The patient is a former Marine with an extensive travel history.
While leading persons in a youth camp through an obstacle course on a rainy day, Driscoll suffered severe back pain which left him unable to move or rise to his feet. He eventually collapsed to the ground as the pain continued. He was taken to the emergency room at Princeton-Plainsboro Teaching Hospital. After he arrived at the hospital, he was unable to empty his bladder. The case was assigned to Dr. House and his team. Dr. Chase asked if the patient had taken an antihistamine, but he hadn’t, and the ER had ruled out enlarged prostate gland and obstructed large intestine and injury to the spine. Ms. Masters noticed the patient was in good shape and suggested steroid abuse, but Dr. House dismissed it as the patient’s other hormones were normal. Dr. Chase said that given the lack of urination, they had to determine whether it was the uethra or the muscles around the bladder that were at fault. Dr. House ordered catheterization.
Dr. Foreman explained to the patient that he should tell them when the urge to void his bladder became unbearable and apologized for the discomfort of the procedure. The patient finally told them he had to urinate, so Dr. Foreman allowed him to void through the catheter, planning to test the urine.
Dr. Taub instructed Ms. Masters how to perform the test. However, the urine showed no bacteria. However, the catheterization showed the pain was a nerve problem - neurogenic bladder. This could indicate a spinal cord tumor or cerebral palsy. However, Dr. Foreman felt that Dr. House would most likely suggest syphilis and went to test for it.
Ms. Masters went to take a blood sample, but the patient flew into a rage and attacked her. Dr. Foreman went to stop the patient and managed to free Ms. Masters and alert security.
The patient was put in restraints and started on haldol, which restored his lucidity. Together with psychosis, the other symptoms fit tertiary syphilis, but the test was negative. Dr. Foreman suggested tricyclic anti-depressants or ritalin would explain the symptoms as well. Ms. Masters suggested several native plants, such as wormwood and jimson weed. Dr. Chase noted that the patient most likely would have mentioned any of those, but Ms. Masters suggested that perhaps Driscoll had been poisoned by one of the boys in the discipline camp. Dr. House ordered an environmental scan of the camp.
Ms. Masters and Dr. Foreman went to the camp. They decided that the most productive course was to ask if any of the kids had trouble with Driscoll. They were led to Landon and MacDonald. MacDonald confirmed that Driscoll was harder on Landon than on the other kids. However, Landon denied doing anything to hurt Driscoll. However, Dr. Foreman noted MacDonald was suffering from allergies. He was asked why he wasn’t taking anything for them, but he refused to say anything.
Dr. Foreman and Ms. Masters considered that Driscoll had been dosed with antihistamines by the boys and started him on treatment. Driscoll apologized for attacking Ms. Masters. The patient complained his heart was racing. Dr. Foreman examined him with his stethoscope and noted his heart rate had risen to 170. Dr. Foreman ordered 6mg of adenosine and told Ms. Masters to get the crash cart.
It took three doses of adenosine to get his heart rate under control, and the tachycardia started when the patient was put on fluids. The reaction appeared to rule out antihistamine toxicity. Dr. Taub thought the tachycardia was a humoral effect caused by mastocytosis, however, that causes symptoms in either the digestive tract or the skin. Ms. Masters suggested a pancreatic insulinoma, but that wouldn’t cause bladder problems. Dr. Chase suggested a pheochromocytoma, which would. Dr. House ordered scans of the adrenal glands and pituitary gland and had them collect the patient’s urine for 24 hours.
Dr. Foreman and Ms. Masters performed the MRI. Driscoll told Ms. Masters that he figured Landon was the one that drugged him. Ms. Masters told him to remember that Landon’s mother had died and he had never known his father.
However, the scans of the adrenals and pituitary were normal, as was a scan of the thyroid gland. The patient’s catecholamines were monitored and they were all normal, ruling out a pheochromocytoma. The patient had to be put on a diltiazem drip to regulate his heart. However, the doctors were paged by the emergency room. Landon had been admitted with identical symptoms.
Dr. Taub went to take a medical history to determine what they had in common. They both ate the same food at camp, but that would have made others sick as well. However, as Dr. Taub tried to proceed, Driscoll and Landon started arguing. Dr. Taub couldn’t find a link. Ms. Masters though they had been exposed to something at the camp like legionellosis or toxoplasmosis, but those didn’t fit the symptoms. Dr. Taub realized nocardia could explain some of the symptoms, but it doesn’t affect the bladder. Dr. Foreman suggested Lyme disease, but neither patient had a rash or tick bite. However, Dr. Foreman pointed out that 40% of patients don’t present with a rash, and tick bites are easy to miss. Dr. House ordered doxycycline.
Ms. Masters administered the antibiotics to Driscoll, but Landon refused medication, saying he wanted to wait. However, Ms. Masters convinced him to take the medication.
However, Landon tried to leave his room, and stole Ms. Masters’ car keys. He said he didn’t want to be with Driscoll. Driscoll tried to follow him, but when he got out of bed, he complained he felt like his leg muscles were in a vise. Dr. Foreman ordered 10mg of diazepam and 40mg of potassium.
The leg cramp was caused by low sodium, which was traced to kidney dysfunction. Neither patient had responded to doxycycline. Ms. Masters suggested arsenic, but that would also cause vomitting and diarrhea. Dr. Chase suggested Whipple’s disease, but neither patient had any digestive tract involvement. Dr. Taub thought the symptoms pointed to botulism - it lives in soil and both patients had abrasions which could allow the bacteria that produces it into their bloodstream. Dr. House ordered anti-toxin.
Ms. Masters went back to the patients and was surprised to learn that, unlike the other kids at the camp, Landon was not there because of a court order. His social worker arranged it. Ms. Masters called the case worker and found out Driscoll had arranged for Landon to be there. Ms. Masters separated the patients so Dr. House could confront Driscoll - Ms. Masters had found out Driscoll had paid the fee for Landon to go to the camp. Driscoll admitted that he was Landon’s father and begged Dr. House not to tell him.
The relationship put genetic disorders on the table. They didn’t respond to anti-toxin and Landon started having seizures. Dr. Foreman didn’t think it was genetic though, because genetic disorders arise at similar ages, not during the same time period. However, Dr. Chase noted several genetic conditions can be set off by environmental factors, and they had been in the same environment. Dr. House suggested Wegener’s disease, which can be brought on by heavy metal exposure. There were lead batteries at the camp, but Dr. Taub pointed out if it were lead, someone would have come down with lead poisoning. Dr. House said they had no better idea and ordered cyclophosphamide.
Ms. Masters asked Driscoll why he didn’t take care of Landon when Landon’s mother died, but Driscoll didn’t find out about the death until after Landon was in foster care. Ms. Masters counselled him to tell Landon the truth and act less like a drill instructor and more like a father.
However, as Dr. House was about to administer lidocaine to a clinic patient, he realized Landon had stitches too. He figured both patients had variegate porphyria which was set off by the antihistamines they dosed Driscoll with and the lidocaine they gave Landon. Landon realized they had the same genetic disease. The condition could be treated with hematin and a liver transplant could cure the condition. Driscoll admitted to Landon he was his father. Landon didn’t believe him, but Dr. House offered a DNA test to confirm.
Both patients started to improve on hematin.