Bert started to develop a rash and respiratory distress in a restaurant after eating some live seafood. He was taken to the emergency room of Princeton-Plainsboro Teaching Hospital. It appeared to be anaphylactic shock. He was tested for allergies, but tested negative for all known allergens. The case was assigned to Dr. House. Dr. Chase thought it was an environmental issue because of the patient’s employment as a property developer. However, Ms. Masters noted that the patient was most likely lying about his occupation - his hands were calloused and had numerous small cuts. Dr. House instructed Ms. Masters to confront the patient about his deception and sent Dr. Chase to supervise her.
Ms. Masters asked to speak to the patient alone, but the wife didn’t want to leave. Dr. Chase told the wife that they wanted to ask about his stool, and she agreed to leave the room. Bert asked the doctors to keep the matter confidential, and he admitted he lost his entire real estate company. His wife didn’t know. He said he was currently working as a janitor to make ends meet. He was involved in industrial cleanups, crime scene cleanups, and septic tank repair. This opened the possibility for toxins, infections and fungi. Bert was cleaning up a crime scene the day he collapsed, but he left no trace of blood, and the autopsy report on the murder victim would take at least a week to obtain. Dr. House ordered antibiotics for infection and an environmental scan of Bert’s office, where he spent time when he wasn’t working. Dr. House went to speak to Dr. Cuddy to see if she could speed up the process of obtaining the autopsy report.
One of the chemicals was boric acid, which explained Bert’s rash. They needed to decontaminate his skin. Suddenly, Bert spiked a fever of 106F. They realized that they needed to coll him before he suffered brain damage.
They used cooling blankets to stabilize his temperature at 102F. They found no traces of boric acid on his skin, ruling it out as a cause of the rash. The murder victim’s autopsy came back and he had no communicable diseases. The Vicodin in his office was genuine, but it doesn’t cause rashes, fever and joint pain. Dr. Foreman suggested that they might be looking too hard for a zebra because of the numerous exposures and it might be something simple. Dr. Chase suggested meningococcemia and Dr. House ordered a lumbar puncture to confirm. He also ordered a better medical history.
Ms. Masters and Dr. Chase confronted the patient, who admitted he took the Vicodin because after a day of work, he could barely move without it and his wife would know something was wrong. He also admitted that in addition to losing his job, he has maxed out his credit cards, taken a second mortgage on their house, and has sold all of their investments. Dr. Chase performed the lumbar puncture.
Luckily, the team was able to restore circulation before there was any serious damage. They figured the lumbar puncture results pointed to a virus. Ms. Masters noted serum sickness fit all the symptoms, but it is usually set off by exposure to medication and rarely by a spider or tick bite. Dr. House discontinued the antibiotics and ordered steroids, which if they were right would start Bert improving almost immediately.
However, Bert soon locked himself inside the washroom and refused to speak to his wife or the doctors. He started having hallucinations.
The patient’s skin rash disappeared, but the psychosis pointed to brain involvement. However, Dr. Foreman noted the hallucinations stopped after the steroids cleared his system. He thought that perhaps their treatment caused the psychosis. It appeared the steroids cleared up the rash, but didn’t affect the other symptoms, and the patient had developed bilateral conjunctivitis. Dr. Taub thought it might be Familial Mediterranean fever, but that presents with abdominal pain and diarrhea. Dr. Chase though it was a systemic fungal infection, but that would have shown up in the blood tests. However, Dr. Masters realized the saline used to store the samples may have contaminated the results. Dr. House ordered new blood and CSF samples preserved with formaldehyde retested and started the patient and his wife on anti-fungal therapy.
The patient finally admitted to his wife that he may have picked up the fungal infection while working as a janitor. However, they had a fight and his wife left the hospital. Bert’s fever also returned (101F) and he had trouble hearing the doctors.
The patient’s deafness persisted and the new blood tests were negative for spores and fungus. Dr. Chase thought it might be tumor necrosis factor syndrome, but it doesn’t cause hearing loss. Dr. Chase put the hearing loss down to Vicodin abuse, but Ms. Masters countered the drug level never entered the ototoxic zone. Dr. Taub thought it was a brain tumor, and Dr. Foreman thought it was a viral infection that had reached his brain. Dr. House ordered an MRI.
While they prepared him for the MRI, the patient complained he felt like he was freezing. However, as they started the scan, Bert had a seizure. Dr. Chase and Ms. Masters rushed to get him out of the scanner.
Bert had suffered the failure of both kidneys and was in a coma. He was put on dialysis and a respirator, but he most likely only had a couple of days left. It was unlikely he would be selected for a transplant given his condition and the lack of a definitive diagnosis. He would also most likely not survive the transplant surgery. Dr. House wanted to start chemotherapy and radiation therapy in the event it was a tumor, but they needed the wife’s consent. Dr. House instructed Ms. Masters to see the wife to get it. Dr. Chase agreed to accompany her and gave her advice on how to approach it. She explained the situation to the wife and misled her about her husband’s ability to hear, and she agreed to the treatment plan.
Bert’s wife apologized to her unconscious husband and broke the news to him that she was pregnant. However, Ms. Masters noted that Bert’s rash had returned.
The team focussed on what might have happened to cause the rash to return. Ms. Masters finally mentioned that the patient complained of being cold in the MRI room, but the room is kept cold and she thought nothing of it at the time. Dr. Taub suggested cold urticaria, but that would have been immediate. Dr. House realized that the patient was in a cold house before the first attack and that Muckle-Wells syndrome explained all the symptoms and why they got worse when he was cold. He ordered rilonacept. However, by the time they got back to the patient, he was having a heart attack. They attempted to revive him, but they could not restore a pulse and had to call time of death.