Medical History Edit
One year before this hospitalization, the patient suffered from second degree burns over 54% of his body while trying to save a fellow firefighter. He received extensive skin grafts, but had returned to his regular firefighting duties before he was re-hospitalized.
Case History Edit
Derek was at a fire when he became disoriented and had trouble breathing. His partner Amy tackled him before he walked into a burning building.
Derek was brought to the emergency room at Princeton-Plainsboro Teaching Hospital. Dr. Cameron was called in for a consult when Derek's body temperature kept rising and falling, often to the point where he was shivering. Derek insisted he was fine but Dr. Cameron told him she would seek a consult from Dr. House.
Dr. Cameron reported to Dr. House that Derek's body temperature fluctuated between 96F and 102F. The patient had been disoriented on two previous occasions in the past two weeks. Dr. Foreman suggested a hypothalamic tumor could explain the shifting body temperature, but Dr. House put the temperature fluctuations down to incorrect readings, most likely due to the patient drinking both hot and cold liquids. However, Dr. Cameron pointed out that the patient had tested negative for hepatitis, tuberculosis, Lyme disease, and HIV and his tox screen was clean. Dr. House reluctantly agreed to take the case. He noticed an arythmia and said the patient's symptoms were probably due to a heart attack. However, Dr. Cameron pointed out that Derek had no chest pain and that smoke inhalation would explain the arythmia. Dr. Chase noted that Derek had several surgeries to treat his burns and he may have contracted a hospital borne infection such as MRSA. Dr. House ordered blood cultures, vancomycin and broad spectrum antibiotics.
Derek was put in the isolation ward and was told about the possibility of MRSA and drew blood for testing. Derek asked if MRSA would make everything look blue. Dr. Cameron knew it would not. They reported this to Dr. House. Dr. Foreman thought it might be heavy metal poisoning, perhaps thalium. However, if it was, Derek would be losing his hair as well. Surprisingly, Dr. House suggested menopause, in this case not due to his age, but due to higher estrogen and lower testosterone. This would explain the temperature swings and disorientation. Viagra would explain the blue vision. Dr. Cameron pointed out that Derek wasn't taking Viagra, but Dr. House felt that Derek just hadn't told them - male menopause would also cause erectile dysfunction. Dr. Chase pointed out that there were no other signs of premature aging, but Dr. House pointed out there are other causes of hormone imbalances. In this case, a burn to his testicles could cause a trauma that would affect his production of testosterone. Dr. House ordered a hormone panel and if it was positive, give the patient testosterone supplements and release him.
Derek took the news well and was released from isolation. Amy came to visit him and Derek suddenly became panicky about the tubes and tried to remove them. Dr. Foreman thought it looked like an allergic reaction. Dr. Cameron tried to calm Derek, but Derek grabbed her by the throat. Dr. Foreman called to a nurse for 2 mg of lorazepam. As the lorazepam took effect, he released Dr. Cameron.
Whatever caused Derek's reaction, it wasn't the testosterone they were giving him - it came back negative for contamination and allergy. There was no sign of a pulmonary embolism. The EKG showed normal tachycardia from his exertion during the attack. Dr. Foreman thought anger that came on that fast had to have a neurological origin. He suggested a CT scan to look for a frontal lobe tumor and a lumbar puncture for meningitis. Dr. House agreed.
However, both the CT scan and lumbar puncture came back negative. With Dr. House being on personal leave, the rest of the team tried to work out a new differential. Dr. Chase thought it might be polyarteritis nedosa or some other vascular disease. However, if that were case, they would have seen brain lesions on the CT scan. Dr. Foreman suggested Legionnaire's disease, which would explain the temperature fluctuations and his altered mental state would lead to the aggression. However, Dr. Cameron pointed out they would have seen respiratory problems. Dr. Cameron wanted to consult Dr. House again, but Dr. Foreman thought they should try to work it out on their own. However, it wasn't for several hours that Dr. Chase realized the patient's clean tox screen might be a problem. Skin grafts hurt a lot and he wasn't taking anything for them. He was probably hiding some sort of pain in order to keep his job and they had to find out where it was. Dr. Foreman suggested that perhaps the opposite was true - he wasn't feeling any pain. Either way, it was worth looking into.
The team was paged and rushed to Derek's room. His heart rate was up to 147 and his respiration was at 42. Amy told them he had been fine just minutes before. Dr. Foreman checked for fluid in his lungs, but they were clear. Derek's O2 stats dropped to 85%, indicating that he should be intubated. However, Dr. Chase realized Derek was having a heart attack.
