Medical History Edit
Over the past several years, Emmy had lost a great deal of weight through proper dieting and exercise. Once very obese, she was now had a healthy body mass index and her body fat percentage was also low.
Case History Edit
Emmy collapsed after moderate exercise when she became unable to breathe and fell down a series of stadium seats, breaking her ankle in the process. She was taken to the emergency room at Princeton-Plainsboro Teaching Hospital. The case was assigned to Dr. House.
Dr. House met with Dr. Taub and Dr. Kutner. Emmy's CT Scan showed no problem with her lungs that would explain a breathing disorder. Dr. Taub believed a person in Emmy's excellent condition may be abusing steroids which could lead to a pulmonary infection. Dr. Kutner didn't think this was likely - Emmy's fitness program is based on a natural approach. Dr. House told him to run lab work for steroids anyway. However, Dr. Cuddy who was sharing Dr. House's office while her own was being worked on, told Dr. House that the patient had already tested negative for steroids and implored them to read her chart. Dr. Kutner thought it might be an allergy - the patient jogged a lot and might have inhaled too much pollution. However, Dr. Cuddy pointed out that she collapsed a half-mile from any road. However, she realized that it had been cold lately and that she may have exercise induced asthma from breathing cold air in too suddenly. However, Dr. House noted that this would not explain the patient's elevated blood pressure.
However, when Dr. House got out of his office, he admitted to Dr. Taub and Dr. Kutner that he lied to Dr. Cuddy about the high blood pressure. Dr. Kutner reminded him that exercise induced asthma would fit her symptoms, and Dr. House agreed. He just didn't want Dr. Cuddy to know that. Dr. Taub pointed out that the only way to confirm was to duplicate the conditions that led to the attack, but she couldn't run with a broken ankle.
Instead, Dr. Taub put her on a hand driven treadmill. They started talking about her diet and she admitted she didn't eat much fat. Although she had no trouble breathing, Dr. Kutner noticed her face was becoming flush. He asked if she was okay and although she responded positively, she immediately collapsed. Dr. Taub could not find a pulse and immediately ruled out asthma. They used a defibrilator to shock her back into sinus rhythm and stabilized her. However, her EKG was normal, so the test didn't set off the heart attack. Dr. House realized the heart problem wasn't due to any defect in her heart and realized it had to be systemic. Dr. Kutner suggested a carcinoid tumor. Dr. House ordered his team to scan for it.
Dr. Taub and Dr. Kutner started an MRI to look for the tumor. They didn't find a tumor, but did find gastric banding from gastric bypass surgery. They realized she didn't lose her weight solely through diet and exercise. They did some investigating and found she had the surgery removed from her medical records so it would not affect her career as a fitness celebrity. Dr. House asked his team to consider diseases related to excess weight. Dr. Kutner suggested she may have had diabetes mellitus type II, which could have caused nerve damage. However, Dr. House dismissed the suggestion as diabetes induced nerve damage would have presented when she was still obese. Dr. Kutner suggested sleep apnea, but Dr. House pointed out her weight loss would have cured that and, if it had caused permanent damaged, there would be other symptoms such as feeling tired after sleeping. He went to join Dr. Foreman and Dr. Hadley, who were busy with a drug trial to get their suggestions. Dr. Hadley thought it might be a complication of the bypass surgery, such as low potassium. However, Dr. Kutner noted that the bypass might have caused malabsorbtion by creating a blind loop in the small intestine. It could have ulcerated during exercise, allowing bacteria to leak into the bloodstream where they could migrate into the heart and lungs - SIBO.
Dr. Taub went to get a stool sample. Emmy explained to Dr. Taub that she underwent the bypass surgery because nothing else she did allowed her to lose weight.
Dr. House went to see how the stool test was going, but was told it would take an hour to spin down the sample. However, Dr. House had a faster way - since SEBO would cause high fat content, her stool should float in water. Dr. House just dropped some in water and watched it sink to the bottom. He realized that it could be sleep apnea and told Dr. Taub and Dr. Kutner to take Emmy to the sleep lab.
