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Casey collapsed during an interview right after finishing a race. She was taken to the emergency room of Princeton-Plainsboro Teaching Hospital and put on fluids. She complained that during the race and just before the collapse, she was feeling disoriented.
Travis Brennan, who was called in for a consult by the emergency room, presented the case to Gregory House and the fellowship applicants. The patient suffered a seizure with visual and auditory deficiencies. Eric Foreman noted the lab results showed signs of dehydration. He thought it was only heat stroke. Dr. House thought the onset of symptoms was too fast - she was fine before the race. However, Dr. Foreman noted the patient was wearing a three-layer fireproof suit in very warm weather. Dr. House asked his applicants to come up with alternative diagnoses while he dealt with a visitor. He put Dr. Foreman in charge.
When Dr. House returned, the team had come up with hereditary brain disorder, TIA and paraneoplastic syndrome. However, Dr. Foreman pointed out that the patient improved on fluids, and none of those conditions would. Dr. House also suggested Cushing's syndrome and calcium deficiency. Dr. House ordered a medical history, full neurology workup and an MRI of her head. He then left with the visitor and left Dr. Foreman in charge again.
The patient did well on the neurological exam. She said she felt no nausea or vomitting before the seizure, although her father did. Dr. Foreman suggested food poisoning and asked if she ate breakfast with her father, but she had not. She had no history of sciatica or spinal injury. However, she appeared to have an abnormal deep tendon reflex. Dr. Foreman said they had scheduled an MRI, but he thought it was merely dehydration and heat. However, the patient was not convinced.
Dr. Foreman called Dr. House with the results. The medical history and scans were normal. However, Dr. Brennan expressed a concern that her reflexes seemed a bit weak. He suggested Miller-Fisher disease. However, Dr. Foreman dismissed this as the reflex was still present. He planned to release her. However, Dr. Hadley called him to report the patient had suffered another seizure and had a vertical nystagmus. She thought it was Miller-Fisher as well.
Dr. Foreman explained the disease to the patient, and how it can cause respiratory arrest. The patient had lost faith in Dr. Foreman given his earlier assurances and demanded to speak to Dr. House. He reassured her that all she needed was plasmapheresis. However, the patient refused treatment and took out her tubes in an attempt to leave. Her father tried to restrain her.
Dr. Volakis tried to call Dr. House, but could not reach him. Dr. Foreman told them not to worry, but Dr. Brennan pointed out his earlier assurances were what cost all of them the confidence of the patient.
Dr. Foreman went to the patient and admitted he made a mistake in dismissing her symptoms. However, the patient soon became unresponsive. Dr. Foreman realized that Casey was in a delerium and then realized she was running a high fever. This ruled out Miller-Fisher disease.
Dr. Foreman started a new differential. Dr. Volakis was still trying to get in contact with Dr. House. Dr. Foreman thought it was Multiple sclerosis, but Dr. Cole thought it was progressing too quickly and suggested meningitis. However, Dr. Foreman pointed out the patient's areflexia didn't fit. Dr. Hadley suggested amyloidosis, but Dr. Taub noted the progression was way too fast for this and suggested lupus. Dr. Volakis agreed as brain and body symptoms pointed to an autoimmune disease. However, Dr. Foreman pointed out that lupus that progressed this quickly would have caused kidney failure. Dr. Foreman ordered interferon for the MS, but allowed the applicants three hours to run tests for the other suspected disorders.
However, the lumbar puncture was negative for meningitis, and the fat pad biopsy was negative for amyloidosis. However, her protein level was 65 and her glucose level was 70, confirming MS. However, her sed rate was 95 and her ANA was weakly positive, which could indicate lupus. However, Dr. Foreman ordered interferon for MS and refused to give her steroids for lupus.
However, Dr. Taub and Dr. Volakis were not convinced and asked Dr. Cameron for advice. She told them all Dr. House cared about was results.
The patient's fever dropped to 101.5F and Dr. Foreman was pleased until Dr. Taub and Dr. Volakis told him that they had treated her for lupus as well. At that point, Casey complained she had no feeling in her legs and didn't feel like she could move them.
The patient's paralysis couldn't be included as a symptom because Dr. Foreman couldn't be sure if it wasn't a side effect or medicine interaction of the steroids or interferon. The combination may also have damaged her immune system. He admonished the applicants for caring more about impressing Dr. House than treating the patient. Dr. Taub suggested it might be botulism given it's quick progression. However, Dr. Brennan thought it was polio. The team dismissed this suggestion - she had a vaccination and the disease is virtually unknown in the United States. Dr. Foreman thought Dr. Brennan was pushing too hard and told him to take the rest of the day off. Dr. Foreman ordered treatment for botulism and an environmental scan to confirm.
The patient did not improve on treatment. Dr. Brennan tested for polio despite Dr. Foreman's orders and came back with a positive test. However, there was no cure and given the state of her symptoms, it was likely that even treating it would not help her at this point. However, Dr. Brennan told them that they had tested extremely high doses of Vitamin C for polio in the 1950s until funding was cut off after the vaccine was developed. Dr. Foreman thought it was pointless, but allowed Dr. Brennan to proceed.
Casey started shivering due to low serum calcium, a side effect of the treatment, but was given supplements to counteract the effects. She soon started to have sensation in her feet. Remarkably, after receiving 150 grams of Vitamin C over a six-hour period, the patient started to improve and was soon asymptomatic.
Two days after he left, Dr. House returned to the hospital and was told about the diagnosis and cure. However, Dr. Foreman came in - he had re-tested Casey's blood from admission for polio and the test was negative. Dr. Brennan and Dr. Foreman accused each other of screwing up the test. Dr. Volakis pointed out the patient was better, but Dr. Foreman though the patient had a disease that relapses and remits such as porphyria. Dr. House didn't think they would miss porphyria's symptoms, such as purple urine. However, Dr. House had another theory. Although the symptoms fit polio perfectly, there was a very unlikely alternative - someone gave the patient thallium to fake polio, then fake the lab test, then discontinue the thallium and give her Vitamin C to make it look like the vitamin cured it. He then looked at Dr. Brennan and asked if he thought they should test for thallium. Dr. House realized Dr. Foreman had been right all along about it being heat stroke. Dr. Brennan admitted the deception - he claimed that he had seen patients in developing nations be cured of polio with vitamin C. Dr. House realized that this anecdotal evidence would be useless because without controls, there was no way to be sure those patient actually had polio. Dr. Brennan needed people to do research to test the theory in a good laboratory with strict controls, and obviously wouldn't get it given that polio had been eradicated in countries that had good labs. Dr. House told Dr. Brennan to resign and leave the building. When he did, Dr. House instructed Dr. Foreman to call the police. He then reminded the applicants that he left Foreman in charge for a reason and they should listen to him next time.