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Medical History Edit
The patient has a frontal nasal encephaloseal with a mid-line cleft, which has badly deformed the left side of his face. It is a mid-line deformity. A documentary production agreed to cover the costs of a facial bipartion, a 10 hour surgery to repair most of the damage caused by the deformity. As a result of his condition, the patient suffered from numerous headaches and used a great deal of acetaminophen to treat them.
Case History Edit
- "Tomorrow at this time, I'm scheduled for surgery. It's a ten hour procedure, throw two in it for prep, thirty-six until I'm just another face in the crowd"
- ―Kenny, looking forward to reconstructive surgery
- Chase: "We have the patient on a pacing wire. It's the only thing keeping his heart going."
- House: "Yeah, we know. We're doctors"
- Chase: "Right. I was just... it was just for them... "
- — Chase plays to the camera
Dr. House was assigned to diagnose the condition causing the irregular heart rhythm. He advised his team the patient had a second-degree infranodal heart block, post-arrest. There were no reports of light-headedness or fainting. Dr. Taub believed increased intercranial pressure from the enlarged head could cause the heart block. However, Dr. House dismissed it as there was no reason for the condition not to have presented earlier if it was due to his deformity. Dr. Terzi believed the patient might also have a mid-line deformity of the heart. However, Dr. House once again pointed out that the patient had been under continuous medical treatment for his entire life and it was unlikely the previous doctors would have missed it. Dr. Cole believed it might be endocarditis. However, this would only make sense if the patient was an intravenous drug user. However, Dr. House agreed there was no reason to rule it out at this point, but due to darkened skin below his nose, the addiction was most likely inhaling freon, a refrigerant. However, Dr. Taub put down the darkened skin to acanthosis nigricans, a common discoloration in such deformities. Dr. Hadley noted similar discolorations on the cheeks and forehead. Dr. House ordered a nuclear study to determine if there were any scarring of the heart.However, the patient's father strongly resented the implication that his son was using drugs, but agreed to the test. However, there was no sign of scarring. Dr. Taub believed it might be toxoplasmosis. However, Dr. House pointed out toxoplasmosis would cause enlarged lymph nodes. He believed Dr. Taub merely wanted to do a lumbar puncture to test for intracranial pressure. Dr. Taub asked to do a CT Scan, but Dr. House still believed it was drugs. Dr. House noticed a decreased uptake on the membranous septum. Dr. Kutner believed it was merely an artifact of the test and wanted to re-perform it. However, Dr. House ordered an EP study. Dr. Taub objected because it would require stopping the patient's heart.
- Taub: " I need to know what kind of drugs, Kenny... and how much"
- Kenny: "Uhm, coke, mostly. Lotta coke. And then uh, when I run out, I used to go to LSD. Or acid."
- Taub: "Those are the same thing."
- — Taub realizes Kenny is lying about drug use
Dr. Taub prepared the patient for the EP study and once again asked the patient if he did drugs. The patient admitted to using cocaine and LSD. However, Dr. Taub soon realized the patient was lying. The patient did admit to alcohol use, but Dr. Taub refused to perform the test. Suddenly, the patient started coughing up blood. Dr. Taub called for help to intubate the patient.Dr. Kutner believed the blood indicated a mallory weiss tear, but there was no pallor or melanin. Dr. Volakis believed it was a nasal papilloma which hemmorhaged and overwhelmed the heart. However, Dr. House pointed out the hemorrhage came after the block. Dr. Terzi believed it might be a bleed in his digestive tract, perhaps a peptic ulcer. However, Dr. Foreman pointed out the patient had no abdominal pain or anorexia, and the digestive tract has no connection to the heart. Dr. Hadley believed it was a nasal-fringal angiofibrosis, but Dr. House had already ruled out any tumor in the nasal cavity. Dr. Cole believed it might be stomach cancer - the cancer caused the bleeding and paraneoplastic syndrome affected the heart. Dr. House ordered Dr. Taub and Dr. Cole to do an endoscopy to find the tumor. However, Dr. Taub believed this would be dangerous - the bleeding might be caused by liver failure related to high intracranial pressure. However, Dr. House dismissed the suggestion as he did not believe that intracranial pressure could affect the liver. However, Dr. Taub was not allowed to explain how high intracranial pressure can cause an increase in the cavernous sinus pressure which in turn causes high pressure in the superior vena cava which shuts down the liver. However, he went with Dr. Cole to perform the test. Dr. Cole agreed with Dr. Taub that the endoscope could cause more bleeding if this was the case.
