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Gabe was admitted to the hospital after suffering from coughing, fatigue and fever for almost a week. He also had a congested chest and was coughing up green sputem. Dr. Cuddy brought the case to Dr. House, who thought it was pneumonia. However, Dr. Cuddy pointed out that the patient's lung x-rays and CT Scan were atypical for pneumonia. There were no infiltrates although his hylar lymph nodes were enlarged. The patient had not responded to cefuroxime and his pulse oxygen was dropping faster than was typical for pneumonia. The patient also had a papular lesion rash on his arm on top of a scab. Dr. House agreed to take the case.
Gregory House reported to his team that the patient had a papular rash, puleur sputem, dysnea and bronchi bilaterally. Robert Chase thought it might be legionnaire's disease. Dr. House ordered a urine antigen test. Allison Cameron thought it might be a fungus. Eric Foreman believed it might by chlamydia. Dr. Chase also suggested that the rash may have come before the pneumonia and it was most likely from a tick bite. Lyme disease was the most likely tick borne disease. Dr. House ordered fluids and that the sepheroxene be continued. He also ordered a biopsy of the rash. He also ordered a more thorough medical history.
The patient denied being sexually active, which ruled out chlamydia. Dr. Chase removed the patient from his room to speak to the patient privately. The patient said he thought he was cursed, and Dr. Chase reassured him. The patient admitted that he had been in an empty house. This suggested a fungus from the damp environment the patient had described.
Dr. Chase went to the house to perform an environmental scan. He managed to find some insulation before he had to abandon the house when the police arrived. An examination of the insulation showed it was made of animal hair. Dr. House re-examined the CT Scan and found a widened mediastinum, indicating anthrax, which can be transmitted through animal hair. The patient was immediately stared on levoquin.
The patient's father was not convinced it was anthrax and suggested leishmaniasis and filariasis. However, the patient was soon in respiratory arrest. Dr. Chase examined his throat and found nodules. Dr. Foreman attempted to intubate the patient, but had difficulty due to the swelling in the patient's throat. Dr. Chase called for ativan. The patient appeared cyanotic. Just before Dr. Chase performed a tracheotomy, Dr. Foreman managed to intubate the patient.
The patient was started on rifampin but the swelling did not change. This seemed to rule out an allergic reaction. Dr. Rowan Chase was consulted and believed the anthrax diagnosis may be wrong. Dr. Cameron pointed out the rash had not turned black from necrosis, which was a classic sign of anthrax. Dr. Robert Chase pointed out that the rash can take up to two weeks to turn black. Dr. Rowan Chase believed it was sarcoidosis as this was consistent with the nodules in the throat. Dr. House agreed and ordered a test of the patient's ACE levels and methyltrexate if the test was positive. The test was positive, but just before the patient was started on methyltrexate, Dr. Robert Chase noticed the rash had turned black.
Although anthrax seemed to be confirmed, that condition could not explain the nodules in the throat. Dr. Rowan Chase believed the patient might have anthrax and sarcoidosis, but Dr. Robert Chase pointed out that both conditions are rare and that anthrax combined with an allergic reaction was more likely. Dr. Rowan Chase pointed out the allergic reaction was bizarre. However, Dr. House believed that Dr. Rowan Chase's theory was possible and ordered treatment for both anthrax and sarcoidosis.
The patient's father confronted Dr. House and pointed out that his donation to the hospital bought him a quick diagnosis of carpal tunnel syndrome and directed House to spend more time on the case. However, the patient then developed a series of lesions on his back. The severity of the lesions would most likely lead to sepsis. Dr. Rowan Chase thought it might be an autoimmune disorder brought on by the anthrax. Dr. Robert Chase believed the father's suggestion of leishmaniasis and philariasis would also fit. He also suggested multiple neurofibramatosis. Dr. House agreed it might be autoimmune and Dr. Foreman started the patient on steroids until they narrowed down the diagnosis. Dr. Robert Chase decided to biopsy the skin lesions. However, the patient improved on steroids as the swelling and fever went down. However, Dr. Robert Chase still disagreed with his father's diagnosis. The patient's ANA was normal and the most common autoimmune disorders were quickly ruled out. Dr. House also thought Dr. Robert Chase was incorrect, but he pointed out that steroids might allow a relapse of the anthrax and make it more resistant. When he could not convince Dr. House, he went to test for the other less common autoimmune diseases.
The patient's appetite returned, but he soon lost the ability to move his hand. He soon started to deteriorate again and his right hand and forearm became paralysed. His fever rose to 105 degrees F. There were clear signs of neural degeneration. Dr. Robert Chase believed it was toxic neuropathy from the steroids and other medication. At this point, Dr. Rowan Chase agreed with his son's earlier diagnosis of multiple neurofibramatosis. Dr. House ordered a CT Scan of the patient's brain. Dr. Chase and Dr. Cameron performed the scan, but it indicated no sign of neurofibramatosis.
Dr. Cameron suggested Buerger's disease, but the patient had never left the country. Dr. House wondered why the patient's father suggested diseases that are only found in south-east Asia. Dr. House thought that they might have set off the symptoms by giving the patient antibiotics. Dr. House confronted the father and grabbed the wrist that was supposed to have been cured of carpal tunnel syndrome, but it was still painful. He asked how the father knew about the two diseases he mentioned, which are common in Asia but uncommon in the United States. He pressed the father on whether he had ever been to Asia. After denying it, the father finally admitted he spent two years on an ashram in India. He had hid it because a guru had stolen all his money. The history of travel to Asia combined with the symptoms of the father and son indicated leprosy. It commonly causes autoimmune disorders and was misdiagnosed in the father as carpal tunnel syndrome. The leprosy would also have affected Gabe's immune system, leaving it vulnerable to anthrax. When they gave him antibiotics, the dead leprosy bacteria sent the immune system into overdrive and the antibodies attacked his nerve and fat cells. Dr. House ordered a test for leprosy, which came back positive. He also ordered thalidomide which would treat the leprosy without the side effects of the immune system disorder. Both the father and son were treated. Gabe soon improved and his lungs were functioning normally and the paralysis lessened. His prognosis was excellent.