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Medical History Edit
Jessica is severely obese - well into the 99th percentile of weight for girls of her age or height and at least one standard deviation above average weight for her age group. She has been put on a strict regimen of diet and exercise, but has not lost any weight, leaving her primary care physician to come to the conclusion that she has been overeating. She is also somewhat short for her age (below the 50th percentile) but within a standard deviation of average height. Both of her parents are above average weight, height and body mass index.
Case History Edit
Jessica was admitted to Princeton-Plainsboro Teaching Hospital after collapsing during exercise directed by her physical education teacher. She had complained of chest pain. The physical education teacher performed CPR until the ambulance arrived. She had no heart beat on admission and the hospital performed an EKG and three CKMBs which confirmed she had suffered a heart attack. Dr. Lenkowitz referred the case to Dr. House.
Dr. Foreman was incredulous about the heart attack, but the tests had been double checked. Dr. Chase thought it might be a drug overdose, but Dr. Cameron pointed out that the patient had been suffering from fatigue, muscle pain, and difficulty concentrating for over a year. Dr. Chase put these symptoms down to a combination of obesity and clinical depression. However, although several doctors had come to the same conclusion as Dr. Chase, Dr. House pointed out the heart attack couldn't be attributed to obesity and depression. Dr. Foreman though it was a genetic disease. Dr. Cameron suggested metabolic syndrome X which causes insulin resistance. However, Dr. Foreman pointed out that this might cause a stroke, a heart attack was unlikely. Dr. House pointed out a heart attack was possible if the patient's blood pressure was very high. Dr. Cameron pointed out the patient's excess weight would mostly likely drive her blood pressure up. Dr. House ordered a hyperinsulinemic euglycemic clamp.
Dr. Cameron explained to the patient's mother that Jessica was most likely producing too much insulin. When the mother was told it was treatable with proper diet and exercise, she doubted that was the answer as she was sure her daughter ate right and exercised regularly, but still failed to lose weight. However, the mother consented to the test. The patient even resisted being weighed as part of the test, but finally got on the scale.
The team performed the test as Dr. Chase slowly increased the flow of glucose into her bloodstream. The patient complained about being thirsty, then became combative when Dr. Cameron tried to reassure her. Dr. Cameron thought she might be hypoglycemic. They finally sedated the patient. The team attempted to explain that such reactions were a common side effect of the test, but the mother reminded them that Dr. Chase appeared to be distracted and that she never wanted the test performed as she felt it unlikely that this was her daughter's problem. However, Dr. House arrived with the results that the patient was not hypoglycemic and the psychosis the patient suffered was not related to the test. However, he had to admit he did not known what caused the psychosis, but agreed it was not something that could be cured with diet and exercise.
Dr. House asked his team what could cause uncontrollable rage in a 10 year old, but Dr. Foreman realized nothing that could would also cause a heart attack. Dr. Chase suggested that the patient had a hypercoagulable state, which could cause blood clots. Dr. Cameron pointed out that clots would more likely cause a stroke, but Dr. Chase pointed out that if a clot reached the amygdala, it could cause uncontrollable rage. However, Dr. Cameron pointed out that 10 year olds are unlikely to have clotting disorders. Dr. Chase once again thought it might be related to her weight, perhaps a fat embolism. However, Dr. Cameron pointed out that fat emboli only happen to patients after surgery that cuts into fat, such as liposuction. However, Dr. House realized that another treatment for obesity could cause psychosis and blood clots - diet pills. They would not show up on a standard tox screen. Dr. Cameron did not think that the mother would give the daughter diet pills. Dr. House ordered warfarin to prevent further clotting and ordered Dr. Foreman to find the diet pills.
Dr. Foreman checked with the patient's teacher, but she didn't know about diet pills. She did tell Foreman that Jessica didn't have any friends. She did suggest an 8th grader who was assigned as Jessica's "buddy". The buddy confirmed that the patient ran laps during recess, but she confirmed that the patient said she was taking diet pills her mother gave her. Dr. Foreman confronted the mother, who denied it, but the patient admitted stealing diet pills from the pharmacy. Dr. Foreman told the mother the pills explained all of her symptoms.
However, the patient soon took a turn for the worse, developing bleeding ulcers all over her chest - skin necrosis. This could not possibly be related to the diet pills. Dr. House thought that the patient had been kept on warfarin instead of being switched to heparin - that could cause warfarin induced skin necrosis. Dr. Chase had given the patient warfarin, but Dr. Cameron insisted she had given the patient heparin. However, no one had seen Dr. Cameron administer the heparin, including Dr. Chase who was there at the time. Dr. House ordered unfractionated intravenous heparin and low molecular weight subcutaneous heparin to reverse the effect of the warfarin STAT. The patient was also sedated to deal with the pain.
Dr. Cameron noted that the patient was not responding to treatment, making it more likely she did administer the heparin just as she was supposed to. However, she could not come up with an alternative explanation. The necrosis continued to get worse. Dr. House just believed it was slow to respond to treatment. However, Dr. Wilson was consulting on the case and noted that the necrosis would kill her within a day. He suggested surgery to remove the dead tissue before it penetrated the abdominal wall. Dr. House agreed and they arranged to have surgery if it did not improve in the next few hours. The mother was told that the necrosis attacked fatty tissue, and that the patient's breasts had to be removed - it was her only chance for survival. The mother consented.
Dr. Cameron accused Dr. House of not being objective about her possibly being in error. She wondered why he wasn't pushing the team for answers, and he replied he had the answer. However, Dr. Cameron pointed out that House rarely works on a case once he figures he has solved it, yet he was still working on this one.
The patient did not improve and the time came to consider surgery. At that point, Dr. House asked Dr. Chase and Dr. Foreman for alternatives. Dr. Chase agreed with the current diagnosis, but Dr. House still asked for alternatives. Dr. Chase started talking about her weight again but asked whether they should consider whether her weight was not a cause of her symptoms but another symptom of an underlying condition. Dr. House asked for diseases that cause both obesity and skin necrosis. Dr. Foreman suggested ulcers secondary to vasculitis, but that doesn't cause obesity. Dr. Chase suggested pyoderma gangrenosum but that would not cause the sores. Dr. House decided to narrow down the focus to diseases that cause obesity. Dr. Chase suggested hypothyroidism, but her mother was heavy too.
However, Dr. House realized both of the parents were tall and the child was not. He listed all the symptoms - stunted growth, high blood pressure, clots, obesity and realized it was Cushing's syndrome - in rare cases it causes hypercalcemia which also causes skin necrosis. However, Dr. Foreman noted the patient's cortisol levels were normal. Dr. House suggested that the cortisol spikes could be cyclical, and may not have turned up on blood tests. Dr. Chase suggested another UFC to confirm, but there was no time to perform one in the one hour they had left before surgery was the only option. However, if they treated her for Cushing's and she didn't have it, she would die.
However, if she did have Cushing's, the mastectomy they had planned wouldn't be effective and the skin necrosis would continue. Dr. House ordered an MRI to check for anything that might cause hypercortisolism. They performed the MRI and found a tumor on her pituitary gland, confirming Cushing's. However, she still needed dangerous surgery to remove the tumor. The surgery went well. The patient was released a few days later. She returned for a follow up visit a few weeks later. Her fatigue was gone and she had lost a substantial amount of weight.