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The patient suffers from early onset familial Alzheimer’s disease and has the typical short term memory loss and mood swings typical of the condition. He had been showing symptoms for about four years. He is, however, aware enough to know he has the disease. He had recently recovered from a sore throat.
The patient was at the hospital for routine tests prior to his entry into a clinical trial when he started vomiting up blood. The emergency room ran tests and showed his ammonia levels were high, but the patient stopped vomiting once he was put on anti-emetics. He was admitted and the case was referred to Dr. House as Andres’ participation in the clinical trial was critical. Dr. Foreman presented the case to Dr. House’s team. Dr. Chase asked about the possibility of hyperalimentation, but the patient was not on intravenous feeding. Dr. Park thought it might be a transient nitrogen load from a bleed in the digestive tract, but Dr. Chase pointed out that this would not cause persistent vomiting. However, Dr. House noted that if Dr. Park were right, the anti-emetics would hide the symptom. He ordered the patient taken off anti-emetics. Dr. Foreman pointed out this risked aspiration, but agreed with Dr. House’s plan. Dr. House also ordered an upper endoscopy to look for bleeding.
Dr. Chase performed the endoscopy and found a Mallory-Weiss tear, most likely caused by the vomiting. However, there were no signs of ulcers or blockages. This explained the blood in the vomit, but didn’t explain what caused the vomiting. Dr. Adams noted the patient’s liver enzymes were elevated and suggested gallstones, but Dr. House dismissed the suggestion as the patient hadn’t complained of pain. Dr. Foreman noted steatohepatitis would cause higher AST and ALT levels. Dr. House ordered statins and a biopsy under anesthetic. Dr. Foreman instead insisted that they merely do an ultrasound to confirm. Dr. House agreed.
However, when Dr. Chase and Dr. Adams returned with the ultrasound machine, the patient’s wife reported he had started vomiting again. Dr. Chase assured her that this was not unexpected and they discontinued the anti-emetics to see if his vomiting had persisted. When Natalie offered Andres a bedpan, he pushed her away. When she went to calm him, he instead struck out at her in a rage, injuring her. Dr. Chase and Dr. Foreman managed to subdue him as Dr. Chase called out for 10mg of diazepam. However, they soon noticed a dark spot at his groin indicating kidney failure.
Andres was put back on anti-emetics and was put on sedation. They speculated about his rage, but Dr. Chase put it down to the paranoia typical of Alzheimer’s patients. Dr. Foreman challenged Dr. House over the decision to discontinue anti-emetics, saying that the patient wouldn’t have hit his wife except for being upset over his vomiting. Dr. House countered that the vomiting was an important symptom and if he had been able to do the biopsy, the patient would have been under anesthetic. Dr. Foreman accused Dr. House of post-hoc rationalization. Dr. Foreman continued with the differential and pointed out rhabdomyolysis accounted for the vomiting, colored urine and kidney failure, but Dr. Adams pointed out the patient had no muscle symptoms and the urine was negative for myoglobin. She suggested thrombotic thrombocytopenic purpura. Dr. House agreed and ordered plasmapheresis.
Dr. Chase explained the treatment to the wife and her friend Joseph. He asked about her eye injury. Natalie realized Dr. Chase was suspicious about her relationship with Joseph, but she denied anything had happened. Dr. Chase suggested she go home and get a full night’s sleep.
However, when Natalie returned the next morning, Andres was missing. The hospital was searched, and Andres was not on the premises. Natalie was worried about him and wanted to go look for him, but Dr. House stopped her and told her they needed to question her to get clues about where Andres might be. Andres did know it was Saturday, and before he developed Alzheimer’s, there were several things he might do on a Saturday. However, Dr. Chase noticed one of the patient’s soccer trophies was missing and Natalie remembered the field he went to was nearby.
Dr. House ordered extracorporeal circulation. Dr. Adams argued that this would raise his body temperature too quickly and cause acidosis. Dr. House noted they could treat the acidosis but not brain damage from proceeding too slowly. Dr. Chase noted that if they didn’t raise his temperature to 95F soon, he probably wouldn’t recover. Dr. Adams wanted to go with multiple warm lavage, but Dr. Foreman agreed with Dr. House.
