The patient has a long history of substance abuse and is a heavy smoker. He frequently gets into fights. He also lies frequently, particularly about his age.
Quidd showed signs of trauma, self-cutting, fever, arthralgia, hyperinflation, anemia, fatigue, as well as blood in both his stool and urine. However, his tox screen showed signs of alcohol, cocaine, amphetamines, and opiates. Senior emergency room attending Dr. Cameron put Quidd's symptoms down to drug abuse and was getting ready to release him. However, Dr. House came to the ER looking for a patient for his fellowship applicants to diagnose. Dr. Cameron insisted there was no mystery but given the patient's uncooperative nature, she was happy to let Dr. House take over.
Dr. House took the case to his fellowship applicants. Dr. Forman thought it was clearly drugs. However, when Dr. House told the applicants that he had to fire two of them within a week, Dr. Kutner suggested endocarditis and Dr. Hadley suggested hemorrhagic lesions in his lungs and digestive tract. Dr. Volakis suggested bronchulitis obliterans from heavy smoking. Dr. Hadley suggested bacterial meningitis. Dr. House directed them to run tests, but Dr. Foreman stopped them saying all the symptoms could be caused by drug abuse. Dr. House countered that the patient had every possible symptoms a drug addict could have. If he only had a few symptoms, drug abuse would be likely, but with every symptoms an underlying illness was more likely. Dr. Foreman pointed out that the proposed tests would be painful and invasive, and given his weakened state, withdrawal from drugs and bleeding, the tests could kill him. Dr. House agreed and allowed one applicant to run one test at a time. Dr. Volakis was allowed to go first. Given the patient's low oxygen states, she wanted to runa bronchoscopy.
Dr. Foreman was opposed to Dr. House's plan to turn the treatment of the patient into a game, but Dr. House insisted it was the only way to build the best team.
Dr. Volakis took the patient to the washroom before the procedure and Dr. Hadley came by to ask her why her theory was predicated on the patient's drug use. When Dr. Volakis said it was because the patient used drugs, Dr. Hadley pointed out it was a bad idea to leave a nicotine addict alone with an oxygen tank. Suddenly, they heard an explosion. Dr. Volakis rushed in to see the patient on the floor with a cigarette nearby.
Dr. Hadley went back to Dr. House to remind him that a bronchoscopy was out of the question now due to the smoke inhalation from the explosion - the patient would have an laryngospasm if they tried. Dr. Volakis said she could do an upper lung biopsy instead, but Dr. Hadley pointed out that procedure was invasive. Dr. House suggested a nicotine patch for the patient and allowed Dr. Volakis to do the biopsy.
Dr. Foreman came by to find Dr. Taub and Dr. Volakis struggling with the patient to try to prepare him for the biopsy. Dr. Foreman went over and found that the patient had no objection to having a needle stuck into his right arm, he was only protecting his left. Dr. Foreman correctly determined he was trying to hide it. He quickly uncovered it and found that Quidd had half-covered his arm in nicotine patches. They started to prep him again, but then Dr. Taub noted a blood clot on the end of his left middle finger. There appeared to be widespread clotting that ruled out bronchulitis.
Dr. Kutner pointed out if a clot reached Quidd's heart or lungs, he would die. Dr. House pointed out that Dr. Kutner was stating the obvious. The patient now had schistocytes, indicating DIC but they still had to determine the underlying cause. Dr. Volakis suggested drug impurities, but Dr. House pointed out that it was someone else's turn. Dr. Hadley admonished Dr. Volakis for always leaping to druge related illnesses and suggested malaria. Dr. Kutner pointed out the patient hadn't left the United States for several years, but Dr. Hadley countered that the disease relapses and remits and explained all the symptoms. Dr. House allowed her to run her tests.
However, when Dr. Hadley and Dr. Taub went to the patient's room, he was missing. They double checked with Dr. House to ensure that he hadn't ordered other tests, and he realized they had lost the patient. They searched for Quidd and finally found him entertaining children in the pediatric ward. They didn't interfere because malaria isn't contagious. However, Quidd soon collapsed on the floor. However, Dr. Hadley checked his pulse and respiration, which were strong.
