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Case History Edit
Dr. Cameron was taking a medical history, but was having difficulty because Alice's parents, who were separated, often started arguments during the process. Alice had no previous history of abdominal pain. The mother noted that Alice's great-aunt had suffered from Crohn's disease and admonished the father for forgetting that during the initial history. However, Alice had no other symptoms of Crohn's. She was not on any medication.
Dr. Cameron discussed the case with the rest of Dr. House's team. Dr. Chase noted that the pancreatitis without a previous history pointed to trauma or a structural defect. However, apart from a shadow on her x-ray, nothing looked unusual. Dr. House arrived and after glancing at the file thought it was gallstones because her bile duct was dilated. He also guessed the patient had pancreatitis without being told about it. He ordered confirmation with ultrasound and then the removal of her gall bladder so they could study the gallstones.
The ultrasound confirmed the gallstones, but the mother was opposed to the cholecystectomy. Dr. House confronted the mother about her decision, but the father was supportive. The mother didn't feel gallstones were a big issue.
Dr. House brought a legal proceeding to have the father appointed as Alice's medical proxy. Dr. House insisted that there was no time for a second opinion. Dr. Cuddy told the judge that although Dr. House may be a jerk, his medical opinion was to be respected. The judge granted the order and the surgery proceeded.
Dr. Cameron thought that Alice must have had an allergy to something used during the procedure. The gallstones were a mixture of calcium and bilirubin, which are not indicative of any particular disease. However, Alice also had a slight fever and mild anemia, which together with the gallstones indicates a bacterial infection. However, Dr. Foreman pointed out this wouldn't cause the rash. However, Dr. House suggested the surgery could have allowed the infection to spread under her skin, causing the rash. However, Dr. Cameron argued an allergic reaction was far more likely and that the fever was merely a by-product of the pancreatitis. Dr. House ordered an allergy scratch test, but expected it to be negative, so he followed that with an order for broad-spectrum antibiotics.
Dr. Foreman performed the scratch test, and Alice complained that her stomach hurt. Astoundingly, all the tests came back positive. Dr. House didn't feel the allergy tests could be right and surmised that the bacteria had now spread to her back through the scratches. He then gave the patient a peanut butter sandwich, to which she suffered no reaction. Dr. House argued that her lack of an anaphylactic reaction indicated that the allergy tests were probably wrong. Dr. Chase noted if she were having allergy problems, antibiotics would most likely result in anaphylactic shock. Dr. House ordered antibiotics anyway, but Dr. Foreman also objected. Finally, the father came to the decision that he did not want Alice to be given antibiotics because of the risk, although the mother was in favor of it.
Dr. House asked for another hearing, but got the same judge. The mother had found out from her pediatrician that Dr. House was one of the best doctors in the country and the pediatrician had no idea what was wrong with Alice. However, the father thought that the mother was merely going along with Dr. House just to disagree with him. The judge determined that neither parent could be objective and appointed Dr. Cuddy to be Alice's medical proxy.
However, Dr. Cuddy would not agree to broad-spectrum antibiotics and instead approved a narrowly targeted antibiotic, metronidazole. Alice did not suffer any adverse reaction. However, her parents started arguing in front of her, causing an anxiety attack. Dr. Cuddy told them to leave Alice's room. Alice started to improve.
However, a few hours later, her mother went to her room and didn't see her. She went to see the doctors to see if she was having a procedure, but they realized her father may have removed her from the hospital. However, as they were setting up a search, he rushed into the lobby saying that Alice's body had gone stiff and that she was unable to move.
Dr. Foreman noted that muscle rigidity almost always has a neurological cause. Dr. Cameron suggests infantile neuroaxonal dystrophy, but Dr. Chase noted that her liver was failing, which ruled that out. Dr. House admonished Dr. Cuddy for not using a broad-spectrum antibiotic. Dr. Chase suggested Wilson's disease, but there were no copper colored rings in her cornea and no changes in her mental state.
However, Dr. House realized Alice's symptoms fit Reye's syndrome and he went to talk to the parents to see if either of them had given her aspirin. Both denied it, but the mother admitted that she had left Alice with a baby sitter. Dr. House suggested charcoal hemoprofusion to Dr. Cuddy. She wanted to confirm with the baby sitter, but Dr. House told her the baby sitter would probably lie about it anyway.
Dr. Cuddy agreed to the chemoprofusion and explained the procedure to Alice. She assured Alice that although the process would be lengthy, it would be painless.
After a while, however, the procedure caused a clot. They arranged surgery to remove it. During the surgery, Alice's body temperature started to rise rapidly. She called for ice packs, but there weren't any in the operating room. Dr. Cuddy disconnected her from the surgical equipment and rushed her out of the room. Dr. Cameron thought that the heparin they gave her could have caused thrombocytopenia. However, Dr. Chase noted that the charcoal they had been giving her would have absorbed some of the heparin, making her anemic and that perhaps she had a primary blood disorder. Dr. House still thought it was an infection. Dr. Cuddy rushed Alice to a shower to cool her off. She noted that the rash had spread to her left arm. Dr. House confronted her about not giving her stronger antibiotics because obviously the metronitizol hadn't been enough.
Dr. House noted that the new rash didn't appear anywhere where they had treated her. The patient had a fever of 103F and was in and out of consciousness, but it was now obvious that whatever was causing her symptoms was not the result of the treatments they were giving her. However, it was also clear that it was too late to use broad-spectrum antibiotics. They had to identify the infection and use a narrow-spectrum antibiotic targeted to it. He went back to Reye's syndrome and realized varicella was often associated with it. However, varicella also causes itching. Dr. Chase noted rickettsialpox causes rash, fever and muscle pain, but not muscle paralysis. Dr. Cameron suggested Rocky Mountain Spotted Fever, which does cause rash, fever, anemia and paralysis. Dr. House ordered chloramphenicol for Spotted Fever.
The rash spread to Alice's left leg and there was no improvement on chloromphenicol. Dr. House figured it had to be necrotizing fasciitis. They would have to amputate the arm and leg. Dr. Cameron wanted to confirm, but Dr. House noted it was moving too quickly and there was no time to do a blood culture or see if it would spread. However, Dr. House confronted his team about the urgency of the matter and went to get consent from the parents and schedule surgery. The parents and Dr. Cuddy agreed and the patient was prepped for surgery.
However, the rest of the team kept reviewing the case. Dr. Cameron noted she developed symptoms wherever they were treating her, such as her stomach and back. While Dr. Chase was playing with a laser pointer, he realized something - some diseases cause sensitivity to light. He ran to Dr. House to tell him that Alice most likely had erythropoetic protoporphyria. Dr. House was unconvinced, but Dr. Chase noted that Alice always got worse when she was under surgical lights and it presented for the first time when she was outside at the amusement park. Her liver failure was the result of the light damaging her red blood cells, releasing protoporphyrin which built up in her liver. Dr. House was convinced and canceled the surgery just in time.
Her parents were told that although she had always had the problem, the protoporphyrins don't start causing symptoms until patients reach Alice's age. Light causes damage to blood cells and the liver tries to filter out the damaged cells but becomes damaged in the process. One of the other by-products is gallstones. The disease can be managed with doses of beta-carotene, the use of special light bulbs and filters on windows to keep out the sun. They were told they both had to be genetic carriers of the disease in order to have a child with the disease.