- "Intracranial pressure CAN cause liver problems. It causes an increase in the cavernous sinus pressure, which causes pressure in the superior vena cava, which shuts down the liver."
- ―Taub chides himself for not standing up to House in front of the camera.
During the procedure, the patient started bleeding again, and it took 20 minutes of banding to stop the bleeding. No tumor was found. Dr. Taub insisted that this showed the bleeding was the result of liver failure and increased intracranial pressure. Dr. House agreed he was wrong about the tumor, but pointed out that if Dr. Taub was correct the patient should also have nosebleeds and labored breathing. Dr. Terzi believed it might be an autoimmune disorder, such as scleraderma. However, Dr. Foreman noted that the patient did not have tight skin on the hands, muscle weakness, and was 14 years too young to develop it. Dr. Hadley believed it might be a mitochondrial disorder. Dr. House ordered Dr. Volakis to look for retinal degeneration, but Dr. Taub once again insisted it was intracranial pressure and they would only see swelling.Dr. Volakis was unable to use the opthamology machine to perform the scan because of the patient's deformity, so Dr. Taub used a scope. He only found swelling and once again attempted to convince Dr. House that it was increased intracranial pressure. However, Dr. House still did not believe that the pressure was the underlying cause, particularly of the liver failure. However, Dr. Taub pointed out that the patient's constant use of acetaminophen may have damaged the liver. Dr. House believed it was juvenile rheumatoid arthritis, which would explain all the symptoms. He ordered steroids. However, Dr. Taub pointed out this would delay the reconstructive surgery for months if Dr. House was wrong. Dr. Taub agreed to speak to the father, but secretly told the father that he thought Dr. House was wrong and should be removed from the case.
- "I think Dr. House is wrong, and that the steroid treatment could be dangerous. I think I can get House thrown off the case, and get Kenny the facial surgery he needs."
- ―Taub mutinies.
Dr. Cuddy admonished Dr. Taub for his insubordination as the patient's father refused to consent to steroids. Dr. Taub pointed out that the patient had a fluid filled cyst that wasn't draining properly and the patient needed surgery. Dr. Cuddy refused to fire Dr. Taub because he was the only doctor the patient's father trusted. She instructed Dr. House to perform a CT Scan to confirm the juvenile rheumatoid arthritis before giving the patient steroids.
The patient was given a CT Scan. Dr. Taub believed it showed the facial deformation was pressing on his right frontal lobe causing a herniation. Dr. House believed it was increased pressure from the juvenile rheumatoid arthritis. Dr. Cuddy agreed with Dr. House and told Dr. Taub to keep away from the patient's father. She allowed Dr. House to give the patient steroids. Dr. House met with the patient and told him he needed steroids despite the delay to the facial reconstruction surgery. The father gave consent. The patient improved on steroids.Dr. Taub reported finding a mass lesion in the left temporal lobe surrounded by edema. However, Dr. House pointed out that if he did have such lesion, the patient should be struggling to breathe. However, it did mean the patient was ready for surgery. However, Dr. House pointed out the patient now had a twitch in his little finger. This indicated that the diagnosis was wrong. Dr. House ordered the surgery canceled.
- Thirteen: "What about Lyme disease? It explains everything - the heart issues, the internal bleeding, even why he'd get better on steroids."
- House: "On the other hand, if he has Lyme Disease, there would be other subtle clues, like a huge, target-shaped rash. But thanks for playing."
- — House shoots down Thirteen
However, Dr. Hadley remained convinced that Dr. House was right and went to observe the surgery. She noticed some pictures taken of the patient about 3 weeks previously. She saw acanthosis nigricans on the pictures, but the pictures did not show any discoloration near his hairline, although there was discoloration there now. The patient's hair was shaved at the hair line showing the target shaped rash and confirming Lyme disease.
Dr. Taub believed the twitching was just nervousness. Dr. Foreman agreed and believed that the patient did have juvenile rheumatoid arthritis and it was improving. However, Dr. Hadley pointed out that Lyme disease would explain they symptoms and why he seemed to improve on steroids. However, Dr. House noted there was no target shaped rash that was indicative of the disease. Dr. Volakis thought it might be rheumatic fever, which would also explain the symptoms and why he improved on steroids. However, it didn't explain liver failure. Taub suggested removing the pacemaker wire. If House were right, the patient would go into cardiac arrest, but if the patient were fine, there would be no effect. Dr. Taub removed the wire with Dr. Kutner standing by with the defibrillation paddles. The wire was removed, the patient's heart rhythm and blood pressure were normal, and the patient was scheduled for surgery.
