The patient was treated for a broken wrist about two years ago.
Joe started having trouble speaking and collapsed while he was giving a lecture on marriage problems. He was taken to the emergency room of Princeton-Plainsboro Teaching Hospital. When he arrived, he exhibited a high fever. His blood volume, autonomic reflexes and heart function were all normal. Dr. Chase noted that the patient’s expertise was telling men to act more like women and wondered if he had any psychiatric involvement. He suggested a cerebral arteriovenous malformation. However, Dr. Park pointed out that the CT scan was clear. Dr. Chase then suggested cephalic fibromuscular dysplasia, but Dr. Park pointed out that didn’t explain the fever. Dr. Taub suggested a pulmonary embolysm. A clot might have affected his lungs, reducing the flow of blood to his brain. He wanted to do a pulmonary angiogram, but Dr. Adams thought that as the patient had no major risk factors, a test of his D-Dimers would be a better idea because it was less invasive. Dr. Taub agreed. Dr. House agreed as well.
Dr. Taub and Dr. Adams met with the patient, who said he stopped acting like a jerk and started being a marriage counsellor after he was beat up by three guys outside a bar. That’s how his wrist got broken. He also told them he changed his diet after he met his wife, and Dr. Taub said they needed more information about that.
The patient’s D-Dimers were normal, ruling out a pulmonary embolysm. The patient also told the doctors he had stopped eating red meat and gluten after he met his wife. Suddenly, Dr. House asked if the patient’s behavior had changed after a trauma. When his team told him it had, he went to see the patient and asked if his testicles had been injured in the fight. The patient admitted he took a couple of blows to the groin. He also Dr. Adams and Dr. Chase bend over so that Joe could take a peek, but noted that Joe was disinterested in both of them. Dr. House ordered a test of Joe’s testosterone levels, expecting them to be very low.
The tests confirmed Joe’s testosterone levels were low. They planned to him testosterone shots and release him. Marlene asked if it would have an effect on his sex drive, and Joe was surprised that she was worried about that. She admitted she wondered why she usually had to initiate sex. Dr. Taub assured them that his sex drive would most likely increase. They planned to discharge him, but as he got up after the shot, he urinated on himself. Dr. Taub cancelled the discharge order.
The patient’s urinary tract was normal, leading them to believe the problem was neurological. Dr. Adams thought the low testosterone levels were irrelevant - the patient had that problem for three years without any other symptoms. Dr. House didn’t want to rule it out, but Dr. Taub agreed with Dr. Adams. Dr. Park suggested that the low testosterone levels were related to something worse. Multiple sclerosis explained incontinence and progresses faster in males with low testosterone levels. Dr. House agreed and ordered a lumbar puncture and an MRI of the spine and skull.
Dr. Taub and Dr. Adams performed the LP while Dr. Adams reassured him about MS. However, Joe said he was beginning to feel the effects of the testosterone shots and wondered if his life changes were merely the result of the lower levels.
The patient’s brain MRI was normal. However, during the MRI, Joe asked if he could scratch his nose. However, he started complaining of double vision.
A brain tumor was ruled out as it would have shown up on the MRI. The eye exam was inconclusive. Dr. Taub suggested thyroid eye disease and Grave’s disease, but Dr. House pointed out the patient’s thyroid hormone levels were normal. Dr. Taub then suggested myasthenia gravis. This would affect the muscles around the eye, causing double vision, and the incontinence would have been caused by an atonic bladder. It could have been set off by very low testosterone levels. Dr. House agreed and ordered intravenous immunoglobulin and plasmapheresis.
After treatment was started, the patient said he felt better as long as he kept his eyes closed. He also said he had more energy and confidence. His wife brought him some food and he complimented her. He also said he wanted to expand their involvement with their new publisher. His wife was pleased with his decision.
