Ian Alston was the young patient suffering from bloody diarrhea that House was convinced was dying of the same disease that had killed another patient of his twelve years earlier in the episode All In. He was portrayed by actor Carter Page.
Ian was admitted to Princeton-Plainsboro Teaching Hospital when he had a bout of bloody diarrhea during a school trip. His parents were called to the hospital and his regular primary care physician, Dr. Cuddy was informed that Ian was in the hospital. He was hemodynamically stable but was suffering from coordination problems. Dr. Cuddy thought it was dehydration due to gastroenteritis and ordered fluids. She told the attending doctor that she would see Ian when she was back on duty. However, Dr. House, who was with her at the time, asked if Ian's head had been scanned and what his heart rate was. The attending said his heart rate was normal and his head hadn't been scanned.
Dr. House excused himself and went to examine Ian. He asked Ian to follow his finger with his eyes, but Ian had difficulty doing so. When he asked Ian to reach out an grab his cane, Ian missed it by several inches. Dr. House realized Ian was exhibiting ataxia because his brain was losing the ability to control his muscles.
Dr. House went to his office to get an old file - Esther Doyle. He then went to get his team together. He was symptoms on the whiteboard and asked what 6 year olds have in common with 70 year olds. Dr. Cameron noted that the immune system of both is weakened making listeria more likely. However, Dr. House said he had already checked for that. Dr. Foreman pointed out leukemia is more common in those age groups and Dr. Cameron said asthma is as well. However, Dr. House rejected those suggestions. Dr. Cameron suggested diabetes mellitus, and Dr. House rejected that too. When Dr. House wrote "kidney failure" on the board, Dr. Foreman noted that Ian didn't exhibit that symptom, although he did have diarrhea and ataxia. Dr. Foreman asked what Ian and the 70 year old had in common, and Dr. House admitted that it was nothing he knew about. Dr. Cameron suddenly realized that Esther's file was 12 years old. Dr. Foreman realized that Cuddy had taken over as attending on Ian's case and wondered why Dr. House was treating him. Dr. House lied and told them that Dr. Cuddy agreed with him that it wasn't gastroenteritis. Dr. House finished writing symptoms on the board that Esther, a 73 year old, had progressed to death. He told them that Esther went from ataxia to kidney failure in 80 minutes and progressed to death within a day. However, Dr. Chase was incredulous - he figured Ian had merely eaten some bad food. Dr. House ordered a colonoscopy and to biopsy any purple papules to check for Erdheim-Chester disease. Dr. Chase was incredulous again - there were only about 200 reported cases of Erdheim-Chester. Dr. House said if Esther's family had allowed an autopsy, there would be another one.
Dr. Chase and Dr. Foreman did the colonoscopy, although Dr. Chase told him he didn't expect to find anything. Dr. Chase told Dr. Foreman that just before Dr. Cameron started, they treated another patient while referring to Esther's file. However, he only had food poisoning. He also told him that before he started, Dr. House referred to the file at least three other times.
Dr. Cameron explained Erdheim-Chester to the parents. She assured him the test would be over soon.
However, during the test, Dr. Foreman found some pustules, although Dr. Chase thought they looked red, not purple and that they were just blood blisters. Dr. Foreman took a sample. Dr. Cameron examined the sample and found no trace of Erdheim-Chester. Dr. House wanted to do a kidney biopsy. They went to see Ian and found his urine was brown, indicating his kidneys were failing just as Dr. House predicted.
Dr. Chase went to do a kidney biopsy, but Dr. House said it was too late - he did one on Esther and it hadn't helped. He wanted to focus on the rest of Esther's symptoms . Dr. Chase suggested that it might be e. coli and they should start Ian on plasmapheresis. Dr. House thought that it was a good idea except for one thing - he had tried exactly that with Esther and it hadn't done any good. Dr. Cameron suggested Goodpasture's syndrome, but it would not explain the papules. Dr. Foreman thought it was heavy metal poisoning, but for that his hematocrit would have to be low and it wasn't - it was 44 and Dr. House recalled Esther's never dropped below 42. Dr. Cameron suggested lymphoma, and Dr. House admitted he had never checked Esther for that. Given Ian's symptoms, it would have to be visible in his blood and brain, so Dr. House ordered a blood smear and immunoassay as well as an MRI. He also told them not to let Dr. Cuddy know.
They tried to perform an MRI of his head. Dr. Cameron admitted to the parents that the previous patient with these symptoms had died 24 hours after admission. They were having trouble getting Ian to lie still and got the parents to reassure him. They were able to perform the scan, and found a small mass near the pituitary gland. This would explain Ian's low blood pressure and also matched Esther's next symptom - pituitary gland failure. However, Dr. Chase returned with the blood tests, which ruled out lymphoma.
Dr. House said their only advantage was that they knew the progression of the disease. It would attack the liver next. Dr. Chase wanted to perform an ultrasound, but Dr. House ordered acetylcysteine, interferon, silymarin and anything else that might protect his liver.
