Case History Edit
While with her lover Damien, Julia started complaining of stomach pains. She called out for her husband Tom. She was taken to the emergency room at Princeton-Plainsboro Teaching Hospital. She was running a fever, but they managed to rule out most of the common conditions that cause both fever and abdominal pain. They referred the case to Dr. House, who was intrigued about the patient’s open marriage. Dr. Chase thought it was probably an intestinal blockage, most likely from herpes colitis. However, the patient’s STD panel was clean. Dr. Foreman pointed out she would test negative for herpes if she was exposed to it within the past six weeks. Dr. House decided to do a barium enema.
Dr. House performed the procedure on the patient. He wanted to talk to her about her open marriage. She said that they just wanted to be open about having sex with other people. Dr. House completed the enema and sent her for x-rays. However, the x-ray was clean, and the abdominal pain appeared to resolve itself. Dr. Taub wanted to discharge her, but Dr. House wasn’t sure there wasn’t an underlying problem. He ordered Dr. Taub to do a barium milkshake and regular x-rays to see how it was passing through her digestive tract.
Dr. Taub also wanted to talk to the patient about her open marriage. She had been married for seven years and the open marriage started four years ago. She started complaining that her heart was racing and then had shortness of breath. Dr. Taub told her to try to take deep breaths and tried to slow her heart rate, but he realized that wasn’t working and that the tachycardia wasn’t related to her intestinal problems. He called for a crash cart.
The arrythmia combined with the abdominal pain pointed to a parasite. Julia didn’t appear to have any exposure, so Dr. Chase went to her husband and asked for a list of his sexual partners within the last six months to see if he had been exposed. He admitted he hadn’t had any other sexual partners in a year, and that he hadn’t been farther than Nebraska. He said he was going along with it because she wanted to do it and he didn’t want to make her feel bad.
Dr. House figured the husband was lying about something, even if it wasn’t about sex. Julia’s sex partners hadn’t been outside of the tri-state area either. Dr. House ordered an environmental scan to see if the husband really had been to Nebraska.
Dr. Chase and Dr. Hadley did the environmental scan. Dr. Chase found plane tickets and restaurant receipts to confirm the trip. However, Dr. Hadley found a loofah, which can harbor parasites.
Julia was soon suffering from leg paralysis. The tests for spinal cord injury, cerebral lesions and hemmhorage were all negative. They had obtained a stool sample which was negative for parasites. Dr. House thought it might be an electrolyte imbalance. Dr. Chase suggested her high sex drive might be a symptom, and Dr. Foreman suggested adrenocortical carcenoma, which also explained her other symptoms. Dr. House ordered an MRI of her adrenal glands.
Dr. Taub and Dr. Hadley performed the MRI, but found nothing on the adrenal gland. However, Dr. Hadley did spot something on the lungs. They did a VQ scan and found a clot. A clotting disorder would explain all the symptoms. However, at that point Dr. Cuddy came in to speak to Dr. House about not acknowledging that there was a problem with Julia’s insurance. She wanted to make sure he didn’t bankrupt them with tests, but he admitted he had already done enough tests to do so. Dr. Hadley was incredulous - she had seen the policy number. However, Dr. Cuddy informed them that the policy had been cancelled for non-payment. Dr. House had finally figured out what the husband was lying about.
The husband admitted he was lying about the premiums and had taken money out of the retirement account. He admitted losing all of their savings.
Dr. Hadley started Julia on heparin and they started a new differential. Dr. House thought it was either DIC, Factor V Leiden, or anti-phospholipid syndrome. Dr. Hadley thought it was Vitamin K deficiency - it caused thrombophila and abdominal pain. Dr. House ordered tests for all of them. Dr. Hadley went to draw blood for the tests.
However, all the tests were negative, which seemed to rule out a clotting disorder. Dr. Chase thought it might be a vascular disorder. However, Dr. Foreman pointed out she didn’t have schistocytes or hemolysis. Dr. Hadley suggested pulmonary arterial hypertension. However, all the imaging showed the patient’s pulmonary artery had a normal diameter.
Once again, Julia started having abdominal pain, except it was worse than before. Dr. Chase wanted to do an ultrasound. However, both the physical examination and ultrasound showed nothing out of the ordinary. Dr. Chase noted that the pain started when she was with her boyfriend, and it may have been brought about by sexual excitement. It could be a problem with the parasympathetic nervous system. However, Dr. House pointed out that system also controls digestion, and she was having no problem with eating. Dr. Taub suddenly realized that the pain often stopped after they gave her tests. The first test was a barium enema, which is only effective against an interceception - part of the intestine folding back on itself. They rushed her to surgery as the condition cuts off blood flow which could lead to necrosis. Unfortunately, the most common cause of interceception in adults is abdominal cancer. Once they fixed the intestine, they would do exploratory surgery for tumors.
Dr. Taub did find an abnormal growth, but the biopsy showed only generalized inflammation. That suggested IVD, but that wouldn’t explain the heart problems or the fact that her kidneys were now failing. However, Dr. House pointed out that IVD could cause ankylosing spondylitis, which would explain the heart and kidney problems. Dr. House ordered sulfasalazine and TNF inhibitors.
Dr. Chase put all the possibilities on the whiteboard - over two dozen conditions. Ankalosing spondalitis had been ruled out because one of her kidneys had already failed. Her kidney biopsy showed IGA nephropathy, which could be caused by any of the listed conditions. Sickle cell anemia was ruled out by blood tests, and there were no flattened viliiae in her intestine, ruling out celiac disease. Her liver enzymes were normal, ruling out hepatitis B and cirrhosis. Alport and anti-GBM were both untreatable. Henoch-Shonlein pupura could be ruled out because there was no inciting respiratory infection or rash . Dr. Taub favoured hemochromatosis. Dr. Foreman thought it might be Weil’s syndrome - it also affects multiple organs and the antibiotics the ER gave her would not affect it. Dr. Hadley thought it might be sarcoidosis. Dr. House ordered treatment for all three.
Dr. Hadley advised Julia to call her husband. When she said she didn’t want to deal with a liar, Dr. Hadley told her that her husband had also lied about having sex with other women just to keep her happy.
The patient called her husband, but after he returned, it was clear that none of the treatments were working. Dr. Hadley wanted to start dialysis. Dr. Taub suggested polyarteritis nedosa. Dr. House agreed to start her on prednisone. However, Dr. Hadley suggested mercury poisoning. Dr. House started talking about the flowers the husband had brought, and Dr. Hadley told him they were from their garden. He saw they were lilacs, and he realized that lilacs are more likely to attract bees. He realized Henoch-Shonlein can also be triggered by bee stings. Dr. Hadley pointed out there was no rash, but Dr. House thought they may have missed it. He went to see Julia and she admitted she was stung by a bee about a month before. He explained that Henoch-Shonlein can cause lesions everywhere, like the heart, lungs and kidneys, but they are always found on the skin. Julia denied she had a rash, but Dr. House examined her closely and found the lesions on the inside of her mouth. She would need intravenous immunoglobulin and cyclophosphamide, but she should recover.