The liver function tests showed that all his liver enzymes were outside of normal range. This appeared to rule out myasthenia gravis. Dr. Adams thought it was sarcoidosis. However, Dr. Chase noted there were no signs of parenchymal lung abnormalities, making sarcoidosis unlikely. Dr. Taub wasn’t convinced he was wrong about myasthenia gravis - the patient’s vision improved on treatment. Dr. Adams pointed out the liver symptoms could be the result of celiac disease - the patient had been eating gluten in the hospital. Dr. Chase dismissed the idea that the patient could have three unrelated diseases. Dr. Park suggested Lyme disease, but Dr. Adams pointed out there was no rash. Dr. Chase pointed out that 10% of Lyme patients don’t present with a rash. Dr. House agreed and ordered antibiotics.
The patient was starting to worry about his temper. His wife came back and asked him why he had changed the terms of the contract without asking her. He assured her everything was going to be fine.
Dr. Chase tried to reassure Maureen that Joe would adjust to the testosterone. However, she had seen one of Joe’s old videos from when before they met and said she would never have dated him.
Joe didn’t improve on antibiotics. Dr. Taub was sure that the patient’s change in diet since admission was significant and that myasthenia gravis and celiac disease explained all the symptoms except low testosterone. Dr. Adams agreed and wanted to do a biopsy of the small intestine. However, Dr. Chase pointed out that given Joe’s low platelet count, he was likely to bleed to death from a biopsy. Dr. House ordered the antibiotics continued.
Joe and Maureen started having an argument about the contract. She left the room and he immediately regretted his behavior. However, Dr. Adams notice the patient had hardly touched his food and decided to do the biopsy despite Dr. House’s instructions to the contrary.
Dr. Adams was right - the patient had the flattened vilii typical of celiac disease. Luckily, the patient didn’t bleed out, but he soon developed breathing problems which appeared to rule out celiac.
The patient was breathing normally, but his lung function was at 60% and his liver was getting worse. Dr. Chase suggested Whipple’s disease, but Whipple’s doesn’t cause incontinence. Dr. Taub suggested intestinal lymphoma, but that wouldn’t affect his vision. Dr. Adams suggested a parasite like strongyloides. Dr. Chase thought it was unlikely, but Dr. Park noted the patient had been to Puerto Rico, and strongyloides is endemic there. However, Dr. Taub pointed out the treatment, ivermectin, would cause seizures in a patient with a weak liver. Dr. House ordered the ivermectin.
Dr. Taub was reviewing the patient’s old videos looking for clues about his condition. He noted that the patient’s voice was lower in the old videos. Dr. House put it down to hoarseness. Dr. Taub conceded the point, but Dr. House wondered why Dr. Taub gave up on the idea so easily. When Dr. House started watching the videos, he became intrigued about the change in the tone of voice and went to see Joe.
Dr. House went to see Joe and told him chronic hoarseness was a symptom of silent thyroiditis. Joe noted he wasn’t hoarse now, but Dr. House reminded him he was hoarse three years before. Dr. House told him that intermittent silent thyroiditis was often secondary to polyglandular autoimmune syndrome type III. As he discontinued the ivermectin, he told Joe PAS III moves from gland to gland, causing other secondary endocrine diseases, including myasthenia gravis and celiac disease. The disease also is worse in patients with low testosterone. The myasthenia gravis caused the symptoms that had him admitted. The celiac disease didn’t present because of his gluten free diet, until he started eating gluten in the hospital. The treatment was steroids and his prognosis was excellent. However, the testosterone problem was unrelated to this condition.
At the time for his next testosterone injection, Joe asked Dr. Taub what the effects would be of lowering the dose. Dr. Taub wondered if he was having adverse side effects, but Joe said he felt great. However, he realized his marriage and career was suffering. Dr. Taub noted that if he didn’t get testosterone, he was likely to suffer from clinical depression and insomnia and his risk for osteoporosis and diabetes mellitus might be higher. The patient said he was willing to take those risks because he felt he was a better person without testosterone.