- Thirteen: "What about around his hairline?"
- Chase: "What? There's no discoloration."
- Thirteen: "There is now"
- — Thirteen has her eureka moment.
The patient was treated and eventually had the facial reconstruction surgery.
A Reflection of House Edit
Kenny has almost no friends and a strained relationship with his father, despite the fact his father cares for him very much. He is socially isolated by both choice and necessity. He cares very little for what other people think of him.
Reaching the Diagnosis Edit
House and the team start with the heart attack. By the time they get the case, they know the cause is an infranodal block, also known as an atrioventricular block. In English, this means that the heart's electrical signals are not passing from one part of the heart to the other. Taub jumps to an obvious conclusion - the patient's oversized head is increasing intracranial pressure. However, House points out that the patient has had the same head all his life without a heart attack. Dr. Terzi's suggestion of a congenital defect is shot down for the same reason. House reminds the team that the patient has been monitored by doctors all his life because of his condition and either of those causes would most likely not be missed by several teams of doctors.After Cole and Thirteen argue about drug abuse, House comes to the conclusion that Freon huffing would explain both the heart attack and discoloration under his nose. Despite protests from many members of the team that acanthosis nigricans explains the discolouration, it it is common in patients with facial deformities and there are patches of discoloration elsewhere, House orders a nuclear study of the heart to look for scarring.
After the nuclear study is negative, Taub still wants to check the patient's intracranial pressure, but House sees through the ruse of looking for toxoplasmosis with a lumbar puncture. Instead, House focuses on the radiology, which shows an anomaly in the septum of the heart. This would explain the block and House orders an electrophysiology study. Taub objects because it would mean stopping Kenny's heart again, but the test would pinpoint the source of the block. If it's the septum, it could be corrected with surgery.
However, on questioning Kenny, Taub is convinced he doesn't know anything about drugs and Kenny's admission that he drinks his father's alcohol most likely shows he is honest. In addition, when Kenny starts coughing up blood, it indicates that the problem goes beyond the structures of the heart.
They start discussing the source of the blood. House rules out a Mallory-Weiss tear - it would make the patient pale and causes a distinct discoloration of the stool. Amber suggests a burst papilloma in the nasal cavities - it would cause the bleeding and a bad enough one could affect the heart. However, the heart attack came before the bleeding. Foreman shoots down Dr. Terzi's idea of bleeding from an ulcer or some other damage to the upper digestive tract - that would cause obvious abdominal pain, anorexia, and wouldn't explain the heart attack. Thirteen comes up with another nasal tumor, an angiofibrosis, which House shoots down for the same reason he shot down Amber's idea. Cole sticks with cancer, but of the stomach - that explains the bleeding and paraneoplastic syndrome explains the heart attack. House instructs the team to look for the tumor with a laparoscope.
However, they find no tumor and the lapraroscope damages the patient's esophagus, leading to more serious bleeding. This indicates that Taub was right about liver damage. However, House is still not convinced that its due to increased intracranial pressure. Increased intracranial pressure would cause nosebleeds and labored breathing. Dr. Terzi suggests that scleroderma would cause liver and heart damage, but Foreman points out that it also causes tight skin on the hands, muscle weakness and doesn't affect people under thirty. Thirteen points out that a mitochondria disease could cause both as well. House orders them to examine the patient's retina to look for signs of it.
Taub, going old-school with the opthamology examination, finds swelling but no degeneration, convincing himself it's increased intracranial pressure. House is still unconvinced that increased pressure would cause the liver damage. Taub counters that the pressure caused the heart problem and the patient's acetaminophen use caused the liver problem. House is unconvinced it's two different conditions and turns to juvenile rheumatoid arthritis, which would explain both. He orders steroids.
However, still convinced its intracranial pressure and not arthritis, Taub undermines House's authority with the patient's father. Cuddy gets involved and forces House to rule out intracranial pressure with a CT Scan.
However, Cuddy can't see any defects in the scan, gives House permission to treat with steroids, and tells Taub not to talk to the patient or his family.
When Kenny's finger starts twitching, House stops believing it's arthritis and realizes they have to start from scratch. Thirteen suggests Lyme disease. It explains all the symptoms, including why he improved on steroids, but House points out the patient doesn't have the classic symptom - a target shaped rash. Amber runs to a similar disease that doesn't cause the rash and responds to steroids - rheumatic fever. However, it doesn't cause liver failure. The team turns back to acetaminophen to explain that. House realizes that if the steroids are treating the condition, they can remove the pacemaker. They try it and Kenny's heart is beating normally.
