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Medical History Edit
The patient was diagnosed with autism and since that time his parents have left their job in order to care for him. He is very low-functioning, unable to speak or communicate and is usually unresponsive to external stimuli.
Case History Edit
One day while having lunch, Adam started coughing and then started screaming while he held his chest at about neck level. After taking Adam to three different doctors who put down the screaming to his autism, his parents were still concerned and brought him to Princeton-Plainsboro Teaching Hospital. Dr. House became interested in the cause because Adam's autism made any underlying illness more difficult to diagnose because the patient could not communicate with them. He described the case to his team as unexplained screaming. However, when Dr. Foreman realized that Adam's autism was very serious, he agreed the screaming could be put down to the autism. However, Dr. House thought it was a symptom - dysesthesia. He was further convinced by the fact that the parents have been caring for the child ever since he was diagnosed with autism and this was the first time they ever brought him to a hospital. Dr. Chase noticed that the patient was clutching his chest and his blood pressure was elevated, with together with the screaming could indicate chest pain. He ordered a stool sample for parasites, blood cultures to rule out infection and an ANA test in case it was lupus. Dr. Chase also suggested it was an allergy, so Dr. House ordered an environmental scan and a lung ventilation scan.
However, when Dr. Foreman was ready for the lung ventilation scan, Adam was playing a hand held video game. Adam's father suggested that they wait a few minutes for him to finish a level, but Dr. Foreman tried to take the game away from him, Adam became extremely upset, so much so that Dr. Foreman backed off and his mother had to comfort him. When they did take him to the scanner, he was even more upset and they had to restrain him.
Dr. Chase and Dr. Cameron did the environmental scan. They noted that Adam's entire day was scheduled.
Dr. Foreman completed the ventilation scan, which was normal. Dr. House convened a differential in the clinic because he was avoiding his office. All the other tests were normal as well. There was nothing in his environment that hadn't been ruled out by a tox screen. Dr. Foreman thought there was nothing wrong with Adam. However, they had not been able to get a stool sample because Adam was constipated. Dr. House ordered them to get a sample directly from his rectum.
Dr. Foreman went to get the sample and saw Adam playing his video game. His mother thought he had improved. However, Adam immediately started choking and spitting up. He had developed a pleural effusion. Dr. House moved the differential to Dr. Wilson's office. Dr. House thought it was a result of the attempt to get the stool sample, but Dr. Foreman advised him he took the sample after Adam spit up. Dr. Chase noted the pleural effusion ruled out any heart failure. However, Dr. House ordered an echocardiogram and broad-spectrum antibiotics.
However, Adam was highly agitated when Dr. Foreman tried to use the ultrasound probe on him. His parents managed to hold him down while Dr. Foreman did the echo. The echo suggested a heart conduction abnormality, which Dr. Foreman confirmed with an EKG. Dr. House convened a new differential in empty office space. However, a conduction abnormality didn't explain the effusion. Dr. Chase thought there had to be something causing problems with both the heart and lungs, an infection, parasite or cancer. However, there were no organisms in the effusion, ruling out infection. The stool stample was negative for parasites. Dr. House ordered a lung biopsy to check for cancer. Dr. Foreman objected due to the difficulty of dealing with the patient, but Dr. House insisted.
Dr. Foreman went to Dr. Wilson for a consult, telling him about the pleural effusion and conduction abnormality. Dr. Wilson asked if there were proteins in the pleural fluid, and Dr. Foreman confirmed that. When Dr. Foreman said they were planning to do a lung biopsy, Dr. Wilson thought it was a bad idea because they are almost always negative. He suggested biopsying a lymph node under the arm, which was more likely to be positive if Adam did have cancer. He asked if Dr. Wilson would mind doing the biopsy himself just to be safe, and Dr. Wilson agreed to do so.
After dealing with Adam, Dr. Wilson realized why Dr. Foreman was so eager to avoid the biopsy himself. Adam refused to have an anesthetic mask placed over his mouth and nose. Dr. House came in and showed Adam he would breathe the gases himself and then offered the mask to Adam. He calmed down and allowed himself to be anesthetized. His parents were astounded that Adam trusted Dr. House, but Dr. House put it down to imitative behavior that is common in all higher primates. However, Dr. House was obviously suffering side effects from the anesthesia - he ran into things, nearly collapsed, and complimented Dr. Cameron. Dr. Wilson examined the biopsy results and ruled out cancer, but found liver cells instead of lymph cells.
