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Daryl plays offensive lineman. He is 6’7” tall and weighs 310 pounds.
Daryl lost his temper at a football scrimmage and started beating up the player he had been blocking during the play. However, after the incident, he kept hitting himself in the head with his helmet. He was taken to Princeton-Plainsboro Teaching Hospital and his case was assigned to Dr. House.
Dr. Hadley noted that Daryl’s symptoms appeared to point to brain involvement. Daryl denied any recollection of the incident that brought him to hospital. Dr. House thought it was merely a concussion, however, the emergency room had done a CT scan and had ruled out concussion, stroke and cortical degeneration. The patient also had a full psychiatric workup. Dr. House though it might be steroid rage, but Daryl’s tox screen was negative for anabolic steroids. However, Dr. House thought the negative test result just showed he was using good quality steroids that are harder to detect. He noted the patient injected lidocaine on a regular basis. Dr. Foreman thought that repeated trauma might have caused a pituitary adenoma that caused GNRH production that would mimic steroid abuse. Dr. Hadley noted that wouldn’t show up on a CT scan. Dr. House allowed them to do a bilateral venous sampling to look for excess hormones and an MRI to look for pituitary damage. However, if those tests were negative, he wanted treatment for steroid abuse.
Dr. Taub asked Daryl if he had any deep persistent pain, but Daryl said that due to the football, his whole body hurt all the time. He explained that they were going to test his pituitary. Daryl asked how long it would take to treat, and his mother explained that he was supposed to be playing in an all-star game where several pro scouts would be in attendance. If he were not there, he would most likely not be drafted into the pros. Dr. Taub assured them if it was his pituitary, the surgery would be minimally invasive and he would only need about two days of recovery.
However, the pituitary scan was normal. Dr. House ordered a somatostatin analog, which would clear the steroids from his system well before his football game.
However, Daryl denied ever using steroids. Dr. Taub explained his GNRH was elevated. However, his mother didn’t believe him either. Daryl maintained his innocence and all of a sudden, he became tachycardia. Dr. Taub ordered him to lie back on his bed. Dr. Taub called for adenosine and a crash cart. He also realized the tachycardia ruled out steroid abuse.
Dr. Foreman reported that the patient had suffered from a paroxysmal tachycardia, but they had managed to restore sinus rhythm. He was considering an EKG and a sestamibi scan. The team proceeded with tests, but there didn’t seem to be anything wrong with Daryl’s heart. Dr. Foreman thought it might be a PFO. It allowed oxygenated and de-oxygenated blood to mix and clot, causing the issues with the heart and brain. However, Dr. Foreman’s brother Marcus Foreman was there and thought it might be the same thing that killed another college athlete, which Dr. Taub remembered was a hypertrophic cardiomyopathy. Dr. House agreed it made sense and ordered a stress test despite the risk of cardiac arrest.
However, the stress test was totally unsuccessful. Daryl pushed himself very hard and his heart rate never rose above 150bpm due to his excellent physical shape. Dr. House went to see Daryl to find him getting dressed to go back to football practice. However, Dr. House wanted to inject Daryl with a vasodilator to raise his heart rate. However, when he looked at Daryl’s hands, he saw that his skin was getting whiter.
The whiteness of his skin indicated Raynaud's phenomenon - spasms in the blood vessels cut off the supply of blood to his fingers, making them appear whiter. One of the conditions that causes this is rheumatoid arthritis, but the test for it was negative. Dr. Hadley thought it might be arterial plaque throwing clots, but Dr. House didn’t think a patient suffering from stenosis would have been able to run on a treadmill without his heart rate staying below 150. Dr. Chase thought it might be Takayasu's arteritis, but Dr. Foreman thought lymphoma was a better fit and suggested a spleenectomy. Dr. Chase thought surgery was premature. Dr. Foreman argued that they couldn’t do a biopsy and pathology in a timely manner, but Dr. Chase realized Dr. Foreman was rushing so that Daryl could recover in time for his football game. Dr. House suggested an ethanol drip. If Daryl started to itch, that would confirm lymphoma, but if he lost his radial pulse, it would confirm Takayasu’s.
