The patient participates in a number of athletic activities, including competitive skateboarding and basketball.
The patient collapsed while performing in a skateboard exhibition. She was taken to Princeton-Plainsboro Teaching Hospital. En route, the CMTs came to the conclusion that her heart had stopped. The emergency room discovered an arythmia.
The case was assigned to Dr. House. Dr. Chase reviewed her chart and found a subsequent EKG, echocardiogram and head CT scan were all normal. The arythmia was obviously intermittent and Dr. House wanted to focus on conditions that caused that symptom. Dr. Chase noted the patient’s brother has a severe case of congenital muscular dystrophy and wondered if Della could have had a latent case. However, Dr. House said if it was MD, it wouldn’t have come on so fast. Dr. Chase suggested long QT syndrome, which could have been set off by any startling stimulus at the skate park, like flashing lights or loud noise. Dr. House ordered his team to scare the patient to see if they could set off another attack, preferably near a defibrillator.
However, when Dr. House discussed his plans with Dr. Cuddy, she told him to do safer procedures - an angiogram and an EP study. Dr. House agreed and informed Dr. Taub. He cut off Dr. Taub when he tried to object that those tests weren’t as good at confirming the condition.
They prepared Della for the EP study and advised her that she should probably use the washroom before they started the test. However, she denied she had to use the washroom even though they had given her 2.5 litres of fluid. However, she hadn’t used the washroom since the previous night. This appeared to point to kidney failure.
Dr. House focussed on what diseases could cause both heart and urination problems. At this point, Dr. Taub asked Dr. House about his new relationship with Dr. Cuddy and whether it was affecting his work, particularly the decision to cancel the scare test. Dr. House said he was find with Dr. Cuddy’s decision and that she turned out to be right in this instance. Dr. Foreman suggested that the patient might have Fabry disease. However, the patient had no family history to support the diagnosis. Dr. Foreman suggested that it might be protein deposits from amyloidosis as this would not show up in her family history. Dr. House ordered a bone marrow transplant.
However, the only match was her brother Hugo. Dr. Taub explained the procedure to Della and her parents in Hugo’s absence, but she refused to take a transplant from him. Dr. Taub assured her there would be almost no pain or risk, but Della focussed on the “almost”.
Dr. Taub went to report to Dr. House, who figured out from Dr. Taub’s demeanour that there was a problem and it had to be that the patient refused the transplant. They started looking for another match.
Dr. Taub shared his concerns with Dr. Wilson, who went to speak to Dr. House about the effect of his relationship with Dr. Cuddy on her ability to supervise him. Dr. House told Dr. Wilson not to be concerned - Dr. Cuddy had always supervised him and it was only one test.
Dr. Taub went to the patient to ask if she was living her brother’s life vicariously by engaging in activities a boy her brother’s age would normally pursue. She agreed that she pursued things her brother’s friend were doing that her brother couldn’t do, but assured Dr. Taub that she saw her brother as an inspiration. However, when she went to take her medicine, she started coughing up blood. Dr. Taub realized she had a hemothorax and she needed a bronchial tube. Dr. Chase examined her and realized she was drowning in the blood. This symptom ruled out amyloidosis.
Dr. House went to Dr. Cuddy to tell her about the patient’s condition and to get permission to fill a quarter of Della’s lung with foam to keep her from drowning. Dr. Cuddy realized if didn’t have enough lung function left after the procedure, she would die. However, Dr. House said the only alternative was to slowly suture the lung to stop the bleeding, but she could die before they finished. Dr. Cuddy approved foam, but instead Dr. House ordered Dr. Chase to suture.
Dr. House went to Dr. Wilson to tell him that although Dr. Cuddy approved his risky procedure, he was sure she didn’t want to and he took the safer course. Dr. Wilson said that Dr. House’s caution wasn’t a bad thing, but he had to work out a solution to the problem of being supervised by Dr. Cuddy, but Dr. House wanted to avoid the issue.
Dr. Chase managed to stop the bleeding, but Dr. Taub warned Dr. House that following Dr. Cuddy’s orders may not work out so well next time. Dr. House started a new differential adding in the bleeding lung. Dr. Foreman though multi-system involvement centered in the lungs pointed to sarcoidosis, but it didn’t explain the hemothorax. Dr. Foreman noted tuberculosis affected all three systems, but the test for it was negative. Dr. Foreman suggested Goodpasture’s syndrome, which affects the lungs and kidneys, and Dr. House agreed that an autoimmune condition would also explain the arythmia. Dr. House ordered immunosuppresants and plasmapheresis to treat it, and a kidney biopsy to confirm.
However, the kidney biopsy was normal. The team decided to test a sample of the lung from the surgery. They found intermal thickening of the blood vessels which ruled out Goodpasture’s. There were also lymphocytic infiltrate. They tested for LAM and the patient was positive. In addition, the patient’s lungs were failing and she needed a lung transplant, which is how LAM would be treated. Dr. Taub had taken the case to the transplant committee, which may have found a donor.
