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Benjamin collapsed outside of a social center to which he had just given a large donation. He was taken to the emergency room of Princeton-Plainsboro Teaching Hospital. They found nothing wrong with him and felt that he had just collapsed after being on his feet for several hours on a hot day. However, Dr. House, who had recently returned to the hospital, took an interest in the case. His consulting resident, Dr. Park, thought it was just dehydration. However, Dr. House ordered an echocardiogram.
Dr. House enlisted the assistance of Dr. Jessica Adams, who assisted with the echocardiogram. After talking to the patient about his philanthropy, Dr. Park was concerned he had a mental illness or another neurological issue as Benjamin had no concerns for his own well being or comfort - he was just trying to give all his money away. However, Dr. Adams reported Benjamin’s echocardiogram showed no sign of cardiomyopathy and a CT Scan showed no sign of stroke or bleeding.
Dean of Medicine Eric Foreman came to see Dr. House, concerned that he was just running tests at the patient’s expense in order to convince the patient he had saved his life so that the patient would make a donation to re-fund Dr. House’s diagnostics department. He wanted Dr. House to discharge Benjamin. Dr. House argued that the unexplained loss of consciousness could be caused by a number of conditions. Dr. Foreman noted the patient improved on fluids and guessed that all of Dr. House’s tests had come back negative. However, Dr. Park supported Dr. House - she mentioned the patient’s extreme altruism was a symptom. Dr. Foreman told Dr. House he had a choice - release him as a healthy patient who was just generous, or treat the altruism as a symptom and realize under the code of medical ethics that he couldn’t accept any money from him. Dr. House ordered Benjamin discharged.
However, Dr. Park decided to run one more test on the patient’s leg muscles. The results were normal, but the patient started complaining about his chest and Dr. Park noted he had tachycardia with a heart rate of 185. Dr. Park administered 18mg of adenosine. Dr. House noted that arrythmia could have caused his collapse. Dr. Adams noted that given the lack of structural problems in the heart, Long QT syndrome was most likely. Dr. Park suggested Whipple’s disease. Dr. House rejected the idea that the generosity was a neurological symptom and since Whipple’s presents with neurological symptoms, he ruled it out. Dr. Adams pointed out the patient had been taking antihistamines which can set off Long QT. Dr. House ordered the patient’s system flushed with saline to remove the antihistamines, followed by an EKG. However, he decided to do the flushing himself.
Dr. House went to see the patient and told him how he lost his department. Benjamin offered $1 million to re-fund his department. Dr. House told him he thought his offer was hasty.
Dr. House sought out Dr. Wilson for an ethical opinion, and Dr. Wilson noted that taking a donation from any patient would be ethically suspect and he can’t accept the donation.
Dr. Park administered the EKG and learned the patient was estranged from his wife and children. All of a sudden, his hands started trembling and the spasms spread up his arms to his body. Dr. Park asked if he was in pain, but he wasn’t. Dr. Park noted this symptom ruled out Long QT.
Dr. House was willing to accept that the generosity was a symptom, but Dr. Adams was still arguing against it. She thought it was a drug. Dr. House doubted that the patient used drugs. Dr. Park thought it might be polyarteritis nodosa. However, Dr. Adams noted there was no rash. Dr. Adams suggested echovirus, which explained the symptoms and can cause personality changes. Dr. House ordered anti-virals and Dr. Park started him on pleconaril.
Benjamin started to improve and Dr. House planned to discharge him. However, Dr. House soon learned that Benjamin was going to donate a kidney to one of Dr. Wilson’s patients who needed a transplant. Dr. House asked Dr. Wilson about it and soon learned that Benjamin hadn’t even met the recipient and had merely heard the nurses talking about her. Dr. House was afraid Benjamin’s mental status was declining despite his improving physical symptoms. He challenged Dr. Wilson on now being willing to take a donation from a patient after earlier rejecting the idea out of hand.
Dr. House and Dr. Wilson went to Dr. Foreman. Dr. House told Dr. Foreman Benjamin was still sick, but Dr. Wilson told him the patient’s symptoms had disappeared. Dr. Foreman went to see Benjamin and, after talking to him, it was clear Benjamin was aware of the risks. Dr. Foreman agreed to the transplant. Benjamin assured Dr. House he was fine and promised to make good on his donation to his department.
Dr. House met with Dr. Park who once again suggested Whipple’s disease, but once again Dr. House rejected the idea to a lack of joint pain. When he arrived in his office, Dr. Hadley was also there to help. Dr. House suggested the patient may not be eating well due to his self-induced Spartan lifestyle, and Dr. Park suggested magnesium deficiency. Dr. House ordered an expanded electrolyte profile. However, Dr. Hadley was sceptical as the patient had no history of anxiety or trouble sleeping. She suggested Whipple’s as well. Dr. Park went to argue that it had already been ruled out, but Dr. Hadley noted that it explained all the symptoms, including the personality change, why he got better on antibiotics and that joint pain wasn’t definitive. Dr. House agreed and admonished Dr. Park for not defending her theory better. Dr. House ordered an endoscopy and PCR test.
Benjamin was prepared for the transplant surgery. However, after he was put under anesthetic, his heart rate rose to 140 and his blood pressure dropped. Dr. Wilson ordered adenosine and Dr. Simpson ordered the surgery cancelled.
Benjamin’s arrythmia had returned and he was put on heparin. Dr. Adams noted his condition was stable, but he was at risk for stroke or embolism. Dr. Park suggested that the patient had been bitten by a poisonous spider - that can take up to three days to appear. However, Dr. Adams noted it would also cause localized pain. Dr. Park suggested light-chain deposition disease, but Dr. Adams noted that almost always causes kidney symptoms. However, Dr. Foreman was suspicious that the patient had developed arrythmia just before surgery and suspected that Dr. House had dosed Benjamin to induce the symptom in order to keep him as a patient. Dr. Park defended Dr. House and Dr. House denied doing it, but Dr. Foreman took him off the case.
After Dr. Foreman left, Dr. House admitted inducing the arrythmia. However, after talking to Dr. Adams about Dr. Park’s refusal to take gifts, he realized that he could prove Benjamin’s altruism was a symptom by seeing how far he would go. He contacted Dr. Hadley to give her instructions.
Dr. Hadley approached Benjamin about the kidney he was donating and pretended she also needed a kidney transplant. Benjamin offered to give her the other kidney. He said he could live on dialysis for several years and then when he died, more of his organs could be donated to save four or five lives. Dr. Hadley left the room and reported this reaction to Dr. House.
Dr. House started a new differential diagnosis. Dr. Hadley suggested Grave’s disease or another thyroid disease. Dr. Park noted Benjamin’s thyroid levels were within normal range when he was admitted. Dr. Adams suggested Coxsackie B, but there was no pericarditis. Dr. Hadley suggested porphyria even though there was no rash. Dr. House agreed it was the best idea they had and Dr. Hadley went to start him on hematin.
However, Dr. House remembered all the tests he gave Benjamin. One of them used iodine contrast. He realized Dr. Hadley was right about it being a problem with his thyroid - Plummer’s disease. He realized a nodule on the thyroid was producing hormones that didn’t show up as too high, but were higher than he actually needed or his brain was used to. It made him irrationally generous and made him vulnerable to overheating, causing his collapse. When they used iodine, it kicked the nodule into thyrotoxicosis causing the rest of his symptoms. He just needed surgery to remove the nodule.
The surgery went well and Benjamin recovered. However, he withdrew his offer to re-fund Dr. House’s department. Dr. House realized his generosity had disappeared and was a symptom.