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Case History Edit
Brandon was brought to the hospital when he painted a picture in a distorted style which he believed was painted in a realistic style showing acute onset visual agnosia. Dr. House's team reviewed the patient's other recent works, which did not show any evidence of distortion. Dr. Foreman pointed out that agnosia is usually the result of a stroke or brain tumor, but the MRI showed no evidence of either of these in Brandon. Dr. Foreman suggested doing another MRI with contrast. Dr. Hadley suggested it might be drugs, but Dr. House dismissed the idea as the emergency room would have tested for that before referring the case. Dr. Hadley wanted to do an environmental scan. Dr. House ordered Dr. Foreman and Dr. Hadley to do the contrast MRI and directed Dr. Taub and Dr. Kutner to do the environmental scan.
Dr. Foreman and Dr. Hadley met the patient, whose agnosia had resolved itself. He wanted to be released, but they insisted on the tests given the seriousness of the symptoms. His girlfriend convinced him to let them do the test.
Dr. Kutner and Dr. Taub went to the patient's studio. However, they could not find any environmental cause for the patient's symptoms. The patient's contrast MRI was also clean, showing no masses or lesions. Cancer and multiple sclerosis could be ruled out, leaving just toxins and drugs as a possibility. Dr. Foreman thought it might be a cavernous angioma that resolved itself. However, Dr. Hadley didn't think the patient would consent to the necessary intrusive vein sampling, given his adversion to even being injected with contrast material. However, the patient's nervousness intrigued Dr. House. He asked Dr. Hadley if the patient's girlfriend was pretty, which she was. This gave Dr. House an idea.
Dr. House told the patient he had a brain tumor and needed exploratory surgery because it wasn't showing on scans. The patient flatly refused. However, Dr. House found his lack of fear intriguing and figured he was delusional, in which case Brandon shouldn't have worried about the contrast, or Brandon already knew there was nothing wrong with him. Dr. House figured that Brandon was on a clinical trial to make money and hadn't told them what drugs he had been taking because he die. He didn't want his girlfriend to know. Brandon admitted that he was on three different clinical trials. Dr. House figured since his symptoms had disappeared the drugs were out of his symptom, but he ordered Brandon to be held overnight for observation and told Dr. Hadley to get details of the drugs used in the clinical trials.
However, a few hours later, Brandon started having seizures. They received the details of the drug trials, and none of them were known for causing seizures. To make them easier to remember, Dr. House gave them names instead of clinical trial numbers. The first one was called Bisexidrene which is an anti-coagulant. It's side effects are nausea, erectile dysfunction and insomnia. The second was Cuckoldisol, an autoimmune treatment with no known side effects. The third was |Worldsauruskneesasil, an anti-convulsant. Dr. Foreman pointed out that if the drugs were working the way they were supposed to, there were a million possible interactions and if they weren't there could be a million more. Dr. House ordered dialysis to remove the drugs from Brandon's bloodstream despite the risk of seizures and liver failure.
The patient improved on dialysis and had no further seizures or visual symptoms. However, he soon suffered a new symptom - extreme swelling of the head and neck, forcing Dr. Foreman to perform a tracheotomy in order to allow the patient to breathe. The tracheotomy was difficult because Dr. Foreman couldn't find the landmarks because of the swelling, but it was successful. The swelling also caused his tear ducts to shut, which meant they had to lubricate his eyes. Dr. Kutner administered steroids and cream to reduce the swelling with little effect. The patient was negative for a thrombosis, Chagas disease and blood cultures. Dr. Foreman thought his immune system as overactive, causing a cytokine storm. Dr. House thought it might be withdrawal symptoms from one of the three drugs. He ordered the drugs started again, only this time the patient would be weaned off them slower to eliminate which symptoms were withdrawal related.
They managed to reintroduce the drugs and wean Brandon off them. His blood tested clear and Dr. Hadley asked the patient to sit up so she could take his blood pressure. Instead, the patient tried to sexually assault her. Dr. Hadley managed to incapacitate him by hitting him in the face and called for an ice pack to stem the bleeding and swelling.
