documentation of this anywhere).

House resumes care of Sister Augustine. He is convinced that she is suffering from some kind of severe allergic reaction. She is moved to a special non-allergenic room, but she still goes into anaphylactic shock. Belatedly, House realizes that she must be allergic to something within her, and a CT scan reveals an old copper IUD. It turns out that she was allergic to copper and the recent exposure to some new copper pans kicked the allergy into overdrive.

The medicine in this episode was pretty good excepting the problems I mentioned above. I will also point out that connective tissue diseases and vasculitis cannot always be ruled in or out by lab tests alone. This is one of the few episodes — and quite possibly the only one — where it take three separate diagnoses to explain the patient’s symptoms.

This was an early episode and the soap opera elements were just coming together. The beginnings of Cameron’s infatuation with House can be seen, as well as the start of the House versus Foreman ego battles.

This episode earns a B+ for the mystery, and an A for the solution; the medicine deserves a B overall (marked down for Cuddy’s ham handedness). The soap opera also earns a B. There’s not much, but what is there is good.

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Yarr, mateys! Thar be spoilers below!

A pregnant woman has is admitted to the hospital for changes in her mental status. Dr. Chase suspects that this is pre-eclampsia (sometimes called “toxemia of pregnancy”) – but seems not to notice that she is missing the three cardinal signs: edema in the feet, high blood pressure and protein in the urine. Sure, she has some abnormal liver labs and that does happen with pre-eclampsia, so I’ll give him a pass on this one. Dr. Foreman thinks that she has some form of vasculitis. Dr. Cameron…isn’t around because she quit last week. Labs and radiology studies quickly show that both of these diagnoses are wrong.

When the patient develops trouble swallowing, House orders a CT scan of her chest which shows a prominent lung cancer. Her neurological symptoms were due to a paraneoplastic syndrome caused by this cancer. This is a very aggressive cancer and Dr. Wilson wants to start treatment as soon as possible. This would require an immediate caesarean section, but the patient refuses because she wants to carry the baby longer and give it a better chance at life. She confides to House that her first child died of Alexander’s Disease and she wants to give this second baby every chance. He reassures her that babies born at 28 weeks gestation (as opposed to the normal 40) have a high survival rate and ultimately she agrees to the c-section.

House enrolls her in an experimental study, but she is turned down abruptly once the researcher in charge is informed she is pregnant. Before any other action can be taken, the patient develops a pulmonary embolus. House presents her husband with a choice: his wife or the baby, because he states that a c-section will kill her “in her weakened condition”, but treating the pulmonary embolus will most likely kill the baby. The husband chooses his wife, but she hemorrhages during the procedure and as she dies a c-section is performed to save the baby.

A strong episode that was never going to have a happy ending. The medicine was pretty good. I’m disappointed in Dr. Chase’s call of pre-eclampsia (as I explained earlier), but Foreman’s theory made sense. The lung cancer and paraneoplastic syndrome diagnosis made for some good drama. House is right that the survival rate for a 28-week premature infant is decent, but he neglects to point out the key fact that most of these premature babies have severe problems both in the nurseyr and later on in life. The wife-or-baby choice seems a little forces and I can’t really see why they can’t try both (but then I’m not an obstetrician or a critical care physician).

Some nit-picks:
1) The doctors are once again doing their own ultrasounds (and how good is ultrasound at picking up a pulmonay embolus? There are much better options).
2) Isn’t it convenient that the MRI crash cart had terbutaline (a drug not normally — or ever! — included in a crash cart).
3) Finally, the infant, while small, was about twice the size of a 28-week premature baby (but I’ll admit it’s hard to find a premature baby actor).
4) The treatment of the patient’s flatline (asystole) was wrong.

The soap opera was excellent on both fronts. The patient and her husband had tough choices to make. More importanlty, Dr. House’s feud with Vogler came to a head this episode. Vogler called an executive committee meeting to revoke House’s tenure. He threatened to take back his 100-million-dollar “gift” if House remained on the faculty. This cowed everybody into siding with him except Dr. Wilson. Vogler then tried to revoke Wilson’s tenure – when that didn’t work he kicked him off the board so Dr. Wilson resigned from the hospital instead. The next night Vogler called another committee meeting. This time, Dr. Cutty stood up to Vogler and in the end House stayed and Vogler and his money walked. This was good drama.

This episode deserves a B+ for the mystery and an A- for the solution. The medicine this week only receives a C (due to Chase’s incorrect diagnosis and House withholding key facts from the patient). The soap opera aspects earn an A+.

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