However, one person who remains unconvinced is Thirteen, who goes to watch the surgery. While they prepare Kenny, she sees a patch of discoloration, near Kenny's hairline, that isn't in an older photo. She has them shave the area and the target shaped rash typical of Lyme's appears.
Explaining the Medicine Edit
- Kenny's cranial deformation, a form of encephalocele, occurs in utero. In the developing fetus, the brain and spinal cord start out as a groove down the back. This groove deepens and widens to accommodate the growing brain and spinal cord. Eventually, this groove, the neural tube, closes entirely, enclosing the brain and spinal cord, even before the skull and vertebrae start to surround them. However, in Kenny's case, the tube did not close completely along the nasal line. The brain and the tissues that surround it kept growing outside the developing skull. Kenny's defect would have been obvious at birth and his head shape probably changed little after he was born. Kenny's encephalocele is between the nose and the forehead.
- Ideally, corrective surgery should be performed in infancy. Surgical correction is possible in most cases and consists of cutting away the excess tissue. The prognosis varies with the severity of the deformation, but in many cases, after surgery, the patient will have a completely normal appearance as can be seen in this "before" and "after" pair of pictures
- Lyme disease can cause a heart block, although this is very rare.
- Kenny most likely would have had the pacemaking wire inserted into a vein, from which it would be guided to the right side of the heart (either the atrium or ventricle would do) and attached to an external cardiac pacemaker. That's why it took so long to take out the wire.
- Freon is stored under pressure and, when released from its container, drops to well below freezing. A person inhaling it could get frostbite from the exposure.
- Taub is right - toxoplasmosis is often asymptomatic. However, if Kenny's other symptoms were due to toxoplasmosis, House is right that his lymph nodes should be swollen as well.
- Acetaminophen is processed by the liver and is one of the most common causes of liver damage.
- The bleeding in the esophagus is caused by liver damage (and is, in fact, a classic sign of liver damage). Lyme does not always result in liver damage, but the infectious agent can result in a form of hepatitis.
- Banding literally uses sterile rubber bands to constrict tissue that is bleeding to cut off the blood flow. It is a common way of stopping bleeding in the esophagus. Eventually, the constricted tissue dies and falls off.
- Since mitochondria are found in all cells, a defect can affect most of the organs. Many patients with a mitochondrial disorder have abnormal liver enzymes, and when left untreated, can result in a heart block. However, most commonly, such disorders are seen in the retina although in many cases it is the retinal disease that causes the mitochondrial dysfunction.
- The PASCAL Dynamic Contour Tonometer started to become commercially available in about 2004. As such, Amber most likely would have been trained on it when she went to medical school. However, the much older Taub would not have had access to such a device during his education and would have been trained to use a light source and scope to make the same observations.
- Like any inflammatory disease, Juvenile Rheumatoid Arthritis is treated with steroids. Lyme, of course, shouldn't be because steroids suppress the immune system and allow the underlying bacteria to grow. However, several of the symptoms of Lyme, like joint swelling, are inflammatory in nature. Steroids suppress these symptoms which is why Kenny felt better, even as he was getting sicker. The appropriate choice for treating pain and swelling from Lyme are NSAIDs, which don't affect the rest of the immune system. Amber is right that the same is true of rheumatic fever, where steroids will suppress the inflammation, but allow the underlying disease to run rampant. Again, NSAIDs woule be the appropriate choice.
- In a normal scan or x-ray of the brain, there is a distinct separation between the two hemispheres of the brain that is almost precisely straight down the center of the skull - the midline. When the midline is clearly to one side or the other, it indicates that a mass on one side is forcing that hemisphere of the brain over to the other side because it is causing increased intracranial pressure. If Kenny's brain deformation were resulting in increased intracranial pressure, he would show such a midline shift.
- Muscle twitching is a rare symptom of Lyme, but can be the result of the neurological damage that results from the disease.
- Kenny's corrective surgery is very complicated. The disfiguration in his case only consists of a cyst, which at least means that there is no brain tissue to remove. However, the cyst grows from a hole in the skull and has its own blood supply. As they get closer to the skull, the blood vessels, which are very large, have to be cut off. They then have to repair the hole in the skull, usually with a bone graft. Most of the skin has to be saved because of the size of the cyst - they needed to graft that onto the completed surgical area and the more of the existing blood supply they can save, the faster Kenny can recover. Luckily, the shape of the underlying skull is probably normal so Kenny will probably not need a great deal of reconstructive work other than the hole in his skull.