This is an article about the patient in the episode Paternity. For James Wilson's brother, see Danny Wilson.
Dan was the high school lacrosse player in the episode Paternity.
Medical History[]
Dan had a recent history of sudden onset double vision and night terrors. After failing to be diagnosed, his parents contacted Dr. House and obtained an appointment.
Case Study[]
Dr. House performed an examination of the patient's eyes and found good margins, no lesions and good colour. Dan had been suffering from night terrors for three weeks, had had difficulty sleeping and was always exhausted. The patient couldn't name any animals starting with the letter "B". (Even easy ones like "bat", "bear", "bunny") Dr. House was able to rule out neurological damage. The two most likely causes of night terrors are post-traumatic stress syndrome or sexual abuse. The patient denied sexual abuse but then admitted he had been hit in the head during a lacrosse game. Dr. House decided it was PTSS and chided Dr. Cameron for taking an incomplete medical history. However, Dan's father insisted that the emergency room had ruled out a concussion. Dr. House that the ER had simply missed it. Dan insisted that the double vision pre-dated the trauma, but Dr. House believed the double vision probably resulted in him losing his bearings, which led to the concussion. He thought that the patient merely needed glasses and went to refer him to an ophthalmologist. However, before he left, Dr. House noted the patient was exhibiting a myoclonic jerk even though he was wide awake. Dr. House admitted the patient.
Eric Foreman noted that all the symptoms indicated an inability of the patient's brain to control his eyes or muscles. The obvious conclusions were a movement disorder or a degenerative brain disease, both of which were untreatable. Robert Chase suggested an infection, but Dr. House noted this was unlikely because his white blood cell count was normal and he had no fever. Dr. House doubted that the patient's father was his biological father which could affect the medical history. Dr. Cameron suggested leukoencephalopathy. Dr. Chase suggested a systemic disease and put down the night terrors to incorrect reporting by the parents. Dr. House ordered a polysomnograph to confirm night terrors. However, the EEG confirmed night terrors.
The patient was given an MRI, CT Scan, CBC, Chem 7, and chest X-ray, but all the results were normal. However, Dr. House reviewed the MRI and found the corpus callosum had bowing, which indicated that something was pushing against it, most likely from a blockage that was allowing intracranial pressure to build up. Dr. House ordered a radionuclide cisternogram to find the blockage. The blockage was confirmed and Dr. Chase scheduled the patient for surgery to insert a shunt into one of the ventricles to allow the cerebrospinal fluid an opportunity to drain.
The surgery went well, but the team tested a bottle of his spinal fluid and found the bowing was only a symptom. The patient's tests indicated multiple sclerosis, but although Dr. Foreman thought this diagnosis was likely, the other doctors pointed out that there were no lesions on any of the scans. A definitive diagnosis of MS would take months to confirm. However, if it was MS, it was rapidly progressing MS. Dr. House ordered treatment even though the best prognosis was that the patient would only be able to walk for another two years and live another five years. The patient was informed.
During the night, the patient was missing from his room. The team went to look for him and informed Dr. House he was missing. Dr. House arrived at the hospital and suggested that they check the roof because orderlies often keep the door opened. Dr. House was correct and Dr. Foreman found the patient disoriented on the roof. The patient appeared to think he was on a lacrosse field. Dr. Chase approached the patient and tackled him before he reached the edge of the roof.
The patient's actions indicated he didn't have MS because the patient was not having a night terror but was in an acute confusional state. This was unlikely with a condition that causes demyelination like MS. It would be consistent with a brain infection. Dr. Cameron suggested neurosyphilis, but he had tested negative. Dr. House ordered high dose penicillin through a lumbar puncture which wouldn't cause any excess pressure because of the existing shunt.
However, during a lumbar injection, the patient started having auditory hallucinations. Dr. Chase ordered intravenous ativan.
The hallucinations and lack of improvement on penicillin indicated the diagnosis of neurosyphilis was incorrect and that the brain infection was worsening. Dr. House put the acronym MIDNIT on the whiteboard. Metabolic diseases like diabetes mellitus were ruled out because the patient's LFT. BUN and creatinine tests showed his kidneys were working normally. Inflammatory diseases such as vasculitis were ruled out by the MRI. The patient was too young to have a degenerative disease. Neoplastic diseases were also ruled out by the clean MRI. All possible infections were ruled out despite the oligoclonal bands by the high but within range white cell count and lack of fever, as well as negative tests. Subdural infections had been ruled out by the CT Scan. Trauma was also ruled out. Dr. House ordered an EEG along with left and right EOG esophageal microphones.
Dr. House was confronted by the parents, but was aware that Dan's blood pressure was 110/70, the shunt was patent and well placed in the right central ventricle. The patient's EKG showed a normal QRS pattern with deep wave inversion from both the limb and peripheral leads. His LFTs were elevated, but only twice the normal range. He also reported the auditory hallucinations.
The patient tested negative for West Nile virus and Eastern equine encephalitis. However, Dr. House also surreptitiously tested the parents' DNA and determined neither of them was the patient's biological parent. Dan was adopted. The parents were discussing moving the patient with Dr. Cuddy when Dr. House confronted them and told them he had sampled their DNA but that the medical history they gave him was inaccurate. However, the parents had given the doctors the medical history of the patient's biological mother. However, the parents were not able to answer whether the biological mother had been vaccinated for measles. Dan was vaccinated at six months old, but if he contracted the disease before that and his mother was not vaccinated, the disease would have run its course, but also would have mutated and laid latent in the brain. This would eventually result in subacute sclerosing panencephalitis, which would cause the patient's symptoms. The patient most likely had not yet reached phase 2, which is untreatable and terminal. The only treatment was intraventricular interferon. However, if the patient did not have the disease, this treatment, which requires a large needle to be inserted directly into the brain, would be fatal. The only way to confirm without a brain biopsy was to take a sample from the retina directly through the eye. The diagnosis was confirmed and the parents consented to treatment despite the dangers. A hole was drilled in the patient's skull to inject the interferon.
The patient's EEG and immune system responded with treatment and the patient's ability to perform cognitive tasks improved markedly – he was able to name several animals beginning with the letter "O". The patient admitted he had known for six years he was adopted because he had a cleft chin and neither of his parents did.
Night Terrors - House M.D.