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Case History Edit
Addie was brought to the emergency room of Princeton-Plainsboro Teaching Hospital when she started coughing up blood during karate class. Although she was exherting herself, she suffered no trauma during the class.
The case was referred to Dr. House's team. Dr. Cameron thought it was the result of infection, toxins or drugs. Addie had no fever and her white blood cell count was normal, which ruled out infection. The blood panel showed no drugs or toxins. Her bronchoscopy was clear, which appeared to rule out the lungs as the source of the blood. Since the blood came from the stomach, Dr. Cameron though it might be a gastric ulcer or other bleeding in the digestive tract.
However, the emergency room had already run a endoscopy and colonoscopy and there was no occult blood in her stool. Dr. House came in and asked if they had figured out that the blood hadn't seem to have come from anywhere. Dr. Foreman thought it might have come from her sinuses, but that would not have accounted for the quantity of blood, and there was no trauma. Finally, Dr. Chase thought the patient might have a problem with her heart - a hypodynamic heart could have forced blood into her lungs, forcing her to cough it up. It would not have shown up on the bronchoscopy because it would still be in the proper arteries. Dr. House ordered Dr. Foreman and Dr. Chase to do a stress echocardiogram and ordered Dr. Cameron to do an environmental scan and re-check the lab work.
The echocardiogram was normal. However, Dr. Chase noticed that Addie had goose-bumps even though she wasn't cold or frightened and her body temperature was normal. They reported this back to Dr. House. Dr. Foreman believed it might be a problem with the hypothalmus, but it couldn't be related to the coughing up blood. Dr. House thought it might be an infection as blood often goes to the site of an infection to deliver antibodies and white blood cells. The lungs would be a perfect environment. He ordered treatment for bacteria, fungus and aytypical infections. He also ordered a lung biopsy.
The patient seemed to recover, but they still could not explain the coughing up blood and she had developed diarrhea. Dr. House put down the diarrhea to the antibiotics, but Dr. Foreman told him the biopsy was negative for infection. Dr. House thought the biopsy was wrong, but Dr. Chase thought that the patient never had an infection. However, given that she had improved, Dr. House dismissed the objection. However, all of a sudden Addie went into respiratory distress and Dr. House had to admit his diagnosis was most likely incorrect. Dr. Chase called for a crash cart and Dr. Foreman realized she wasn't able to breath at all. Dr. Chase managed to intubate her and the team managed to stabilize her before she went into respiratory arrest.
They finally determined that Addie had developed a pleural effusion and cleared her lungs. They performed a thoracentesis which indicated a low protein count and the effusion was transudative which indicated either cirrhosis of the liver or heart failure. However, the previous tests on her heart and liver function were normal. However, there was also blood in the effusion, which led Dr. House back to believing it was an infection. However, Dr. Chase pointed out there were only traces of blood. In addition, Dr. Cameron pointed out that if the blood were significant, it could mean lung cancer, breast cancer or lymphoma. Dr. House dismissed the objections and ordered the dose of antibiotics doubled and to check her lungs. Dr. Chase pointed out that they already had checked her lungs and they were normal. However, Dr. House pointed out that they had really only checked the breathing surfaces of the lungs, not the outside. He ordered an arteriogram.
However, the arteriogram was normal, ruling out the lungs as the source of the problem. However, Dr. House still believed there was an infection. The fact she was no improving on antibiotics could mean she was missing a protein. However, her proteins had been tested and were normal. However, Dr. House pointed out that there are human proteins that can't be tested for, and Dr. Chase realized he was talking about Complement factor H deficiency - this would mean she couldn't fight off infection even with antibiotics. It was a terminal diagnosis - her body would keep getting infections until it shut down completely. Dr. House planned to deal with symptoms as they arose. This might extend her lifespan. However, Dr. Foreman pointed out there was no way to test the diagnosis. Dr. House told Dr. Cameron to take a sample of her eye cells because these would be the first to be attacked if she did have the disorder.
Addie was feeling better and didn't want to undergo the procedure, which involved having a needle pushed into her cornea. However, Dr. Chase pointed out that she felt well just before she went into respiratory distress. He reassured her the test wouldn't hurt. He performed the procedure and obtained a sample of cells from the retina.
