Frankie has been a vegetarian for several months, although she continues to eat fish.
Frankie came to the emergency room of Princeton-Plainsboro Teaching Hospital after presenting with multiple bruises to her face and bleeding out of her mouth. She was admitted for observation after the doctors determined she had some sort of colaguopathy.
Dr. Chase thought it might be congenital thrombocytopenia, but her platelet count was normal. Dr. Hadley thought it might be something related to photographic chemicals, but given her blogging, she most likely used digital cameras. Dr. Taub thought it might be a problem with one of the other chemicals involved in binding platelets together, but Frankie’s clotting factors were normal as well. Dr. Hadley thought it might be some other toxin and wanted to do an environmental scan of the apartment. Dr. House agreed.
Dr. Taub and Dr. Hadley went to Frankie’s apartment. They ran into Frankie’s neighbour, who was going to call the police until he found out they were doctors. Dr. Taub talked to him and he mentioned that Frankie did composting, but it was attracting rats. He put down rat poison, but Frankie collected it. Since rat poison is a blood thinner, it explained Frankie’s symptoms.
Frankie insisted she washed her hands after touching the rat poison, but Dr. Foreman told her that given she had touched it several times over two days, they had to be sure. However, when she went to urinate, she reported that the urine was mud colored, indicating kidney failure. This ruled out rat poison.
Dr. House started a new differential. Dr. Hadley suggested hemolytic-uremic syndrome, but Frankie’s creatinine levels were normal. Dr. Foreman pointed out Frankie’s cholesterol levels were normal. Dr. Taub suggested Gaucher’s disease, which would affect her ability to synthesize Vitamin K. However, Dr. Chase pointed out her vegetarian diet would give her plenty of dietary Vitamin K. He thought it was Sjögren's syndrome. Dr. Foreman noted she had just eaten fish, and Haff disease could result in rhabdomyolysis. Dr. House thought Hoff disease was the most likely given the time line of the progression of the symptoms and ordered saline and mannitol.
Dr. House assigned Dr. Chase to read Frankie’s blog to look for medical clues. However, Dr. Chase couldn’t find anything medically relevant. Dr. Hadley informed him that one of the readers of Frankie’s blog had already asked about donating his kidney. However, as he discussed the case and his personal life with Dr. Hadley, Dr. Chase remembered that Frankie complained on her blog about not being aroused for sex. Lack of vaginal secretions can be a symptom of Sjogren’s.
Dr. Chase rushed Frankie for a sialogram and asked her to lie flat on her back. However, Frankie insisted on propping herself on her elbow and lying on her side because she said it was uncomfortable. Dr. Chase suddenly realized that discomfort lying down often indicates a problem with a heart valve. Moreover, this would explain all of her symptoms - Sjogren’s could have damaged the heart valve, which then in turn caused clotting which damaged the kidneys. He conformed it with an echocardiogram, found that her mitral valve was severely damaged and scheduled her for heart surgery. Dr. House was so impressed he nearly complimented Dr. Chase on his medical skills.
They explained the options to Frankie. A heart valve from a pig would be the best choice if she wanted to have children, but she would need surgery about every ten years to replace it. A plastic valve would last much longer, but she would have to take blood thinners which are known to cause birth defects. Dr. Chase was aware from the blog that Frankie and her boyfriend Taylor were ambivalent about having children. Frankie wanted to write about it on her blog and although Taylor tried to dissuade her, she did. After consulting her readers, she wanted to go with the plastic valve. However, Taylor was afraid she was doing it to please her readers and threatened to leave.
Frankie was prepared for surgery. However, in the prep room, she started suffering from pains in her right side and started vomiting. Dr. Foreman rushed her into the operating room. It turned out that her appendix had ruptured. They surgically removed it and did a biopsy, which showed abnormal cells consistent with lymphoma. She started to realize that the reason they didn’t put in the new heart valve was that it was pointless. Dr. Chase confirmed that the burst appendix most likely spread cancer cells throughout her body and chemotherapy was not likely to be effective. However, Dr. Cuddy had approved an experimental treatment where they would develop a vaccine that targeted her cancer cells but would not damage other cells, allowing the immune system to have a better chance of fighting off the disease. Taylor asked for a prognosis, and Dr. Foreman said they weren’t certain, but she might have one year left. Frankie consented to the treatment.
However, Dr. Chase noted that Frankie seemed too calm, almost if she were in denial about the diagnosis. Dr. Foreman noted that denial is common in terminal cancer patients, but Dr. Chase thought it could be a symptom. The vaccine was soon ready. Frankie was given two injections with no adverse side effects, but after the third she developed a fever of 104F. It appeared the new antibodies had tripped an autoimmune response. They used ice packs to bring down her temperature.
Dr. Cuddy wanted to terminate the treatment. Dr. House started asking when the symptoms developed and Dr. Hadley mentioned that she had found the patient sleeping peacefully when she gave her an injection the previous afternoon. Dr. House wondered how someone could sleep in a hospital during the day. Dr. Chase mentioned that wasn‘t unusual for her because Frankie usually stayed up late and slept late. Dr. House asked how he knew that and Dr. Chase replied the patient had told him. Dr. House thought it was relevant and asked when she said she had started staying up late, but Dr. Chase wasn‘t sure. Dr. House checked the time posts on Frankie‘s blog and noted that before six months ago, her posts were mostly in the afternoon, while for the last six months, they were in the middle of the night. Dr. Taub realized she might have day-night reversal, a sign of liver disease which didn‘t fit with lymphoma. Dr. House realized that they only diagnosed lymphoma based on the abnormal cells they found. He ordered a liver biopsy.
The liver biopsy ruled out lympoma. The cells they thought indicated lymphoma were re-examined and found to be from a build up of granulomas. However, this was a worse diagnosis than lymphoma. Unless they could find out what was causing the liver failure, she would die within four days. Frankie got angry and broke down crying in her boyfriend’s arms.
Dr. Foreman suggested that the vaccine may not have caused the fever - it persisted after they took her off the vaccine. This would indicate an infection, but the other symptoms didn’t narrow down the possibilities - no-one she had been in contact with was sick, there was nothing in her medical history, she hadn’t travelled and there was nothing in her blog. Dr. House figured there must be something she wasn’t telling them. However, Dr. Chase pointed out her blog was very frank and she had left out nothing that was even highly private. Dr. House decided to start broad spectrum antibiotics.
However, after a long period of thought, Dr. House realized there was something Frankie might not talk about in her blog. He went to ask if her stool floated or sank, and whether they were soft or hard. Embarrassed, she said they floated and were soft. She said she didn’t blog about it because no-one wanted to hear about it. Dr. House said that regular people might not care, but it was very medically relevant. He asked if her stool had changed, and she said it had after she became a vegetarian. However, Dr. House pointed out that the digestive tract of vegetarians gets more efficient, making the stool hard and dense enough to sink. Dr. Hadley realized she had nutrient malabsorption. Together with the other symptoms and the fact no-one she knew had it, one non-contagious infection fit the bill - Whipple's disease. Dr. House ordered cotrimoxazole. Dr. Chase told her she would still need a new heart valve and would have to be on medication for a few years to completely treat the Whipple’s, but she would most likely fully recover. Frankie turned to her boyfriend and told him she was going to get the pig valve.