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The case was assigned to Dr. House. The emergency room had found no sign of trauma or any bleeding in the space behind the eye. Dr. Park suggested lymphocytosis noting that the patient’s ALC levels were at the high end of the normal range. Dr. Adams suggested cavernous sinus thrombosis, causing a clot at the base of the brain. Dr. House ordered the blood panel re-done and a CT veniogram of the patient’s head.
The veniogram showed no clots or malformations. Dr. Adams approached Dr. House about the patient’s girlfriend. The patient obviously wanted to see her, but she was unreachable by phone and the neighbor Molly had never seen her. Dr. Adams suspected the patient was a drug addict going through withdrawal and he kept the drugs at his apartment. Inhalants were a likely choice given his symptoms. Dr. House ordered an environmental scan.
Dr. Chase and Dr. Adams went to the patient’s apartment. It was tidy, but Dr. Adams didn’t see anything that obviously pointed to a woman living there. However, Dr. Chase found flowers and a card made out to Amy. While searching, Dr. Adams found what appeared to be the body of someone in the bed as there was no sign of breathing. However, on closer examination, it turned out to be a realistic doll of some sort.
The patient explained he referred to the doll as his girlfriend to avoid explaining himself. Dr. Adams was worried that the patient might be delusional or was hearing her talk to him, but the patient clearly understood that “Amy” wasn’t a real person. The patient had been in relationships with women but found them unfulfilling. Dr. Chase noticed the patient was sweating. The patient complained about it being hot, even though the room temperature was close to normal.
It was clear the patient had a fever, but the team argued about whether the patient’s attachment to the doll was a neurological problem. Dr. House figured out that the doll was probably harboring some type of infection and ordered the team to run blood cultures on swab samples.
Dr. Chase and Dr. Adams started gathering samples from the doll. However, the surface and interior features all appeared to have been recently cleaned. However, Dr. Chase did find some sort of mass within the doll. They decided to put the doll into the CT Scanner and found an empty space in the “abdomen”. Dr. Chase guessed that the space might be harbouring clostridium perfringens, which gave off gas that expanded. However, Dr. Adams noted that this wouldn’t explain the neurological issues. Dr. House told them to get the patient’s consent to cut into the doll. Dr. House thought that either there was something in the space that was making the patient sick and he would readily agree, or he would refuse and Dr. Adams was probably right about the patient having some sort of mental illness.
The patient agreed to cutting into the doll. Out of respect for the patient’s feelings, Dr. Chase suggested to Dr. Adams they do it in a procedure room rather than in the patient’s room. Dr. Adams cut the doll open and started blood cultures, but the interior looked clean and there was no smell. To make the patient feel better, she even sutured and bandaged the cut. However, she figured the cavity was merely an air bubble that was trapped in the mould when the doll was made. The patient was very appreciative of Dr. Adams care, but all of a sudden he went into respiratory distress. Dr. Adams called a code.
Henry had crackling lung sounds. He was given diuretics to reduce his fluid levels, but he still needed oxygen. His heart was normal, and Dr. Chase guessed it might be high output failure due to anemia. However, the patient’s hematocrit was normal. Dr. Adams thought it might be DIC. She then suggested that the hole in the doll might be the result of the silicone it was made of degrading. The patient may have inhaled some of the particles. Dr. House agreed silicone deposition was a good fit and ordered plasmapheresis.
Dr. Adams assured the patient that the treatment wouldn’t be painful. However, his neighbor Molly came to visit and saw the doll. Henry explained about it and Molly made an excuse to leave.
However, a few hours later, the patient started having visual hallucinations that Amy was alive and bleeding over him. Dr. Chase administered lorazepam and realized that no matter what the patient’s previous mental state, he clearly had neurological symptoms now. Dr. Adams examined the patient, found his liver was palpable and distended, and realized the patient was hallucinating because his liver was failing.
Dr. Taub did tests and found the patient’s trans-aminase levels confirmed liver failure. The patient needed a transplant within about two days. This appeared to rule out silicone deposition, but did indicate vasculitis. However, the blood tests for it were negative. Dr. Park suggested hepatic fibrosis. It could damage platelets, which would explain the bleeding. However, Dr. Adams made an offhand remark about the patient’s doll costing $7,000, but Dr. Taub noted that he knows they only cost $5,000 and that the patient must have had it customized. Dr. Adams got back to the hepatic fibrosis, and noted it doesn’t cause difficulty breathing, but Dr. Chase countered that it would if the associated liver failure caused pulmonary arteriovenous malformation. Dr. House agreed with the fibrosis diagnosis and ordered steroids. However, he also wanted to know how the patient had the doll customized, even though it didn’t appear to be medically relevant.
Dr. Adams got in touch with the company that made the doll, which was modeled based on photos sent by the patient. The patient admitted it was an ex-girlfriend, a yoga instructor, who left him. Dr. Adams confided in the patient that her husband cheated on her with a woman he met coming back from their honeymoon. The patient said that it was simply his ex-girlfriend wasn’t in love with him. The patient started complaining the lights were bright and started vomiting. Dr. Adams asked if his neck was stiff. When the patient said it was, she realized he probably had meningitis.
Henry’s fever reached 105F and he didn’t respond to medication. They realized that he would probably be dead before the blood cultures showed results. A lumbar puncture showed a high number of white blood cells in his cerebro-spinal fluid, meaning the meningitis could be carcinomatous. However, the cytology results for cancer were negative. Dr. Chase suggested an amoebic infection could explain fever and meningitis, but Dr. Adams pointed out it wouldn’t explain liver failure. Dr. Park pointed out that a clot could be responsible for the liver failure. However, Dr. Taub couldn’t fathom how an amoeba would get past the patient’s cribriform plate - amoebic infection is usually the result of swimming in lake water and the patient hadn’t left New Jersey, where all the lakes frozen this time of year. However, Dr. Chase suddenly realized the ex-girlfriend was a yoga instructor and may have been into alternative medicine. He remembered something he saw at the patient’s apartment that looked like a small teapot with a very long spout. Dr. House drew a diagram on the board and Dr. Chase confirmed that’s what it looked like. Dr. House described it as a neti pot, used for flushing out the sinuses with water to rinse out mucous. If the patient had used salted tap water instead of distilled water an amoeba would have penetrated the cryptoform plate. Dr. House ordered metronidazole, hoping that they had caught it in time.
The patient improved rapidly. His fever started getting lower, his neck was less stiff, and his liver function tests improved markedly.