Dr. House moved the differential back into Dr. Wilson's office and asked for a new diagnosis to explain the liver cells. Dr. Foreman said it was impossible - the lymphatic system circulates fluids, not organ cells. Dr. Cameron pointed out cancer cells often make their way into the lymphatic system, but Dr. Chase pointed out these weren't cancer cells. The difference between the two was that cancer cells, being damaged, can make their way into blood vessels and travel everywhere in the body. However, the tests on Adam's liver were normal - there was no damage. However, Dr. House pointed out damaged liver cells could travel just like cancer cells, and liver damage would also explain the pleural effusion and the conductive abnormality. However, Dr. Cameron reiterated the liver was fine. Adam had been vaccinated for the most contagious types of hepatitis and type C was only transmitted by sex and needles. However, alcoholism could damage the liver, but the scans of his liver showed no cirrhosis. Dr. Chase noted the parents were devoted to Adam and wouldn't be poisoning him, but Dr. House pointed out that Adam was not the type of child parents are happy with. He ordered a biopsy to confirm the cirrhosis.
Dr. House asked Dr. Foreman what else was in the stool sample. Although it was negative for infection, it did have traces of iron, zinc and calcium carbonate. As calcium carbonate is often used as an anti-diarrhea medicine and Adam had hard stool, Dr. House wondered if it was diagnostically significant. However, they soon found out Adam was being rushed to the cardiac intensive care unit. Dr. Chase noted Adam was in defibrilation and charged the defibrillator paddles. After several attempts, they managed to restart his heart and got him stable. Dr. Cameron reported that Adam had suffered a first degree atrial ventricular block. They reviewed his symptoms. If his liver was damaged, the pleural effusion would compromise his lung function. However, the biopsy ruled out cirrhosis. Dr. House turned his mind back to the calcium carbonate. In addition to being used to prevent diarrhea, it is the main component of chalk. He summarised that Adam ate chalk and would eat other things as well, a symptom called pica. He thought Adam had eaten something toxic that weren't checked for in a regular tox screen. He ordered Dr. Foreman to re-do the environmental scan and to bag samples of anything Adam could put in his mouth. Dr. Foreman did a thorough search and found jimson weed, which contains atropine, which causes hallucinations and can also cause pleural effusions and arythmia. However, it would not explain the screaming. The treatment for jimson weed poisoning what physostigmine, but it was contraindicated for patients with heart problems. They had to confirm the diagnosis, but that would take at least three days for the lab tests and the patient would not survive that long. They went through the schedule to try to show he had the opportunity to eat the jimson weed. House went to Adam and asked the parents if he ever ate anything inappropriate. He took Adam's picture book and put the pictures of his environment on it along with a picture of jimson weed and asked him what he ate. Adam pointed to the sandbox. At that point, Dr. House notice Adam's eyeball rolled back into his head.
Dr. House converted another differential in the chapel. The eyeball indicated ocular paralysis consistent with jimson weed poisoning. However, Dr. House said the eyeball didn't merely stop working, it reversed itself in the eye socket. Dr. Cameron suggested multiple sclerosis, and Dr. Chase suggested a stroke, but Dr. House dismissed both ideas. Dr. Foreman suggested a microtumor, small enough for the scans to miss it. It would explain all his symptoms, but would require that there be three different tumors that were all missed. However, they now knew where to look and Dr. Foreman planned to do a CT scan of Adam's head and, if necessary, remove Adam's eye.
Suddenly, Dr. House realized something and canceled the surgery to remove Adam's eye. He had noticed Adam kept drawing wiggly lines. He took a look into Adam's vitreous humor and found a parasite - racoon roundworms. These are not excreted by a human host and thus did not show up in his feces. Raccoons commonly use sandboxes as toilets and Adam probably ate some ringworms in the feces mixed with the sand. Because the worms are localized, they would not show up in most random sand samples. Once he ingested them, they spread to his lungs, causing the pleural effusion, his liver, causing the damage, and his eye, damaging the muscles that control it. He needed laser photo-coagulation to fix the eye and benzimidazole to kill the worms. His prognosis was excellent and he was expected to make a full recovery.
Adam was soon well enough to be discharged. Dr. House noted that the parents seemed to be less than delighted to see Adam had recovered. They thanked Dr. House on the way out.
However, as Adam left, he gave his video game to Dr. House and made eye contact with him - the first time he had made eye contact with anyone.
His parents were delighted he was able to make a connection with another person.