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The patient recently lost three teeth due to traumatic injury. He has suffered numerous other traumatic injuries, many of which required emergency room visits and surgery. He has suffered three concussions since he was ten years old.
The patient started coughing up blood and collapsed during a hockey game after knocking another player to the ice. He had just come onto the ice and was not otherwise fatigued or overworked, and his opponent in the fight had not hit him.
After no obvious cause for the symptoms could be determined, the patient was referred to Dr. House. Dr. Taub thought the cause was obvious - a broken rib that had punctured a lung. However, the emergency room had eliminated that as a cause almost immediately. X-rays had also ruled out traumatic sequelae, tuberculosis and lung cancer. Dr. Chase suggested sarcoidosis - the nodules typical of the disease might be too small to show up on x-rays. Dr. Adams noted the patient was a duck hunter and suggested psittacosis. Dr. Taub suggested an infection from his lost teeth, but Dr. Park noted there was no continuing dental pain. Dr. Taub suggested a tear of the esophagus from a traumatic injury. Dr. House ordered Dr. Chase to do a CT Scan for sarcoidosis, ordered Dr. Adams to run sputem and blood cultures for infections, and ordered Dr. Taub to test the patient’s stool for blood.
The patient was anxious to leave the hospital because he had been told that some NHL scouts had his eye on him.
The CT Scan showed no sign of acidosis, but did show his spleen was enlarged.
Dr. Taub thought the patient had a deep vein thrombosis, another common complication of trauma and surgery. However, Dr. Park though leukemia fit the symptoms better. Dr. Taub argued that in a patient with a history of frequent trauma and surgery, a thrombosis was much more likely. Dr. Chase suggested ultrasound to look for the thrombosis and a white blood cell count for evidence of leukemia. Dr. House agreed.
Dr. Taub drew the patient’s blood. However, he also noticed the patient had enlarged breasts.
Dr. Chase thought the breast enlargement might be the result of liver failure, which would interfere with his hormone levels. Dr. Park noted that alcoholism was the most likely cause and wanted to do an environmental scan of the patient’s home and locker room. Dr. Chase also suggested hemochromatosis, but Dr. Adams pointed out it’s unlikely to cause coughing up blood. She thought it might be leptospirosis. Dr. Taub admitted it fit the symptoms, but pointed out the patient is a large, muscular professional athlete and steroid abuse was a more likely diagnosis. Dr. House admonished Dr. Taub for coming up with diagnoses that were always related to the patient’s livelihood. He ordered Dr. Adams and Dr. Taub to run antibody titres for leptospirosis and Dr. Park and Dr. Chase to do an environmental scan for alcohol and steroids.
The environmental scan of the locker room paid off when Dr. Park found a prescription for ganciclovir in another player’s gym bag. Mononucleosis explained all the patient’s symptoms and the Epstein-Barr virus that causes it also causes liver damage.
However, when Dr. Taub went to see the patient, he found him out of bed, on the floor, crying.
Dr. Park dismissed the crying as another consequence of hormone imbalances. In addition, the patient was generally improving on treatment for mononucleosis. However, Dr. Taub felt it was a symptom of chronic traumatic encephalopathy from frequent blows to the head. He noted that always causes aggressive behavior and clinical depression. However, Dr. House thought the patient’s sadness was more likely to be the result of knowing his hockey career might be close to being over. Dr. Taub argued that if he continued to be a hockey enforcer, he might die. Dr. House once again admonished Dr. Taub for his failure to be objective about the patient. Dr. Park pointed out that the only way to confirm chronic traumatic encephalopathy was during autopsy. Dr. Taub pointed out that an MRI might show white matter disintegrity that would be typical of the condition. Dr. Adams pointed out that with only three concussions, chronic traumatic encephalopathy was unlikely. Dr. Chase pointed out that hockey players usually underreport concussions. Dr. House refused to permit the MRI and instead ordered a psych evaluation. He ordered the patient discharged if he didn’t start crying again.
The patient’s psych evaluation was normal. Dr. Taub reported the results and the patient apologized for his behavior. He said he was just upset to be in the hospital. However, he said he was feeling much better. Dr. Taub mentioned that depression could indicate chronic traumatic encephalopathy, but the patient was already well acquainted with that condition as one of his relatives kept sending him articles about it. The patient refused to be tested for it.
To prove to Dr. Taub that he wasn’t being objective, Dr. Chase fooled him into thinking that he was scanning the patient’s brain when he was actually scanning Dr. House. Dr. Taub was sure he saw evidence of brain trauma, and when he did, Dr. House revealed his deception. However, just afterwards, the patient suffered what appeared to be a stroke.
However, on further examination, the patient had only suffered an isolated ophthalmoplegia. Dr. Taub suggested tertiary syphilis. Dr. Chase pointed out the patient’s youth, but Dr. Taub pointed out the patient had been living away from home since he was fourteen. Dr. Chase thought it was more likely to be microscopic polyangiitis. Dr. Taub wanted to start plasmapheresis, but Dr. Chase pointed out that they should confirm with an ANCA panel because plasmapheresis could cause internal bleeding. Dr. Taub pointed out that microscopic polyangiitis can progress very quickly. Dr. House agreed with Dr. Taub and ordered plasmapheresis.
However, the patient soon lost feeling in his arms. In addition, the ANCA panel was negative, ruling out microscopic polyangiitis. Dr. Adams suggested Lyme disease - the patient could have been exposed to ticks while hunting. However, Dr. House pointed out there was no sign of a rash and no heart involvement. Dr. Chase suggested ALS, but Dr. Park pointed out the other sensory involvement ruled it out. Dr. Taub pointed out the paralysis started in his face and went to his arms and descending paralysis indicates botulism. Dr. House pointed out the environmental scan found no contaminated food, but Dr. Taub argued that botulin toxin is often injected by athletic trainers to treat muscle spasms. Dr. Adams wanted to start treatment with anti-toxin, but Dr. Taub pointed out that it can cause anaphylactic shock. He wanted to run tests to confirm. Dr. House once again admonished Dr. Taub for his lack of objectivity - Dr. Taub had earlier wanted to start treatment with confirmation, but since his opinion of the patient had changed, he wanted to be more careful. Dr. House ordered the anti-toxin.
The patient had no adverse reaction to the anti-toxin and soon regained movement and feeling in his arms. He continued to improve, but soon developed problem breathing. The paralysis reasserted himself and spread to his legs. The tests for botulism were negative.
Dr. House encouraged his team to come up with very unlikely diagnoses. Dr. Adams suggested the patient may never have been vaccinated for polio, but Dr. Taub pointed out that the patient had been given at least two complete physicals a year ever since he was young. Dr. Park suggested metachromatic leukodystrophy, but Dr. Taub pointed out the patient’s cognitive abilities were unimpaired. Dr. Chase suggested a prion disease, but Dr. Taub pointed out that the brain biopsy would be very dangerous given the patient’s medical history - he was likely to have swelling in that region. However, Dr. House had no other suggestions and ordered the brain biopsy.
Dr. Taub asked Dr. House to remove him from the case. Dr. House refused and told Dr. Taub he had to work through problems. However, this gave Dr. Taub an idea. He rushed to stop the biopsy and explained that the patient had Miller Fisher syndrome as the result of his Epstein-Barr infection. He had realized the plasmapheresis had a delayed effect - even when they took him off it, it continued to work and resulted in a reduction of his symptoms that they attributed to the anti-toxin. However, it explained why the improvement stopped and the patient became worse. Dr. House ordered the patient be put back on plasmapheresis.
The patient once again improved. He signed a large NHL contract.