The team started treatment and it seemed to be working to protect the liver, although his level of platelets was dropping. Dr. House was encouraged as it appeared to be a new symptom. Suddenly Ian had trouble breathing. Respiratory failure was the symptom Esther had after liver failure. Dr. House realized whatever the disease was, it had merely steps.
Ian was put on a ventilator and stabilized. At this stage, Esther had only lived another two hours. Dr. Chase thought the cytelcistine might be responsible, but Dr. House noted that although it is a side effect, it would have taken longer than 20 minutes. Dr. Cameron thought it might be the interferon - it affects the immune system and would have affected blood cancer like leukemia. However, Dr. Foreman noted that if it was a blood cancer, the interferon would have slowed its progress, not sped it up. Dr. Cameron wasn't sure - there are about 500 different types of blood cancer. They needed to speak to an oncologist.
Dr. House managed to convince Dr. Wilson to agree to a consult. Dr. Wilson agreed that depending on the type of blood cancer, interferon could either improve it or make it worse. He took a look at the blood sample and saw no sign of leukemia. they had no time to do a bone marrow biopsy. If it was an occult blood cancer, interferon was unlikely to make it worse, especially this fast. Dr. Cameron thought it might be an autoimmune disease - interferon would make that worse. Dr. Foreman suggested sarcoidosis, but Dr. Cameron pointed out that Ian didn't have enlarged hylar lymph nodes. Dr. Chase suggested juvenile rheumatoid arthritis, and Dr. Wilson suggested Kawasaki's disease. However, Dr. Foreman noted that Kawasaki's doesn't affect the elderly. Dr. Wilson said it didn't matter - Kawasaki's may not explain Esther's symptoms, but did explain Ian's. Dr. House wanted to know why Kawasaki's couldn't effect the elderly. However, confirming Kawasaki's required tests for ANA and sed rate and couldn't be done in time. However, Esther's sed rate had been 98. When Dr. Wilson reminded him that didn't confirm Ian had it, Dr. House planned to look at the coronary artery. Dr. Wilson realized Dr. House was working on Esther's case again.
The echocardiogram found no aneurysms, blood clots or irregularities in the coronary artery. However, they did find a small mass in his right atrium. Esther showed no such mass. It could be bacteria, muscle or connective tissue. Dr. House wanted to do a biopsy. Dr. House started the procedure, but Ian went into cardiac arrest. Dr. House grabbed the defibrillator and called a code blue. However, it was eight minutes before they got Ian's heart started again. He had most likely suffered brain damage. Dr. House completed the biopsy.
Dr. Chase suggested they test for histiocytosis, but Dr. Foreman noted it was rare in the elderly. Dr. House noted that whatever it was, it was rare. Dr. Cameron suggested tuberous sclerosis. It would explain the symptoms, if not why he had suddenly developed symptoms from a lifelong genetic disease. Dr. Chase noted that although leukemia might be unlikely, it hadn't been ruled out. Dr. Cameron suggested multiple soft tissue tumors from sarcoma. She also suggested multiple neurofibramatosis. Dr. Foreman brought up sarcoidosis again as well as chondrocytomas.
Dr. Cuddy came to confront Dr. House about treating her patient and ordered him to stay away from Ian.
Dr. House kept working on the case. He still had the sample he took. They could run three tests on it. He figured Cuddy would test for sarcoidosis herself. The team figured that it has to be a disease that was already present, otherwise how could it spread so fast. Autoimmune diseases were more likely. Between tuberous sclerosis and histiocytosis, the latter was more likely in an older person like Esther, so they decided to test for that first. They cut off a third of the sample and added immunoperoxidase. However, the sample didn't turn red, ruling out histiocytosis.
Dr. Chase still thought it was a disease that caused abnormal cell growth. Dr. Foreman pointed out that sarcoma affects muscle cells which are spread throughout the body. Dr. Cameron thought a genetic disease was more likely in a six year old - tuberous scerosis. Dr. House thought sarcoma was more likely, but the test for tuperous sclerosis was more reliable. They did the next test for tuberous sclerosis. After cutting half the remaining sample, the tests for the kepy proteins were negative.
With only one test left, Dr. Cameron suggested chondrocytomas, but Dr. Foreman noted Ian would not be this sick if he had that. Dr. Chase wanted to test for neurofibramatosis - it was not the most likely, but it would be the best news. Dr. House took a short break to see Dr. Cuddy and the patient. He admitted he had no ideas. However, he spoke to Dr. Wilson who told him how he beat a pair of kings with his pocket aces. When Dr. House came back he asked them to test for Erdheim-Chester again. He though that it may not have reached the intestines when they tested it earlier. His team was opposed, but Dr. House insisted. Dr. Cameron saw macrophages and then Dr. Foreman confirmed CD-68 - it was Erdheim-Chester. Dr. House ordered that treatment be started. Ian slowly started to recover and was soon breathing on his own and responding to stimuli.