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Medical History Edit
Both Donny's father, paternal grandfather and paternal line great-grandfather died of heart failure just after turning 40. As a result, Donny has become fatalistic and takes risks in his job, resulting in several broken bones and other injuries.
Case History Edit
Donny was brought to Princeton-Plainsboro Teaching Hospital's emergency room when he fell approximately 30 feet while pursuing a suspect. Upon arrival at the hospital, he was diagnosed two broken bones, a severe concussion and a collapsed lung. He wanted to be released but Dr. Cameron told him he would have to be admitted for two days. His partner told Dr. Cameron that Donny wasn't suicidal, but was fatalistic because he thought he would die soon. Donny told Dr. Cameron about his family history of heart trouble, and that he had already seen several cardiologists, none of whom found anything wrong. Donny was sure they were wrong.
Dr. Cameron brought the matter to Dr. House. However, he thought the family history was a coincidence and not a genetic problem. He also pointed out that Donny had no symptoms of heart trouble. Dr. Foreman, who was still in charge of diagnostics, agreed to start a differential diagnosis for genetic heart conditions. Dr. Chase suggested Marfan syndrome and brugada. Dr. Cameron suggested familial hypercholesterolemia. Dr. House thought they should pass on it, but Dr. Foreman ordered an EKG, echocardiogram, cardiac catheter and genetic testing. Dr. Cameron went to get blood samples.
However, all the tests were negative. Dr. Chase thought they should discharge him, but instead, Dr. Foreman got permission from the patient to exhume the bodies of all his male line ancestors. The great-grandfather's skeleton was nearly intact, and the grandfather's skeleton even had some genetic material. However, the father's body had completely petrified to liquid from being in a completely sealed coffin. Dr. Foreman started sequencing the gene for the cardiac sodium channel.
The review of the ancestor's DNA showed no consistency over the genetic markers that might indicate genetic diseases, but Dr. Cameron was hopeful the son's DNA would be helpful in this regard. However, to get a pure sample, they would need an invasive and painful bone marrow biopsy from the son. However, the son refused the procedure.
Dr. Cameron suggested that the mother speak to Donny. She went to tell him about his son, but he resisted seeing him as well. She brought in the son anyway, However, Donny didn't want to get involved with the son because he knew how bad he felt when his own father died.
The son did agreed to the bone marrow biopsy, but the tests were normal for all twenty genetic diseases that affect the heart. Dr. House decided to discharge him with a false diagnosis, Ortoli syndrome and a placebo he had to take for a few weeks. He told Donny that the technology to treat the condition didn't exist when his father died. He then discharged the patient.
However, later that night, Dr. Foreman came to see Dr. House at home to tell him that Donny had collapsed and died four hours after he was discharged. His apartment manager had found him on the floor of the laundry room and he wasn't breathing. The emergency workers were called but couldn't revive him. Dr. Foreman told Dr. House not to be too hard on himself - the patient was asymptomatic and all his tests were negative. Donny had been taken to Princeton General, but when Dr. Foreman found out, he requested that he be sent to the PPTH morgue so he could perform the autopsy himself. Dr. Chase prepared to inform the ex-girlfriend personally.
Dr. Foreman started the autopsy by doing an external examination and then getting the skin saw to do a standard Y-incision. However, he noticed Donny was bleeding at the incision site. All of a sudden, Donny sat up and screamed in pain. He then started gasping for breath. However, his systolic blood pressure dipped below 60 and he lost consciousness again. It was apparent that his severe low blood pressure and bradycardia was mistaken for death. Dr. Cameron pointed out that ingestion of tetrodotoxin can cause a deathlike state, however, it didn't explain why his male ancestors would also have died at the same age. Dr. Foreman pointed out that sick sinus syndrome can also cause severe bradycardia, and Dr. Chase pointed out an atrial block could cause it too. However, Dr. House wanted to direct his attention away from the patient's heart because they were so thorough about examining it. Dr. Chase thought it might be a metabolic disease, and Dr. Foreman suggested a genetic disposition to isolated anti ro-antibody disease. Dr. House agreed and suggested steroids.
Donny regained consciousness and told Dr. Cameron that he remembered putting his laundry in the dryer, but nothing after that. She told him he had been declared dead and an autopsy had been started. He complained that his jaw ached and continued to complain that it felt worse. In order to relieve the pain, he grabbed a pair of forceps from a cart and removed one of his teeth. However, a dentist examined the tooth and there was nothing wrong with it. Dr. Cameron thought that the severe pain could indicate bone cancer, but that wouldn't have any heart involvement. Dr. Foreman disagreed, it could be paraneoplastic syndrome. However, Dr. Chase pointed out that primary bone cancer isn't hereditary, so it wouldn't explain the ancestors. However, Dr. Cameron suggested Li-Fraumeni syndrome - it is hereditary and increases bone cancer risk. Dr. Foreman ordered a gamma survey to look for tumors. However, the scan showed no tumors.
Dr. House came in the next morning to ask for more ideas, but neither Dr. Foreman or Dr. Cameron had any. He went to leave and realized that there is no pain without nerves. Donny could have hereditary sensory autonomic neuropathy type 1. This would cause the brain stem to miscommunicate signals so the brain would mistake nerve pain for tooth pain and it also causes bradycardia. All he needed was carbamazepine. Dr. House went to get Dr. Chase to administer the treatment. Dr. Chase told Donny they would know in a couple of hours if it were working. However, Donny lost control of his intestines. This seemed to rule out the diagnosis and indicated Donny's illness was getting worse. Dr. Chase thought it might be an autoimmune disorder, but Dr. Foreman pointed out the patient didn't improve on steroids. Dr. Cameron suggested Wilson's disease, but Dr. House pointed out that if it were this advanced, it should be affecting the liver. Dr. Foreman suggested that if the liver were non-functioning, the lab tests would look normal. They decided to try penicillamine.
However, after talking to Dr. Cuddy, Dr. House realized there was one other possibility. He went to tell Donny he wasn't going to die. He had realized that Donny had an aneurysm in his brain stem. It expanded and started pressing on all the nerves that control things like tooth pain and heart rate. Eventually, it would have gotten large enough to shut down the signals from his brain to his heart. Donny was skeptical, but Dr. House told him that he would have to cut into his brain to confirm the aneurysm, and if he had one, he would have to treat his son as well. Donny agreed to tell his son himself.
The surgery on both Donny and his son was successful. Donny went to see his son in recovery and asked him if he wanted to see a movie.