Case History Edit
Abby was rushed to Princeton-Plainsboro Teaching Hospital when her boyfriend noticed that pink foam was oozing out of her mouth and she had stopped breathing while they were at a planetarium show together.
X-rays showed that Abby had pulmonary edema and the fluid had nearly suffocated her. That meant the problem was either in her heart or lungs. The tox screen was negative for everything except alcohol, but her blood alcohol count was only 0.05, meaning she had drunk no more than the equivalent of two drinks. There was no sign of trauma. Dr. Foreman suggested binge drinking - that might have raised her blood pressure, setting off a hypertensive crisis which lead to heart failure. Dr. Chase realized that Dr. House would want an MRI with C13 pyruvate to check her cardiac lactic acid levels.
Dr. Chase and Dr. Taub performed the MRI. They spotted something on the mitral valve. Dr. Hadley thought it might be a fungus, but the emergency room had already done blood cultures and found no fungus or parasite. Dr. Taub thought it might be a fastidious enteric bacteria. However, Dr. Foreman thought that Abby should be showing intestinal symptoms if that were the case. Dr. Taub noted there were other ways she could contract such a bacteria, but Dr. Chase ruled out the other most common entry paths - intravenous drug use, tattoos and scars. Dr. Hadley wanted to do a transesophageal echocardiogram, but Dr. Taub noted that if the valve was about to dehis, the echo could trigger a heart attack. Dr. House ordered them to do the echocardiogram with a crash cart nearby.
Dr. Hadley and Dr. Taub prepared Abby for the procedure. However, the valves looked fine - no vegetations or myxomatous changes. As Abby was showing awareness, Dr. Hadley asked for more sedative. However, Abby had a sudden violent reaction - they realized she had a rupturing aortic dissection. Dr. Hadley removed the endoscope and they rushed Abby to surgery. On the way, they couldn’t figure out what precipitated the dissection - her heart rate was controlled and her blood pressure was normal.
Dr. Taub managed to repair the damage, and the loss of blood from the rupture was minimal. Dr. Hadley grabbed the defibrillator to start her heart, but got no response. Dr. Taub pushed 5cc of adrenaline before another try, but Dr. Hadley instead started manual cardiac massage. When that didn’t work, Dr. Taub wanted to try the defibrillator again, but Dr. Hadley managed to restore normal sinus rhythm before he used the paddles.
Abby was put on a ventilator. Dr. Taub reported that neither the echocardiogram nor the examination during surgery showed any vegetations on the valves and no structural abnormalities. Dr. Foreman realized the dissection meant they were wrong about alcohol causing the hypertensive crisis. Dr. Taub thought the dissection was probably a genetic defect. Marfan syndrome had been ruled out. Dr. Hadley suggested a severe allergy. A strong immune system reaction would explain the pulmonary edema, and inflammation could weaken the aorta. However, Dr. Chase noted Abby was getting worse - allergy patients get better in hospitals because they are away from the source of the allergy. Dr. Hadley countered that if the source of the allergy was inside her, she would continue to get worse.
Dr. Hadley went to Abby’s boyfriend Nick and asked for a semen sample. However, Nick insisted he always used a condom. However, they pressed and he admitted that he didn’t use a condom for all sex acts, and that the last time they had unprotected sex was the night before Abby collapsed.
They did a scratch test with Nick’s semen. They explained to Abby’s mother that, although it is uncommon, semen can cause a severe systemic response. Abby started complaining of pain in her stomach. Dr. Chase noted blood in her urine, indicating kidney failure.
Abby didn’t have a reaction to the scratch test. Dr. Taub thought it might be a neuropathy, such as lightning pains from syphilis. However, syphilis had been ruled out as her VDRL and enzyme immunoassays were negative. Dr. Hadley suggested a blood clot, but Abby was on blood thinners for the aortic surgery. Dr. Taub suggested interstitial nephritis, but it would cause edema or the dissection. Dr. Chase noted cancer would explain both, but had no suggestion as to where it might be. Dr. Foreman suggested a full body scan and, although Dr. House prefers not to do them, agreed.
Dr. Foreman and Dr. Taub did the scan. During the lengthy period of the scan, Abby started hallucinating that she was being sucked into a black hole.
