Ben was struck in the groin while performing, and suddenly became unable to move his arm or leg. He was taken to Princeton-Plainsboro Teaching Hospital where the emergency room determined he had suffered from a transient ischemic attack. However, a CT Scan of his head and a cerebral angiogram were both normal. His clotting parameters were also normal. The case was assigned to Dr. House.
On review, Dr. Taub suggested an arterial spasm from cocaine use, but the tox screen was clean. He next suggested a massive sympathetic discharge from the blow to the groin, but the carotid duplex was normal. He next suggested endocarditis which released a vegetation that broke up before they performed the angiogram. Dr. House thought it was plausible and ordered a transesophageal echocardiogram to confirm.
Dr. Chase assured Mrs. Parker that endocarditis was very treatable.
However, the echocardiogram showed the heart valves were normal, although he had a thickened pericardium. That could not have caused the TIA. Dr. Adams suggested syphilitic vasculitis, which would explain both symptoms. However, Dr. Park noted that the patient’s syphilis test was negative and that he had never been sexually active. Dr. Chase suggested histoplasmosis, but the patient showed no sign of being immunosuppressed. Dr. Adams suggested it might be Sjogren’s syndrome, which could cause chronic pericarditis and cerebral arteritis. Dr. House thought it might be right and he ordered intravenous immunosuppresants.
The patient’s low platelet count made Dr. Taub think it was DIC. However, the blood smear showed no schistocytes. Dr. Park pointed to the patient’s low red blood cell count and wondered if the patient might have a retro-peritoneal bleed. Dr. Adams though the low white blood cell count might be the result of an infection. However, Dr. House thought all three together pointed to aplastic anemia, in which case Ben would need a bone marrow transplant. Dr. House ordered a transfusion of platelets and a search for a compatible donor.
Unfortunately, Mrs. Parker was only a 3/6 match, and all his other relatives were worse matches. Dr. Park went to check the bone marrow registry. They asked Mrs. Parker if she knew anyone on the father’s side of the family who they could check, but as far as she knew he was an only child and his parents had died years ago. Ben started to complain of back pain and his blood pressure started to drop.
The realized that Ben was having an allergic reaction to the donor platelets and they had to stop the transfusion. They informed Dr. House, but he started to think - the mother was obviously overprotective and the father had died of melanoma while very young. She wondered why Ben had never seen a dermatologist. He told they to use cross-matched platelets to see if the patient would tolerate them, and then told them to get more details about the biological father’s death because he thought the mother was hiding something medically relevant.
Dr. Taub and Dr. Chase pressed the mother for more details of the melanoma. At that point, the mother admitted the biological father never had melanoma and was still alive. Her husband was shocked that she had kept that information from them. She said it was because he was an itinerant drunk and she didn’t want her son to know.
Dr. Park and Dr. Taub tracked down the biological father, but when he realized that he was going to be kept from seeing his son, he refused to cooperate. Dr. Taub told the mother that the biological father refused to talk to them and she agreed to see him herself. However, at that point, Ben developed a pleural effusion. Dr. Park thought Ben was bleeding into his lungs, but when she used a needle to withdraw the fluid, it was clear. She realized the problem wasn’t Ben’s bone marrow, but his liver.
Liver failure explained all of Ben’s symptoms, but they didn’t know why the liver had failed. They tried antibiotics, but Ben didn’t respond to them. Dr. House wondered why the mother lied about the biological father. Dr. Taub wanted to focus on the underlying problem - he believed the liver wasn’t synthesizing necessary proteins and as a result fluids were leaking out of the blood vessels. Dr. Chase thought the patient had to be hyperamoneic - the toxins that the liver usually filters out were poisoning the patient. The problem was that the treatment for one was counter-indicated if he had the other - hemodialysis for the hyperammonemia and a liver transplant for a protein synthesis issue. Dr. House proposed giving the patient more protein - if it was a protein synthesis problem, there would be more fluid and heart failure and if it were hyperammonemia, the extra toxins would result in a coma instead. Although it was risky, any other test would be slow and inconclusive. He told them to get the mother’s consent and she agreed.
Ben was given protein rich drinks. He started complaining that his eye felt weird. It was bulging out.
They gave Ben injections of steroids and his eye retreated back into its socket. This appeared to rule out any problem with the liver. Dr. Adams suggested angioedema, but Dr. House pointed out there was no abdominal pain. Dr. Park suggested anasarca, but Dr. Chase pointed out that the swelling would be affected by gravity. She then suggested that swelling that started that fast and localized must have come from the lymph nodes, indicating Burkitt’s lymphoma. Dr. House agreed and ordered preparation for chemotherapy.
Dr. Park reassured the patient that they had caught the condition early and his prognosis was good. However, Ben started to crash.
Ben was suffering from multiple organ failure - the heart, lungs and now the kidneys. They thought it was moving too fast to be Burkitt’s. Dr. Park suggested multiple aneurysms, but that would mean all his symptoms except the TIA were just a coincidence. Dr. Adams suggested cholesterol embolii, but Dr. House pointed out those only occur after major abdominal surgery. However, at that point, the patient’s biological father came to visit. The mother was furious, but the stepfather told her he had called him so he could spend a few minutes with his son before he died. However, the mother pushed the biological father away, and he turned to go. Dr. House noted the biological father was exhibiting tabes dorsalis from late stage syphilis. He realized that the mother’s enmity towards him was most likely the result of sexual abuse of their son. The biological father went to leave. Dr. Taub reminded Dr. House that Ben had tested negative for syphilis, but Dr. House realized that if the active bacteria had retreated to the arteries of the brain (which syphilis will do in later stages) it would result in a negative test. The blow to the groin released the dormant bacteria that were in his pelvis. When they gave him immunosuppressants, they sent the bacterial infection into overdrive. The antibiotics they have him later killed the bacteria, but left so much detrius behind that they caused a severe Jarisch-Herxheimer reaction. The mother admitted she knew about the molestation, but since Ben didn’t understand and wasn’t traumatized, she just made sure the biological father left and made sure Ben thought he was dead so he wouldn’t look for him. Dr. House ordered a further course of penicillin together with anti-TNF antibodies. He also instructed his team to inform the biological father’s sexual partners about the syphilis and the police about the molestation. Dr. Adams asked if they shouldn’t inform Ben about the molestation, but he noted that would be both psychologically damaging and ethically questionable. She protested the patient had to know the diagnosis and they couldn’t do that without telling him how he got it. Dr. House left it to Dr. Taub to decide the best course of action.
Dr. Taub told Ben about the syphilis, but lied to Ben about how he could have contracted it.