|Diagnosis||Celiac disease with associated pellagra and Vitamin K deficiency|
The patient had recently given birth and was caring for her newborn son Mikey
Kara's husband found Kara unresponsive in a bathtub full of water, and his son Mickey underwater and seemingly not breathing. He had only been with them a few moments before and both had been acting normally. Paramedics were called who managed to revive the newborn and brought Mickey and Kara to the Princeton-Plainsboro Teaching Hospital ER. The paramedics reported that Kara had a tonic-clonic seizure, but she was now responsive. Dr. Chase examined Kara.
Dr. Chase referred the case to Dr. Cameron, who referred it to Dr. House. Dr. House wondered why Dr. Chase was working in the ER, and Dr. Cameron told him that Dr. Cuddy had assigned him to a two week rotation. When Dr. House learned the only symptom was a seizure, he thought it would be easy to diagnose. Dr. Foreman returned from recovering from his illness. Dr. Cameron explained that epilepsy was ruled out and the patient had elevated calcium levels. Dr. Foreman thought it had to be hypoparathyroid, cancer or calcium mediated neurotoxicity. However, the ER had already ruled out all three.
Dr. House consulted with Dr. Chase, who thought it might be polyarteritis medosa. However, this would cause impaired kidney function, and her kidneys had tested fine. Dr. Cameron thought it might be Whipple's disease, Dr. Chase thought it might be streptococcus, and Dr. House thought it was vasoconstriction. Vasoconstriction could cause seizures or stroke and elevated calcium was a symptom. Dr. House told his team to run a Whipple's test, do a swab for strep, and to perform a digital subtraction angiogram. However, Dr. Chase was unable to perform the angiogram as Dr. Cuddy had assigned him to the ER. Dr. House spoke to Dr. Cuddy and realized that Dr. Chase had requested to be sent to the ER.
Both Kara and her husband tested negative for strep. Kara was about to get an MRI, when her whole back started spasming, and blood rapidly came pouring out of her vagina. She was not having a seizure. They gave her lorazepam for the spasm.
Dr. Chase thought that the mother had taken lithium, but there was no record she ever took it. Dr. Foreman thought it might be myoluminous meningitis. Dr. House ordered an S-Pep and an MRI to check for meningitis and an environmental scan for lithium and to check the water in the patient's home.
The MRI was negative for abcesses and masses, ruling out meningitis, but she did have a sub-arachnoid bleed into her brain. Her prothrombin time was elevated, showing her blood was not clotting, explaining the earlier bleeding. However, Dr. Foreman did find alcohol in the patient's home. Alcohol would explain the elevated calcium. However, her tox screen was clear for alcohol. Dr. House thought it might be delerium tremens, but Dr. Foreman suggested conversion disorder. However, Dr. House thought alcohol was a better fit and ordered her started on phenobarbitol coma to treat the DTs.
The patient was eventually taken off phenobarbitol and awoke feeling better. Dr. Foreman learned that Kara and her husband had met in Alcoholics Anonymous. However, soon afterwards, Dr. House discovered the patient trying to smother Mikey. Dr. Foreman subdued the patient and Dr. House reminded Dr. Foreman that he probably should have pressed conversion disorder harder. The patient reported having auditory hallucinations suggesting that Mikey would be better off dead.
Dr. Cameron suggested that Kara had faked the seizures to cover up an earlier attempt to drown Mikey in the bathtub. However, Dr. Foreman believed the seizures were genuine. He thought it was postpartum psychosis, which triggered the hallucinations, and the conflict triggered the seizure. However, Dr. House pointed out that the internal bleeding and elevated calcium pointed to a physical illness, not a mental illness. He ordered his team to induce a seizure through stress. When Dr. Foreman resisted the suggestion because she was on haloperadol, Dr. House also reminded him that the test would be dangerous and unethical and that it was his job to point that out. He ordered them to take her off haloperadol, hook her up to an EEG, flash lights at her and inject her with a placebo. If the EEG matched her seizure, it was real. Otherwise, she was faking and they should call the police. The bone marrow biopsy for meningitis came back negative and she did not have a seizure. However, she did enter an encephalathic delerium. This ruled out post-partum psychosis and conversion disorder. The delerium appeared to be progressive and, if it continued, would shut down all her brain functions. Dr. Foreman suggested Wernicke's disease, but the treatment for that was thiamine and she was given that. Lithium does cause delerium, but she could not possibly have had access to it in the hospital, so she should be getting better if that were the cause. Dr. Cameron suggested Whipple's again, but the test for it had been negative. Dr. House finally suggested pellagra - it is common in alcoholics. However, Dr. Chase came in to report that Mikey had died.
Kara was given niacin and her psychosis went away, confirming the pellagra. Dr. Foreman explained to the patient that she had been suffering from delusions, but that her memory of trying to smother Mikey was real and that Mikey had died as a result. However, after hearing the news, Kara vomitted blood. This was not a symptom of pellagra. Dr. Cameron thought it might just be alcohol related gastritis.
However, Dr. House wondered how Dr. Chase had failed to save Mikey from rising potassium. Dr. Chase had given Mikey one full gram of polystyrene, which should have lowered Mikey's potassium levels. Dr. House went to the father to ask to perform an autopsy on Mikey because he thought Mikey and Kara had the same underlying disease. He couldn't do a biopsy of Kara's intestines without causing fatal internal bleeding. Although the father resisted, Dr. House reminded him that he had been drinking the day of the seizure and that he probably ignored the symptoms of Kara's oncoming psychosis. The father finally consented.
Dr. Chase performed the autopsy on Mikey and discovered he had flattened vilii. The intensive care unit uses wheat gluten to bind polystyrene, indicating that Mikey had been suffering from celiac disease - wheat gluten intolerance. Kara almost certainly had it too, which led to her intestine becoming damaged and unable to absorb vitamins. The niacin deficiency led to pellagra, and the Vitamin K deficiency led to the internal bleeding. Mikey died because he couldn't absorb the polystyrene through his damaged intestine. Dr. House ordered a gluten free nutrient IV, which would allow her to recover. The excess calcium and bloody vomit were the result of stomach cancer, a common complicaton of celiac disease - MALT lymphoma. The case was referred to Dr. Wilson.
However, Kara refused to be treated by Dr. Wilson. She felt guilty over Mikey's death. Dr. House reminded her she was psychotic at the time and it wasn't her fault. He reminded her if she didn't get treated for her cancer, she would die, and she didn't deserve that. However, she said she didn't want to live. Dr. House accepted her decision and refused Dr. Foreman's request to get a court order to treat her. Her husband also asked her to accept treatment, but she still refused.