Dr. Hadley insisted the hallucination meant Abby had a problem with her brain, but Dr. Chase noted that brain problems don’t affect the aorta. Dr. Foreman noted that a vascular problem could explain both - the inflammation could have caused an aneurysm that caused the hallucinations. However, there was no sign that the aorta itself was inflamed. Dr. House wanted to know what the hallucination was about, but Dr. Hadley pointed out that the content of a hallucination is medically irrelevant. However, Dr. House countered that the brain often does things automatically even when it can’t consciously perceive something - for example, if you have a gastric ulcer, the brain will increase production of stomach mucous. Dr. House thought that Abby’s brain was trying to tell her something, but Dr. Taub revealed that all the patient hallucinated about was being sucked into a black hole. Dr. House realized they needed more information. He suggested running a pattern recognition program. Dr. Foreman wanted to do an MRA with contrast to look for an aneurysm. Dr. House agreed with the MRA, but wanted to go ahead with the pattern recognition if the MRA was clean.
Abby complained to Nick that she could barely breathe and she was aching all over. Nick made a marriage proposal, but he suddenly realized Abby was having trouble understanding him. Abby started hallucinating again and had a seizure. Dr. Foreman ordered 4mg of lorazepam. Abby’s systolic blood pressure rose to over 200mgHg and she bit her tongue.
Abby’s seizure lasted more than a minute, but her echo EEG showed no synchronous discharges. The MRA showed no aneurysm and no vascular malformations. Dr. House wanted to move on to the pattern recognition program, but Dr. Hadley suggested the patient’s out of body experiences were caused by sensory overload in the temporal-parietal junction. However, that area of the brain was clean on the MRI, MRA and whole body scan. Dr. House wanted to know about the hallucination. Dr. Taub finally told him that she saw a younger version of herself who started talking to her. Dr. Foreman still thought that cognitive pattern recognition was still 50 years away from being a useful diagnostic tool. Dr. Chase thought that even if they could manage the initial mapping, another seizure could set off a stroke. However, Dr. House thought the pattern recognition was the only thing they had left to try. He sent Dr. Foreman off to get the mother’s consent, and sent the rest of the team to prepare the cognitive science lab.
Dr. Foreman explained the procedure to the patient. They would play videos to her for six hours while they monitored her brain activity. At that point, they would put her under sedation and monitor her unconscious brain. This would provide an image of what was going on in her brain. He told them they had no other diagnostic test to try.
They did the procedure mapping out Abby’s responses to the video. She completed it without incident. They then asked her to think of something, and a person playing baseball appeared on the screen. They realized that it had worked. Dr. Foreman was still sceptical that it would work on her subconscious brain.
They sedated Abby, but very little appeared on the screen at all, just some stars that made them think she was thinking about her future studying physics at university. Next, a male figure appeared. However, Abby’s father died when she was 8 in a plane crash. Nothing she thought about seemed to help.
Dr. Chase wanted to start over again. Dr. Hadley suggested a liver issue, but the liver could not have affected the aorta. Dr. Chase suggested polycystic disease as well to explain the dissection. However, Dr. House thought the combination of two rare conditions was unlikely. Suddenly, Dr. Foreman thought that her calcified pineal gland (a normal condition for someone her age) could be hiding a tumor. Dr. House realized it was a possibility and ordered an MRI with 3 tesla .
Dr. House reviewed the playback of the images from the brain scan. Dr. Foreman reported they didn’t find a tumor, but they did find elevated levels of lactate dehydrogenase isoenzymes which again pointed to an allergic reaction. However, there was no allergy to cause them. Dr. Foreman was about to suggest a parasite from the Middle East could cause the problem when Dr. House pointed out that not only had the patient never been there, but that all the blood and urine samples had been clear for parasites. Dr. House was at a loss for ideas.
Abby continued to get worse. Dr. House reviewed all the scans. However, when he talked to Dr. Taub about having affairs with younger women, he asked if Nick’s father traveled on business. He had realized that he was the one in Abby’s visions. He went to Nick’s father and asked him if he travelled, and he said he went all over France, Italy and the Mediterranean. Dr. House told the father that although Abby could have fought off a parasitic infection, it could not dispose of the shells of the parasites. In some cases, those set off a severe allergic reaction - cerebellar schistosomiasis delayed hypersensitivity allergy. It’s treatable, but the treatment is risky. He then asked the father if he ever had sex with Abby. He got angry, but Dr. House cut him off by telling him that unless he could confirm she had exposure to the parasite, he couldn’t treat for it and that if he continued to lie, she would most likely die. At that moment, Nick and Abby’s mother came along. The father finally admitted that he had sex with Abby once when she broke up with Nick and he was drunk. Dr. House started the treatment.
Abby was treated and slowly improved. Nick and his father started to talk it out, and eventually went back to talk to Abby and they made up.