The donor lung came through and they did the lung transplant. However, although the surgery was successful, the new lung started failing after about an hour. They reconfirmed their LAM diagnosis. Either Della was rejecting the new lung, or the donor lung was infected before the transplant. Dr. Chase wanted to do a lung biopsy to check, but there was no guarantee they would hit the right spot. Moreover, if they gave her steroids to stop the lung rejection, it would make any infection worse, and antibiotics for infection would make the rejection worse if there was no infection. The treatment that would pose the lesser risk was to treat for rejection, and Dr. House ordered methylprednisilone on the theory that she had hyper-acute rejection, but if she didn’t improve, to switch to antibiotics. However, Dr. Taub reminded Dr. House that any treatment that could kill the patient would have to be approved by Dr. Cuddy, and she would merely choose the safest course, so he wanted to let her decide. Dr. House ordered Dr. Taub to get permission, and told him to call Dr. Cuddy an idiot for always choosing the safest course.
However, Dr. Cuddy came to confront Dr. House. She said the odds were against the patient having hyper-acute rejection. Dr. House said he agreed with her and made out like Taub was acting on his own.
They started the patient on antibiotics instead, but she failed to improve. The patient’s blood pressure started to drop and they realized the treatment wasn’t working. This appeared to indicate the problem was tissue rejection. They started her on intravenous methylprednisilone.
Dr. House admitted to Dr. Wilson that he gave in to Dr. Cuddy. Dr. Wilson once again told him to work it out with her.
The steroids didn’t work either, ruling out both infection or rejection. Dr. House realized the only other thing that made sense was that the patient didn’t have LAM despite the positive test for it.
Dr. House ran into the brother, who was worried about her because she had never before got sick, even with a common cold. However, although Dr. House initially treated this as a distraction, he was incredulous that Della never had a cold. He went in to ask her the last time she had a cold, minor aches or swelling. her mother confirmed she never gets colds and it had been years. However, Dr. House questioned the patient about it and she admitted to having had minor aches and pain in her ears an chest for about a year, ever since she went to Denver. She ignored it because she figured it was nothing compared to what her brother was going through.
Dr. House told Dr. Taub to get in touch with the transplant committee again, House realized the long term cold symptoms, lung failure, failure to improve on drugs and worsening symptoms at high altitude pointed to a clotting disorder, sickle cell trait. It even explained the false positive on the LAM test. However, the diagnosis merely pointed to a poor prognosis - the transplant committee was unlikely to approve a second transplant given the failure of the first transplant. However, Dr. House realized there was one live donor available - the brother.
Dr. Cuddy found out about Dr. House’s plan and told him he couldn’t advise the parents to authorize a bone marrow and partial lung transplant from the brother. Dr. House had confirmed the sickle cell trait diagnosis and reminded Dr. Cuddy that this was their only treatment option. Dr. Cuddy reminded Dr. House that give his MD, the son would be unlikely to live past 25 in any event and a transplant could halve his life expectancy. Dr. House argued the parent should have that choice. Dr. Cuddy insisted that they could not compromise one life for another. Dr. House agreed not to raise the subject, but Dr. Cuddy was worried that his judgment on the matter was being clouded by their relationship. He admitted that was probably the case, and Dr. Cuddy admitted she was having trouble making decisions involving his patients as well. Dr. Cuddy agreed to find another supervisor for Dr. House.
Della’s father comes to Dr. House to see if anything can save Della, and Dr. House reluctantly admits that they could take marrow and half a lung from their son. However, he also tells him this would shorten his life an prevent him from ever using a respirator. However, they have to make the decision by the next morning to do any good.
The father and mother discuss the problem overnight. Della wonders where her parents are and why they were arguing. Della realizes they are considering taking a lung from her brother to give to her. Dr. Taub tells her she’s wrong and not to worry about it. However, Della sneaks out of her room and suffers a respiratory arrest in the stairwell in what appears to be a suicide attempt.
The hypoxia resulted in Della’s condition accelerating, and the parents are told any decision has to be made quickly.
Dr. Cuddy reports to Dr. House that human resources can’t find a new supervisor for him - two department heads threatened to quit over the matter. She gives him permission to approach the parents about the treatment option, but he admits he already did when the father came to see him. Finally, the parents decide that they are not going to allow the live transplant. Dr. Cuddy tries to assure the parents that a donor lung could become available, but Dr. House loses his composure and tells the parents that although the patient doesn’t want the transplant, they should know better and allow it. He reminds them that their son’s maximum life expectancy is about a decade without the transplant, while Della could live for decades with it. Dr. Cuddy starts arguing with Dr. House about it and the brother overhears it. He goes to his sister and insists that she accept the lung transplant from him. He feels he will be able to share her life with what he has remaining and live on inside her instead of living the rest of his life without her.