However, the macular biopsy was negative. Dr. Chase insisted this meant Dr. House was wrong about complement protein H deficiency. Dr. Foreman thought the altered blood flow to the brain was either a clot or a tumor. Dr. Cameron pointed out that clotting and bleeding don't go together, which meant a tumor was more likely. However, Dr. House still thought there was an infection and pointed out the negative biopsy didn't prove he was wrong, although a positive biopsy would have proved he was right. Dr. Foreman wanted to do an MRI of Addie's brain, and Dr. House agreed as long as they looked for an abcess as well.
During the MRI, Addie complained that her head hurt. However, the scan of her brain was clean. However, when they took her out of the MRI, her scalp had split wide open, she was bleeding from the wound and the underlying flesh was exposed. They took a biopsy from the exposed area, but there was no pus, and Dr. Cameron thought it wasn't an infection. However, Dr. House thought that she was either getting a series of infections based in her small intestine which alternatively flared up and died down, or that she had complement protein H deficiency, which was allowing new infections to arise.
Dr. Chase thought an autoimmune disease was more likely. However, giant cell arteritis would not explain the transudative pleural effusion. However, Dr. Foreman thought it was unlikely that an invisible protein was causing three independent infections that affected her lungs, pleura and brain. Dr. Chase favored the immediate use of steroids as if she had an autoimmune problem, it would soon be too late to treat it. However, Dr. House pointed out if it was an infection, steroids would kill her immediately. However, he approved steroids as long as precautions were taken.
Dr. Chase prepared to give Addie intravenous steroids while Dr. Cameron stood by with the defibrillator in the event the steroids had the possible side effect of giving her a heart attack. Dr. Chase started the steroids and Addie suffered no ill effects to the surprise of Dr. House.
Dr. Cameron went to Dr. House's apartment when he failed to answer his phone to report that Addie's kidneys were shutting down. She was suffering from hemolytic-uremic syndrome and was put on dialysis. Her red blood cells showed shistocytes. Dr. House pointed out that hemolytic uretic syndrome is usually caused by infection or protein deficiency. However, Dr. Chase asked if it were either an infection or protein deficiency why she didn't suffer the cardiac arrest Dr. House predicted when they put her on steroids. Dr. Cameron pointed out if Dr. House was right, there was nothing to be done. A further infection would hit her hard because the steroids would have suppressed her immune system. Liver failure and cardiac arrest were likely. However, the symptoms seemed to indicate the complement protein H deficiency diagnosis was correct, even if it was terminal. However, Dr. House didn't want to inform the patient until she had a stroke or heart attack to confirm the issue.
As predicted, Addie suffered a heart attack. Dr. Foreman managed to revive her, but she was still barely alive. He reported that the diagnosis had been confirmed and Dr. House went to deliver the news. He told Addie she was dying and that her infections would get worse. The prognosis was that she would live two more days. When he went to tell her the diagnosis, she said it didn't matter and when he started, she said she didn't want to hear what it was. Dr. House went to leave, then came back to ask her why she didn't want to know and why she wasn't curious. Her parents asked him to leave the room. However, he suddenly realized something and left the room.
He went to talk to Dr. Wilson about the patient's lack of curiosity, and Dr. Wilson said her reaction was probably because she was miserable about being told she was going to die. However, Dr. House noted that her emotional reaction didn't change when she received the news. He suddenly realized that the patient was suffering from clinical depression and had probably attempted suicide. He went back to Addie's room and told her parents to leave the room and that Addie was going to live. He confronted her as he realized she had probably tried to kill herself by swallowing caustic kitchen cleanser (like drain cleaner) in a capsule.
The capsule would prevent burning of the mouth and throat during the attempt. However, in this case, the capsule didn't dissolve until it reached the intestine. Although the body healed the damage, the scar tissue bridged a vein and artery. Normally, the veins in the intestine flush away bacteria to be disposed of in the liver, but the scar allowed the bacteria access to the artery and from there they caused the serial infections that the team thought were impossible. She just needed surgery to fix the problem, but she would also need psychotherapy for the depression. She admitted to the suicide attempt. She said she didn't know why she did it, but she had never been happy. She asked Dr. House not to tell her parents, as they would blame themselves. He said he was bound by medical ethics not to disclose it if she promissed not to attempt suicide again. She promised, but Dr. House didn't believe her.
The surgery went well and Addie was on the road to recovery. Dr. House spoke to the parents and disclosed that Addie had tried to commit suicide and that he shouldn't have told them that. Her father promised to get her into therapy, but Dr. House told them to make sure she was put on medication as well. However, he declined to help them further.