Emmy was taken to the sleep lab for observation. They suddenly noticed that she had left the sleep lab. They found her on a treadmill exercising on her broken ankle. She said that after sleeping a couple of hours, she felt great and her ankle didn't hurt. However, Dr. Taub noticed her leg was bleeding. He pricked her with a needle below her knee, but it didn't hurt. She had numbness in her left foot that was ascending.
Dr. House admonished Dr. Taub for letting Emmy get out of the sleep lab without being noticed. Dr. Kutner reported that her alpha waves on the EEG had ruled out sleep apnea. The ascending numbness could indicate a problem with her nerves, brain or both. Dr. Hadley suggested Multiple Sclerosis, while Dr. Kutner suggested early-onset Parkinson's Disease. Dr. Taub suggested transverse myelitis. Dr. House realized they had to figure out if the problem was in her nervers or brain and ordered an Ncv test.
Dr. Taub went to administer the test. The patient said if she revealed her bypass, no-one would listen to her about fitness. The patient started having trouble lifting her left arm, showing muscle weakness. Dr. Taub cancelled the test as it obviously wasn't a nerve problem.
Dr. Taub reported the muscle weakness to Dr. Kutner and suggested it might be myasthenia gravis. However, Dr. House doubted this was the case as her breathing had improved and the weakness was only in her extremities. Dr. Kutner suggested botulism from the use of botox to tighten up her loose skin. However, Dr. House pointed out heavy metal poisoning was just as likely and ordered chelation therapy.
Emmy did not improve on chelation and her muscle weakness started getting worse. Dr. Hadley suggested coronary cardiac fistula, but Dr. House pointed out the symptoms started in her lungs, not her heart. Dr. Foreman suggested Austrian syndrome, but the patient had no history of alcohol use. Dr. Taub thought it might be Guillain-Barre syndrome set off by the bypass. She might have mistaken the muscle weakness for ordinary fatigue from exercising. Dr. House agreed and ordered plasmapheresis.
Emmy was afraid she was going to be confined to a wheelchair. However, Dr. Taub insisted she should still walk.
However, Emmy continued to get worse and started having hallucinations. This ruled out Guillaine Barre, but pointed towards a brain disorder. Dr. Hadley suggested CNS lymphoma. Dr. Taub suggested a prion disease, but Dr. House pointed out if that was the case, there was little they could do for her. He approved a brain biopsy but Dr. Cuddy overheard and overruled him, telling him to test for CNS lymphoma first as the test was far less dangerous. She told him to also rule out astrocytoma and brain tumors before he did the biopsy. Dr. House instructed his team to do so even though he knew the tests would be negative.
The brain MRI was clean for CNS lymphoma and Dr. Taub went to prepare her for the test for other types of brain tumors. The patient asked for a piece of chocolate cake. Dr. Taub told her not to give up, but she felt that the diagnosis was likely to be something very bad. She admonished Dr. Taub for being so hard on her for her deception about bypass surgery and asked him what was next if it wasn't a brain tumor. He told her they were thinking about a prion disease. She asked for the cake again and Dr. Taub relented.
Dr. Taub reported the negative CNS test and asked if he should speak to Dr. Cuddy about approving the biopsy given that the patient was getting worse. Dr. House said he would do it himself. When Dr. Taub objected, Dr. House pressed on. However, when they arrived at Emmy's room, they found her feeling so much better that she was out of her bed exercising.
Emmy's rapid recovery puzzled Dr. House, but Dr. Hadley pointed out that sick people get better all the time just because the immune system does what it is supposed to. However, Dr. House pointed out that this had never happened with patients sick enough to see him. Dr. Taub told him that after the MRI, all he did was get her some chocolate cake and give her a banana bag. Dr. House admonished Dr. Taub for not telling him about the cake before.
Emmy got worse again, but Dr. House brought her another piece of cake. He had figured out she had hereditary coproporphyria. The treatment is a high carbohydrate diet rich in sugar as other foods aren't properly broken down in her body due to a lack of a critical enzyme. When she was obese, she was inadvertently eating a diet that treated the condition. However, she opted for a drug that managed the condition without curing it. Dr. Taub realized she didn't want to lose her looks by gaining her weight back. Dr. House agreed to put her on the drug treatment.