The patient was brought into Princeton-Plainsboro Teaching Hospital after being ill for three days and not having left her bed. When her husband attempted to rouse her, she struck out at him in anger and then apologized and said there must be something wrong with her.
After admission, she averaged 18 hours of sleep a day. Allison Cameron referred the case to Gregory House who believed it was merely clinical depression. When Dr. Cameron persisted, saying seven other doctors had ruled out numerous diagnoses, Dr. House became intrigued with Dr. Cameron's interest and agreed to review the chart. On further review, in addition to hypersomnia and irritability, Dr. House noted that she had a fever, which ruled out clinical depression. The patient's sed rate was elevated, indicating inflammation. It was obviously affecting the patient's brain. Vasculitis appeared unlikely as there were no other signs of systemic inflammation. Robert Chase suggested parasites, but the patient had no history of foreign travel. In addition, her blood smear was negative for parasites. Dr. House suggested a tumor on her brain stem, but Eric Foreman pointed out that it was unlikely that six other doctors missed a tumor directly on the brain stem. However, Dr. House ordered new blood work and a new MRI with 2mm slices through the mezodiemcephalic region.
Dr. Foreman and Dr. Cameron explained that the new MRI was going to have a more narrow focus than the previous radiology work as some tumors are small enough to miss unless you know exactly where to look for them. However, the MRI showed no lesions or masses. As they spoke to the patient, she had a grand mal seizure. Dr. Cameron called for adivan. The patient started aspirating and Dr. Foreman called for suction. They managed to stabilize the patient, but immediately thereafter she was having difficulty writing.
Dr. Foreman thought the problem might be a glioma that was too small to see with the MRI. He suggested a PET scan. However, Dr. House pointed out that a glioma that didn't show on a contrast MRI must be smaller than a grain of sand - too small to cause symptoms. Dr. Chase thought it might just be postictal disorientation, but that should have improved right away. He also suggested late stage Lyme Disease, but Dr. House noted the husband was very close to the wife and would have noticed the target shaped rash. However, James Wilson, who was providing an oncology consult, suggested paraneoplastic syndrome from breast cancer. The patient's mother had died from breast cancer.
They performed a mammogram of the patient. However, there were no tumors, only some small calcifications. Dr. Wilson thought it might be small cell cancer. He suggested a PET scan as well. Dr. Chase wondered how the patient could have paraneoplastic without a tumor, and Dr. Wilson pointed out in 12% of cases, paraneoplastic presents where there is no tumor. However, Dr. House pointed out that all those 12% are untreatable. He decided to give the patient immunoglobulin for her symptoms, hoping the tumor would become big enough to find. He ordered Dr. Foreman to perform an environmental scan of her work place - the home could be ruled out because the husband wasn't sick.
Dr. Foreman went to the restaurant where Elise worked as a rotisseure, the person responsible for preparing roast meats. None of the other personnel was sick, there were no insects or other pests, and they did not use dangerous chemicals to clean. However, Dr. Foreman noticed they served rabbits, a species that harbors tularemia.
While Dr. Cameron was questioning the patient to test her mental faculties, the patient complained of bad itch on her left arm. Dr. Cameron left to get some hydrocortisone creme, but the patient started hallucinating that there were insects all over her arm. The patient had to be sedated despite her hypersomnia. Dr. Wilson thought her hallucinations were also the result of paraneoplastic syndrome, but Dr. Cameron pointed out that sudden onset of the symptom after intravenous immunoglobulin isn't consistent with paraneoplastic. It was consistent with an infection. However, blood cultures had ruled out most bacteria, and the symptoms ruled out all other bacterial diseases. Her serology had ruled out a virus and parasites had been ruled out by c-sub smear. However, Dr. House pointed out African trypanosomiasis would not show up on smears as all the parasites would be in the brain. However, the patient had never been to Africa, and she had never had a blood transfusion. Dr. Foreman brought up the possibility of tuleremia, but it also presents with a rash. Dr. Foreman suggested she may have inhaled the organism as she cuts up meat as part of her job. However, the patient had no respiratory symptoms. Dr. Foreman suggested that she may have passed it off as a bad cold. Although Dr. House thought it was unlikely, he had to admit tuleremia was the best diagnosis they had.
Dr. Chase and Dr. Cameron ran serum antibody tests to attempt to confirm tuleremia. However, previous tests only showed slightly elevated antibody levels. Dr. Cameron suggested they merely treat the patient for tuleremia and trypsansomiasis, but Dr. Chase pointed out the treatment for tuleremia can cause aplastic anemia and 10% of patients treated for trypsanomiasis die from the treatment. Dr. House felt any test for tuleremia would probably be inconclusive anyway.
Suddenly, Dr. House remembered there was a third way to contract trypsanomiasis - sexual transmission. There was a precedent. However, the husband had never been to Africa either. Dr. Cameron protested that the two were devoted to each other. Dr. Foreman was assigned to question the husband, and Dr. Chase was assigned to question the wife. After ruling out the symptoms of tuleremia, they asked them if they had had an affair. The husband denied cheating on his wife, and the wife denied cheating on her husband. Dr. House agreed if there was no cheating, trypsansomiasis was impossible and ordered treatment for tuleremia - intravenous chloramphenicol, 25mg/kg of body weight 4 times a day.
Dr. Cameron was caring for the patient at 4 a.m. when she realized the patient could not be roused after a short period awake and had fallen into a coma. Her vital signs were fine and her pupils were reactive. However, she did not respond to pain.
As the patient was getting works on chlorantheticol, it was obvious she didn't have tuleremia. This only left trypsansomiasis as a possible diagnosis. Dr. House thought it was ironic that ten doctors needed a coma in a patient sleeping 18 hours a day to diagnose it. However, there was still no way to explain how she had it. Dr. House examined the patient to look for lymphadenopathy and spoke to the husband. The husband said he didn't have an affair and he trusted his wife. Dr. House asked for the husband's consent to treat her despite the risk of death from the treatment. Dr. House told him if he even thought there was a possibility that she cheated, he should agree. If he was sure she had not, he should reject the treatment. However, if she had trypsansomiasis, she would be dead by the following morning. When the husband said he didn't know if he trusted his wife that much, Dr. House ordered the treatment - melarsoprol, a drug that is essentially arsenic mixed with antifreeze that can melt plastic and needs glass syringes and special intravenous tubing. It's side effects are nausea, abdominal pain, blood toxicity, nerve damage and Arrhythmia. It is also very painful.
The patient did not get worse after the treatment started, a good sign but not conclusive. However, the patient's fever spiked at 104 degrees F, an echocardiogram showed global hyperkinesis, and her blood pressure dropped to 90/40. Dr. Chase administered 270mg/min of dopamine, but after 10 minutes there was no improvement. Dr. House told the husband that given Elise's lack of progress, it was likely the melasoprel was destroying her heart faster than the parasites and it was unlikely she would recover. However, a few minutes later, the patient's heart rate and blood pressure started to rise and she came out of her coma. Her prognosis soon improved and it appeared she would make a full recovery. However, after she was awake, her husband left the hospital. Dr. House asked the patient who her sexual contacts were so he could be notified and treated. The trypsansomiasis was traced to her husband's jogging partner.