Case History Edit
Joe presented with itching and a rash and was taken to Princeton-Plainsboro Teaching Hospital by ambulance. On examination, he presented with palpable pupura and elevated ALT and AST levels, indicating liver damage. Liver damage explained the cryoglobulins in his blood. However, the cause of the liver damage was unknown - the patient had no sign of drug or alcohol abuse. The case was assigned to Dr. House. Dr. Chase suggested hepatitis C, but the tests for it were negative. Dr. Taub suggested a toxin, and Dr. Chase suggested tetrachloroethylene. Dr. House ordered an environmental scan.
Dr. Foreman and Dr. Taub took along Ms. Masters, a third-year medical student. When they broke into the patient’s house, Ms. Masters was surprised, but Dr. Foreman explained that if they tell patients about it, they often hide things relevant to the diagnosis. Nevertheless, she stayed outside while Dr. Taub and Dr. Foreman searched the premises. Dr. Foreman found a jug of unpasturized cider. He convinced Dr. House that the cider could have been contaminated with E. coli by an apple that fell on the ground. Dr. House ordered astreanam and plasmapheresis.
The patient was busy assisting with Senator Anderson’s campaign. He figured out when they mentioned the apple cider that they had been to his house. Suddenly, the patient dropped his smartphone and became unresponsive. They realized Joe was paralyzed.
Joe started to recover. Dr. Chase thought it was a transient ischemic attack from a clot that broke up before they could find it. Ms. Masters thought it was portal vein thrombosis caused by Wilson’s disease. However, Joe’s cornea was normal. She suggested a neuroendocrine tumor, but Dr. Taub pointed out Joe didn’t have diminished mental capacity or loss of judgment. Dr. Taub suggested DIC. However, Dr. Chase backed Ms. Masters - Joe did show loss of judgment. It appeared he had leaked an inflammatory political commercial online. Dr. House ordered a CT Scan for neuroendocrine tumors and a D-Dimer and fibrinogen for DIC.
Joe insisted his judgment was sound and the scan was a waste of time. He also denied leaking the commercial. The scan was negative. Dr. Taub was completing the blood work. However, the tests were normal, ruling out DIC.
Dr. Taub and Dr. Foreman went to the patient to get a more complete medical history to look for a source of toxins. Senator Anderson was there as well and told the doctors they had been to a tomato farm, but he didn’t even get off the campaign bus. At that point, Dr. Taub noticed blood in Joe’s urine, indicating kidney failure.
Dr. House thought it might be thrombotic thrombocytopenic purpura, but his platelet count was 200,000, ruling it out. Ms. Masters suggested Henoch-Schönlein Purpura. It doesn’t usually cause clots, but vasculitis could explain the symptoms. Ms. Masters knew the alternative treatments were chemotherapy and steroids. Dr. House wanted to use chemotherapy because it’s more effective, but Ms. Masters said they have to present the alternatives to the patient, and she was sure Joe would choose chemotherapy in the circumstances. Dr. House agreed to let her explain the alternatives to the patient. However, Joe chose steroids because they were less likely to interfere with his work. Dr. House stressed that chemotherapy was the much better choice, but the patient insisted on steroids.
However, Dr. House surreptitiously switched out the steroids for chemotherapy. Ms. Masters was shocked by the deception, but Dr. House fired her and told her that if she told the patient, he would have her thrown out of medical school.
However, the patient developed pulmonary edema, ruling out Henoch-Schönlein Purpura. Dr. Foreman noted that Ms. Masters decision to support the patient’s decision was valid. Dr. Taub thought it might be an infection. Dr. Chase pointed out he didn’t respond to astreanam, but Dr. Taub pointed out that schistosomiasis wouldn’t respond to it and Joe kept tropical fish. Dr. House ordered another environmental scan. Dr. Taub, Dr. Chase and Dr. Foreman couldn’t find any snails at the patient‘s home, but they got arrested for breaking and entering. The patient was getting worse with fluid in his chest.
Dr. House approached Ms. Masters who started going over where the liver failure may have started. If it started in the ducts it could be primary biliary cirrhosis. Dr. House suggested primary sclerosing colingitis, but Ms. Masters pointed out his Vitamin A level was normal. He suggested cholecystitis, but Ms. Masters was listening to Senator Anderson on the television firing Joe from the campaign. All of a sudden, Dr. House realized that Senator Anderson had a rash on his hand and was sweating.
Dr. House went to Joe and accused him of having sexual relations with Senator Anderson because hepatitis C would explain their symptoms. Joe also denied intravenous drug use, but finally admitted to sharing straws to snort cocaine. The patient pointed out he tested negative, but Dr. House realized the cry globulins being produced by the dying liver would result in the test coming back as a false negative. There would be other ways to test for it, but since Joe had plasmapheresis, the toxic by-products and antibodies would also be missing from his blood. There was therefore no way to prove he had it. Dr. House administered interferon.
Dr. House found Ms. Masters again and told her that Joe had hepatitis C but wasn’t responding to interferon. Ms. Masters recalled research that some patient with hepatitis C who also had hepatitis A recovered from both. However, the majority died very quickly. Dr. House wanted to infect the patient with hepatitis A and went to Dr. Cuddy for approval. However, the treatment was untested and exposed the hospital to liability, so she refused. However, Ms. Masters stood up for Dr. House. Dr. Cuddy also pointed out they had no proof he had hepatitis C. She agreed to let them try the treatment if they confirmed hepatitis C.
Dr. House told his team that they needed a false positive hepatitis C test. Dr. Chase suggested testing Senator Anderson, but Dr. House pointed out that would only be evidence, not proof. Dr. Taub suggested they just keep testing him until a test came out positive. Dr. House agreed.
However, to get a positive test, Dr. House drew blood from Senator Anderson and put Joe’s name on the vial. Dr. Cuddy allowed the treatment. Dr. House insisted that Ms. Masters get the patient’s consent. However, she refused to lie about his chances, which were only about 15% in his favor. However, she also told him that it was his only chance Dr. House was risking his career to treat him. The patient agreed to the treatment.
The patient responded to treatment and his ALT level started to come back to normal.
However, Dr. Cuddy found out Senator Anderson had been in the hospital just before Joe’s positive test.