They started the procedure, and Daryl started to itch. Dr. Foreman explained that this most likely meant lymphoma, but they could remove his spleen immediately with a laparoscopic procedure and his recovery should be only a few days. He could return after his game for radiation therapy.
Dr. Foreman reported that Daryl had no abnormal B-cells or T-cells, ruling out lymphoma. The liver biopsy only revealed non-specific inflammation. Dr. Foreman thought it might be polymyositis, but Dr. House pointed out that it also causes muscle weakness. Dr. Chase suggested Felty's syndrome, but it would have caused spleen inflammation. Dr. Taub suggested viral hepatitis from using a lytocaine needle twice. Dr. House ordered a blood test.
They attempted the blood test, but Daryl’s blood clotted in the container. Dr. Foreman reported this to Dr. House who realized Daryl had a blood issue. Dr. Foreman thought it must be cryoglobulin anemia from doing practices in cold weather. Dr. House ordered warfarin.
Dr. Foreman explained the diagnosis to Daryl, and that it would take 2-3 weeks to treat. However, he would fully recover. However, his mother pointed out that if he didn’t play, his football career would be over. She wanted to delay treatment until after the game. However, Dr. Foreman pointed out that if they didn’t treat him and he played, he could die during the game.
Daryl improved on heparin and his color returned. However, Dr. Foreman came by and found Daryl getting ready to leave. Daryl said his team doctor had been by and cleared him to play. Dr. Foreman realized Daryl hadn’t told him that he was on heparin. Daryl’s mother admonished him to stay, but Daryl said he would be back after the game. His mother asked Dr. Foreman to follow him.
Dr. Foreman did follow Daryl to the stadium. Daryl insisted on playing, but as he headed out to the field, he suddenly had shortness of breath and went down to one knee. He complained his vision was blurry, and then he complained of blindness and asked to be returned to the hospital.
Dr. Taub tried to add the blindness back to the differential, but Dr. Foreman admitted spiking Daryl’s water bottle with nitrates. This temporarily robbed his brain of oxygen rich blood, causing temporary vision loss. His vision was already returning. Dr. Chase wanted to put him back on heparin, but Dr. House noted that Daryl was weighed both on admission and when he was recently readmitted, but had only lost one pound of weight. Patients of Daryl’s size usually lose well over ten pounds during a hospital stay of that duration. Dr. Taub noted they had already ruled out steroids, but Dr. Chase realized that excess hormone production could also be paraneoplastic syndrome. Dr. House ordered testing for any cancer that could cause excess production of human growth hormone.
All the tests for cancer were negative, and Dr. House thought he might be wrong about the weight loss, but they had already found blood in Daryl’s urine indicating kidney failure which also pointed to cancer. Paraneoplastic syndrome was the only condition that linked all of the conditions. Dr. House realized that the cancer may not be inside Daryl.
Dr. House went to examine Daryl. He told Daryl that as an African-American, his dark skin was due to melanin, a pigment. Unfortunately, doctors often rule out melanoma in African-Americans as a diagnosis as it is caused by exposing skin to light with is usually shielded by the melanin. However, all dark-skinned people have light patches on their palms and the soles of their feet. However, melanoma could easily be mistaken for a bruise on a person with as many minor injuries as Daryl had from football. Dr. House started examining these areas for irregularly shaped patches as melanoma was the only diagnosis that fit. He finally found a small very dark mole between the big and second toe of Daryl’s right foot. He explained the cancer caused paraneoplastic syndrome which accounted for his symptoms. Dr. House planned surgery, but Daryl didn’t see what the point was as he couldn’t play football. Dr. House reminded him that he had received a free college education and could at least start a normal career without debt.