The patient was restrained. Dr. Kutner said the clinical trials couldn't be the cause given his blood was now clean. Dr. Taub thought the drugs may have set off a dormant neurological condition. Dr. Foreman thought it might be Kluver-Bucy syndrome, but this would not explain the seizure or the cytokine storm. Dr. Foreman thought those might be caused by withdrawal, but Dr. Hadley also pointed out that Kluver-Bucy syndrome leaves lesions on the temporal lobe and they had already scanned it. However, Dr. Foreman pointed out if the damage was circulatory and not structural, it wouldn't show up on the MRI. Dr. House ordered Dr. Taub to do a cranial MR angiogram. The angiogram showed narrow blood vessels in the Circle of Willis. However, Dr. House pointed out narrow blood vessels are congenital and should have caused problems for years. Dr. Taub suggested that a heart arythmia from the experimental drugs might have caused low blood pressure leading to brain damage where the vessels narrowed. Dr. Hosue ordered an EP study to find the arythmia.
Dr. Taub, Dr. Kutner, Dr. Hadley and Dr. House performed the study, but he went into detac. Dr. Kutner applied the defibrilator and got the patient's heart rate stabilized. However, during the defibrilation, Dr. House noted the patient's hair was growing in a different color - red. This ruled out Klug-Rebussy, but showed that the patient's melanin levels were being affected. Hormones could do it, but the patient's hormone panel was normal. Age does, but it removes color, it doesn't change it. Dr. Foreman suggested Wallenberg's syndrome, which can cause hair color change and arythmia. The EP Study showed a long QT interval, leading Dr. Kutner to believe it was Romano-Ward syndrome, but this would not cause the hair color change. Dr. Foreman thought it might be a secondary gene mutation, but Romano-Ward usually kills patients outright before it is diagnosed, so Dr. House didn't feel it was a good explanation. Beta-blockers weren't working, and the patient's heart could not handle an ICD. Dr. House thought that the patient's irregular heart rhythm was affecting his entire neurology and wanted to perform a cardiac sympathectomy, essentially removing the nerve connections from the heart to the brain. However, the procedure has massive side effects, including possible damage to his swallowing, vocal cords and ability to sweat. In addition, he would not be able to feel angina. Dr. Hadley thought the patient might not survive surgery, but Dr. House felt they had no other choice.
Dr. Taub and Dr. Hadley explained the procedure to the patient, but he did not recognize them, showing the return of his visual symptoms. Dr. Taub was sure this indicated some type of intermittent visual disorder, and Dr. Hadley felt they could not proceed with the surgery. However, Dr. House still thought the patient had Ramano-Ward and wanted to proceed with the sympathectomy. Dr. Taub thought that perhaps he absorbed toxins into his fat and they were released when he lost weight in the hospital. Dr. Taub asked for permission to look for the patient's old paintings, but could only give him one hour because of the patient's condition.
When Dr. Taub asked about his old paintings, the patient admitted to his girlfriend that he hadn't sold more than two since he met his girlfriend. He told Dr. Taub where the unsold paintings were. Brandon was prepped for surgery as Dr. Taub went to an old warehouse. On reviewing the paintings, Dr. Taub showed that when the patient was on the trials, the art showed signs of visual agnosia, but when he was off the trials, he didn't. He called Dr. House to tell him the agnasia had to be related to the drugs even though he couldn't figure out where they were coming from. Dr. House reviewed all the drug trials again and saw that one of the earlier trials was an antacid. Dr. House called Dr. Chase to tell him to cancel the sympathectomy and instead to do stomach surgery to remove a bezoar. The antacid allowed vegetable fibers to accumulate in Brandon's stomach, which the drugs then stuck too as well. As the bezoar formed and dissolved, it often released massive amounts of the drugs back into his system. Dr. Chase removed bezoar about the size of his fist. The patient recovered from surgery and his prognosis was excellent.