Dr. Cuddy came to Dr. House to tell him to control his patient. Dr. Kutner came in to report that the malaria test was negative. However, the tests did show the DIC was caused by bad blood fragments. Dr. Kutner suggested exposure to blood during sex, and Dr. Hadley suggested a side effect from the malaria medication. Instead, Dr. Hosue went to see the patient's band mates in the waiting room and found that one had needle marks from injections. He found syringes in his jacket and realized the bad blood fragments were from needle sharing. This caused the DIC and meant the DIC wasn't a symptom. He ordered all the tests re-done, the ejection of the band mates and restraints for the patient. However, when Dr. Kutner went to check the patient, he found him collapsed on the floor suffering from respiratory distress. Dr. House noted to Dr. Hadley that at leasst she was right that the drugs weren't the cause of his illness because they wouldn't cause respiratory distress.
The clots were drug related however, although the coughing up blood and respiratory arrest definitely weren't. Dr. Volakis suggested inhalants, Dr. Hadley suggested bleeding in the lungs, and Dr. Taub thought it was an infection. However, Dr. House found the results of a lumbar puncture, which he didn't authorize, which was clear. Dr. Hadley admitted to performing the test. Dr. Kutner suggested a chronic pulmonary embolism. Dr. House went to allow Dr. Kutner to test for it with an ultrasound, but Dr. Volakis pointed out the patient's D-dimers were normal and that Dr. Kutner merely wanted the opportunity to run unauthorized tests. Dr. House directed Dr. Foreman to run the ultrasound, but it was obvious that he was not going to.
Dr. House did the ultrasound himself. He found some masses near the patient's heart. However, there was no sign of an embolism. The images were fuzzy because the patient's couldn't hold still due to the shaking from the withdrawal. Dr. Kutner wanted to do the echocardiogram again after giving him a sedative to keep him still. However, Dr. House pointed out that the sedatives would decrease his respiratory drive, which in his current state of respiratory distress would probably kill him. Dr. Taub suggested it might be a congenital anomylous blood vessel on his heart that had wrapped around his trachea. However, due to the patient's shaking, an MRA would not show the necessary detail. Dr. House suggested exploratory surgery. He and Dr. Taub went to see Dr. Chase who resisted due to the danger of the surgery. However, Dr. Taub pointed out that if they were right about the malformed blood vessel, in the best case the patient would be on a Ventilator for the rest of his life. Dr. Taub managed to convince Dr. Chase by saying that if the patient died, it would look like Dr. Chase refused merely because he was fired by Dr. House. Dr. Chase gave in and prepared the patient for surgery.
The surgery showed no problems with his blood vessels, but the lymph nodes were severely enlarged. That was what showed up on the ultrasound. The patient started to crash and Dr. Chase ordered two units of PRBCs.
Dr. House pushed his team for more answers but was only able to motivate them by threatening to fire them. Dr. Kutner suggested ARDS, but Dr. House put down the stiffening of the lungs to the surgery. Dr. Hadley suggested anaphylactic shock, but there was no sign of bronchospasm. Dr. Kutner suggested the enlarged lymph nodes were casued by chronic overstimulation of the immune system from drug impurities. Dr. House ordered them to get a sample of the drugs for testing and to put him on dimercaperol for heavy metal poisoning.
However, Quidd refused to tell Dr. Volakis where he got his drugs. Dr. Kutner reported they couldn't find the drug source, that the dimercaperol wasn't working, and that Quidd often volunteered at a home for abandoned children. Dr. House didn't think this was relevant.
He went back to his team, but got no new ideas. Dr. Foreman still thought the patient's problems could all be explained by drug abuse. Dr. House then remembered what Dr. Kutner told him about the abandoned children Quidd worked with and came up with another idea.
He went to Dr. Cuddy to ask for permission to do a brain biopsy. He thought the patient had measles from being with the abandoned children. Dr. Cuddy thought it was likely had had been immunized, but Dr. House pointed out the patient's drug use had made him immunocompromised, that's why he had no rash or fever that would indicate the disease as those are immune responses. However, once the immune system kicked back in, it overreacted, causing the other symptoms. Dr. Cuddy was impressed, but refused a biopsy unless there were other neurological symptoms. Dr. Volakis pointed out the patient kept swallowing, which could be a complex partial seizure. Dr. Cuddy suggested Dr. House try to induce a seizure. Dr. Kutner wanted to use flashing lights, but Dr. House had a better idea - he played the patient's own music back to him. The patient seized and they planned the biopsy. It was positive for measles and they were able to start treatment with corticosteroids.