The patient still didn’t have a heartbeat and wasn’t breathing. Dr. Foreman assured Natalie that this was normal in hypothermic patients and didn’t mean there was permanent damage. Once Andres’ body temperature rose close to normal, his heart would start beating again and they could use a defibrillator to bring him back to sinus rhythm. However, he admitted if the heart didn’t start on its own, there was nothing they could do.
Dr. Adams was afraid the patient was trying to run away because he realized the burden he placed on his wife. When Andres’ temperature reached 93F, the EEG started to show brain activity. He soon showed ventricular fibrillation and was defibrillated. Dr. Chase warned Dr. Adams that in this state, any accidental movement could result in him going back into V-Fib. They managed to restore his heart beat with a blood pressure of 101/59. Dr. Foreman told Natalie that there still might be brain damage and they still had to treat whatever made him sick.
Andres finally regained consciousness and was lucid, but could only speak Portuguese. In addition, Andre’s body temperature continued to rise about 98F.
Dr. House and Dr. Foreman argued about the cause of the fever. Dr. Foreman said that the patient being outside couldn’t have exposed him to a virus because the fever came on too fast, but Dr. Chase noted that the cold could have caused cell necrosis. Dr. House thought it was still TTP, but Dr. Foreman wanted to add language loss and aggression to the list of symptoms. However, Dr. House was sure those symptoms were due to the Alzheimer’s. Dr. Foreman noted the patient spoke English perfectly well on admission, had never hit his wife before, and they had to treat the language loss and aggression as relevant. He suggested a disseminated viral infection with encephalitis. Dr. House agreed it was a possibility and ordered interferon.
Dr. Chase explained to Natalie that the encephalitis symptoms might have been mistaken for more Alzheimer’s symptoms, but she countered that it could also be brain damage from the hypothermia. She was afraid his symptoms were going to get much worse and that she couldn’t take care of him anymore. She disclosed she only knew Andres for eighteen months before his symptoms came on.
However, Andres soon went back into ventricular fibrillation. Dr. House managed to shock him back into sinus rhythm. This appeared to rule out encephalitis, but Dr. Foreman still thought the neurological symptoms were relevant. He thought it might be aseptic meningitis. Dr. Chase countered that they would have seen meningial signs, but Dr. Foreman pointed out they may have been masked by his Alzheimer’s. Dr. House thought it might be a toxin, but Dr. Foreman pointed out that the patient always remained locked indoors and that the wife had cleared the house of toxins because of the risk of accidental poisoning. Dr. House said that a lot of normal household items don’t look toxic and the wife used to be a florist. He ordered an environmental scan for toxic plants, methyl bromide and medications. However, Dr. Foreman overruled him and ordered the team to test the patient’s cerebro-spinal fluid for causes of meningitis. Dr. House decided to talk to the wife about possible toxins as due to the terms of his parole, he was not permitted to leave the hospital except to go home without Dr. Foreman’s permission.
Dr. House started questioning Natalie about gifts of fruits or vegetables from South America. He asked her to get Joseph to collect samples of plants from her house and she agreed. He started to listen to Andres and, because Dr. House understood Portuguese, he was able to translate. However, he was only talking about the restaurant where he had his first date with his wife. Natalie asked him to translate. Andres was talking about their first date. However, she soon realized that Andres didn’t recognize her.
However, as Dr. Foreman was talking to some donors, he realized some of the flowers in his office were still fresh looking even though they were a week old. He excused himself because he realized that Natalie probably did the same thing his florist did when she was a florist - add aspirin to the water. If Andres’ sore throat was due to influenza, it would have caused Reye’s syndrome. Dr. Foreman took this to Dr. House and since the aspirin would not have been locked up, he realized that Andres may have kept taking aspirin for his sore throat, not realizing he had done so. Dr. Foreman had already ordered steroids.
Andres started to improve, and the next time he woke up, he was speaking English and recognized his wife. However, he saw her eye injury and didn’t remember how it happened.