They managed to stabilize Derek, but they realized he wouldn't stay stable for long. His blood tests showed elevated troponins and CK-MB. They realized that Derek was hiding his chest pain. He was having a series of heart attacks. Dr. Cameron didn't think that would cause the aggression, but Dr. Foreman pointed out that the hypoxia would explain the disorientation and the excess adrenaline released during the heart attack would cause the rage. However, Dr. Chase pointed out they didn't know what was causing the heart attacks. Dr. Cameron insisted on talking to Dr. House.
Dr. House was having problems during his detoxification from Vicodin, but agreed to see them. Since his vascular system seemed clean, he surmised there must be an external source for the heart attacks. However, the three attacks took place in wildly different places and didn't seem to have anything in common. However, Dr. House asked if any person was there for all three attacks and Dr. Cameron confirmed Amy was there for all three. Dr. Chase couldn't figure out how Amy could have caused the attacks. Dr. House suggested trying to induce an attack. Dr. Cameron went to take Amy to visit Derek and when she entered the room, Derek was fine at first, but soon had another heart attack.
Amy agreed to be examined to determine why she was causing the attacks and agreed not to see him. She told Dr. Cameron how Derek got burned - he got caught in a backdraft while trying to save her when she got trapped in a fire. However, all the tests were negative. Dr. Cameron went to talk to Derek about her to see if there was a psychological cause. He admitted he was in love with her, but couldn't tell her because she was engaged to his brother. She figured it was broken heart syndrome. Dr. Foreman pointed out that his generally only affects very old women, but Derek's hormone imbalance resulted in the same effect. Dr. Chase pointed out that the syndrome would only lead to cardiomyopathy, not heart attacks, but Dr. Cameron noted if the cardiomyopathy was untreated, it could lead to heart attacks. They had put Derek on beta-blockers and nitroglycerine, but they were not having any effect. Dr. House wondered what else could be done. Dr. Cameron suggested anti-depressants, but Dr. House noted that these would just slow down his autonomic nervous system more, leading to more heart attacks. Dr. Chase suggested propylthiouracil to slow down his metabolism, but this would also weaken Derek's heart. Dr. Foreman said the only other option was blood thinners. Dr. Chase said it was as simple as keeping Amy away from him, but Dr. Cameron feared he would have an adverse reaction if he were told he could never see her again. Dr. Foreman thought Dr. Chase's suggest was the best course available - the only other course of action was to damage Derek's brain so badly that he would forget Amy altogether. Dr. House asked why they couldn't do that and went to Dr. Cuddy to get permission.
Dr. Cuddy resisted until Dr. Cameron confirmed that they couldn't use anti-depressants. Dr. House suggested electroshock therapy, even though it would remove all of his memories. Dr. Cuddy finally relented.
They explained the procedure to Derek. Although his experiential memory would be removed, he would remember how to do tasks. Dr. Cameron suggested he tell Amy how he felt, but he refused to do so because he felt it would hurt both her and his brother. He also realized she didn't love him. He consented to the procedure.
Derek was given a muscle relaxant to prevent convulsions during the procedure. They started the procedure. In the recovery room Derek still had his mental faculties, but couldn't remember anything. His brother and Amy came to visit him, and he had no adverse reaction.
Derek went through four courses of electroshock. Apart from his voice being higher, there was no other adverse reaction. His EKG and blood pressure were normal. They planned one more course. They updated Dr. House.
However, Dr. Cameron was later talking to Amy and asked her about the engagement to Derek's brother. However, she denied she was getting married to the brother and told them they weren't even dating. The team immediately reported that Derek's belief was a delusion to Dr. House. They realized that whatever he had, it was stilla affecting him. Dr. Foreman did an MRI and found slight hypoprofusion in the anterior cerebral cortex. Dr. House asked if they had performed a clotting time test or tested his LV function. Dr. Chase confirmed his blood was normal and the heart was pumping it to the brain. Dr. House realized something had to be obstructing blood flow. However, there was no hyperintensity to suggest a foreign body was at fault, and there was no infection or vasular malformation. Dr. House suggested the problem was lower down. Dr. Cameron reported the cytology and the lumbar puncture suggested a tumor. Dr. House ordered a selected vertebral angiography and left the court hearing he was attending to return to the hospital.
Dr. House had realized the high voice was a symptom of menopause, not the electrical shock. After setting up the test, Dr. House ordered it centered on the interpeduncular cistern. The dye indicated a spinal meningioma, which is far more common in women than men. It was pushing on the nerves to the vocal cords, making them sound higher. The nerve is also next to the meningal branch of the bratequal artery. This blocked blood flow to the brain, creating false memories. Although the electroshock didn't fix the problem, it did buy them time to find the real problem. He scheduled surgery to remove the meningioma.
The surgery was successful and Dr. Cameron reassured Derek that his family and friends would take care of him.