Three days after emergency treatment, Bob was referred to Dr. House as no doctor could figure out why he had stopped breathing. Bob started describing his symptoms to Dr. Cameron. He had felt like his throat was getting very dry, then his tongue started swelling up. Food allergies had been ruled out, one doctor thought it was merely a panic attack and the next wanted to remove his tonsils. He admitted he was having sex at the time of the attack.
Dr. Cameron reported back to Dr. House. Dr. Foreman thought it might be vocal cord paroxysms from rough sex - it can cause choking. However, there was no sign of neck trauma. Dr. Chase thought they should reexamine the possibility of food allergies. Dr. Foreman thought it was a neurological issue like progressive bulbar paralysis. However, Dr. Cameron pointed out that ALS would affect the muscles in his face first. Dr. House thought that the patient may have mistaken suffocation for choking and the problem might be in his lungs instead. He ordered further blood tests, a CT Scan of his chest and a plethysmograph.
Bob was instructed to pant for the plasismograph. It revealed decreased lung capacity indicating interstitial pulmonary fibrosis. However, the cause was unclear. Arthritis, sarcoidosis and prescription drugs had been ruled out, and he had no exposure to coal dust or asbestos. Dr. Cameron thought it was ideopathic, but Dr. House corrected her - the cause was currently unknown, but there was no evidence that it couldn't be traced to a cause. However, for the time being, Bob was stable. Dr. House wanted to wait for a new symptom to appear. At that moment, the team was paged - Bob was complaining of a severe itch and had red marks all over his chest.
Bob hadn't received any medication, so an interaction was out of the question. Dr. Foreman thought it might be lupus. Dr. Chase still thought it might be a food allergy. However, Dr. Cameron disagreed - it wouldn't explain the lung scarring. Dr. Chase argued that food allergies have been linked to autoimmune conditions that cause lung scarring, but Dr. Cameron argued those studies weren't reliable. Suddenly Dr. House realized that heavy metal poisoning can cause all these symptoms, including the swelling in his throat that Dr. House had thought was a lung problem. However, they were at a loss for an environmental cause until Dr. Cameron noted that they had been to Mexico where lead is still used in ceramics. Dr. House ordered an environmental scan plus tests of his hair and blood for lead, mercury and arsenic. He told Dr. Chase to also get in touch with the resort they stayed at in Mexico.
However, when Dr. House consulted Dr. Wilson, they came to the conclusion that to get lead poisoning this severe, Bob would have to have eaten off of lead-glazed pottery for months.
Dr. Foreman and the wife did an environmental scan of their home. The only thing out of place were some ants, which were soon ruled out as possibly being poisonous. The resort in Mexico was a 5-star establishment that didn't cook with pottery. The tests for heavy metal were also negative. Dr. House wanted all the tests repeated because the symptoms fit so well with heavy metal poisoning. He also ordered that Bob be started on treatment for lead poisoning, although he did let Dr. Chase test for milk, wheat and legume allergies.
During the allergy scratch test, Bob started complainign that he felt his feet were on fire and he said he may have stepped in something. However, he socks were clean. When Dr. Chase tried to remove them, Bob cried out in pain. Dr. Chase ordered Gabapentin.
The extreme pain in the extremities ruled out allergies. Dr. Foreman thought it was a clear neurological problem, but Dr. House once again pointed out it is a classic symptom of heavy metal poisoning. However, all the tests were negative. Dr. Foreman suggested lupus again, but Dr. House pointed out this disease was progressing too fast and there was no joint pain. Dr. Foreman wanted to do an ANA, but Dr. House overruled him.
Once again, Bob's tongue swelled up, cutting off the airflow to his lungs. Dr. Chase prepared to intubate. Bob started to aspirate and Dr. Chase called for suction. However, there was too much vomit so the only alternative was a tracheotomy. It was successful and they managed to restore air flow.
Bob's urine test showed elevated protein levels and red blood cells. Dr. Foreman argued this was a classic case of lupus induced kidney failure. Dr. House pointed out heavy metal poisoning could explain the vomiting, but Dr. Foreman said it was more likely that it was the kidney failure. Dr. Foreman had started Bob on steroids and insisted on doing an ANA and serum complement test. However, Dr. House had noted that Bob had not improved on steroids, but Dr. Foreman pointed out that there were other treatments that might, such as cyclophosphamide or immunosuppressants. However, Dr. House pointed out that due to the danger of those treatments, the ANA and serum complement weren't enough - to conform they would also need an anti-DNA IV pyelogram and kidney biopsy. However, House had to admit that he had no idea which heavy metal was poisoning Bob. Dr. Foreman went to the wife to break the news and seek consent for treatment. She agreed.
Then, while dealing with another couple who had developed herpes, Dr. House started suspecting the wife. He asked Dr. Cameron to search her belongings, but she was incredulous. Dr. House pointed out that the disease was getting worse, while even heavy metal poisoning would get better once a patient reached the hospital, even if they didn't treat him - it would cut off the source. He figured she was deliberately poisoning him. Dr. Cameron pointed out all the tests had been negative. Dr. House countered that the standard tests only test for toxins that are regularly found in air or food. There were dozens of other possibilities they didn't test for because deliberate poisioning is the only way to be exposed to them. Dr. Cameron thought it still might be lupus, but Dr. House noted he still wasn't improving on lupus treatment. They had ruled out every other possibility except deliberate poisoning. Dr. House insisted Dr. Cameron search the wife, but she refused.
Instead, Dr. House asked the wife if he could search her purse. He told her he thought she was poisonign her husband. She handed over her handbag, but he found nothing suspicious. However, she refused a body search. Dr. House went to Dr. Cuddy for permission, but she refused as well. Dr. House and Dr. Cameron started arguing about it, but Dr. Cuddy told him in no uncertain terms that neither he nor a member of his team could do the body search.
Once again, Bob started to crash. Dr. Foreman called for the defibrilator and adrenaline. They managed to restore his pulse and his pupils were responsive. His heart had not been stopped long enough for hypoxia, but it might have been a stroke. Bob finally started responding to questions.
Foreman pointed out the heart failure showed a systemic disease and lupus was most likely. However, the immunosuppressant drugs weren't working. Dr. Chase wanted to start cyclophosphamide. Dr. House wanted to give Bob interferon just in case it was a viral infection. Dr. Cameron pointed out the patient had no fever. Dr. House hypothesized that Bob had come in with a post viral autoimmune reaction and the immunosuppressants had allowed a dormant virus to spread. Dr. Foreman pointed out that if he was right about lupus, the interferon would make it worse.
Dr. Foreman went to see the wife to tell her they were starting interferon for a viral infection because the progression of the disease seemed to rule out lupus. The wife wanted to know the risks, but Dr. Foreman told them that given his condition, it was the only thing they could suggest. The patient consented to treatment.
However, Bob's lungs and kidneys continued to get worse. The dose of interferon had already been increased, and the team had run titers to test for viruses, but they were all negative. Dr. House wanted the dose of interferon increased again.
However, while dealing with the herpes couple again, Dr. House came across a gold ring. He realized gold can result in heavy metal poisoning as well. He also remembered that the wife had a family history of arthritis and they sell a gold laced arthritis medicine - gold sodium diamylate - in Mexico. He ordered the interferon stopped and a blood test for gold. He also instructed Dr. Cameron not to let the wife use the washroom. He went home to get his childhood chemistry set and stannis chloride. He confronted the wife and rubbed it on her hand before she had a chance to wash them. Her fingers turned purple, showing exposure to gold compounds. Bob also tested positive for gold with the result testing at the maximum level the equipment could register. The lung damage was permanent and Bob would require a transplant, but his kidneys would recover. The wife was arrested. Bob was started on Chelation therapy with dimercaprol and his kidney function slowly started to improve. They they then broke the news about his wife to him.