Due to his occupation, the patient has suffered multiple traumatic injuries which have required extensive surgical repair. He has metal rods holding together the bones in every limb. He has pins stabilizing his spine. He has five screws and a titanium plate in his skull
Lane had successfully finished a bull ride. He was thrown, but quickly rose to his feet. However, he became disoriented in the arena and was unable to move. The bull struck him with its head, narrowly missing Lane with its horns, throwing Lane several feet away. It then attacked him with its hooves, resulting in several traumatic injuries. Lane was conscious and responsive after the attack, but still disoriented.
The patient was treated at Princeton-Plainsboro Teaching Hospital for a rupture in his diaphragm, a broken sternum, and a broken nose. He also had partial hearing loss. This could have been explained by the trauma, but the patient also appeared to have a neurological disorder and was suffering from a slight fever, nausea and peripheral muscle weakness that was not consistent with trauma. The case was assigned to Dr. House and senior fellow Dr. Foreman started a differential diagnosis. Because of the metal in the patient’s body, he could not have an MRI, and any X-ray or CT Scan would most likely be affected by the metal as well. Ms. Masters suggested the loss of hearing could have preceded the trauma. A pathology in the inner ear could cause a loss of equilibrium and disorientation, mimicking a neurological disorder. She suggested a vestibular caloric stimulation and ENG, which would show if his balance was affected. Dr. Foreman agreed with the diagnosis plan.
The ENG was normal, but Dr. House noted that the patient’s ability to keep his balance was probably exceptional given his occupation. They had to find a way to challenge him to confirm if his ability to keep his balance was affected. The team devised a test requiring that the patient balance on a tilt table on just his right leg while his visual field was being changed. He was told to advise them if he had any nausea or disorientation - if so, they would stop the test. However, the patient had no difficulty keeping his balance. Dr. Foreman thought it was a brain problem, and the team tried to figure out a way to look inside his skull without scans. However, the patient went to get a drink of water and complained it was brown. Dr. Foreman noticed that Lane was bleeding from his mouth.
Dr. Chase thought there might be a tumor in the salivary gland and wanted to do a biopsy. However, Dr. Taub thought a bleed in the digestive tract was more likely - it would explain nausea and weakness as well. Dr. House ordered both a scope of the digestive tract and the biopsy.
Ms. Masters and Dr. Taub used an endoscope to scan the patient’s digestive tract. However, Ms. Masters noticed that the patient’s sclera had turned yellow, indicating jaundice and problems with the liver. X-rays showed what appeared to be a mass, but a conductive rod in the patient’s ribs obscured the view. Dr. House ordered exploratory surgery.
Dr. Chase performed the surgery with Dr. Taub assisting. However, they found no mass even though there was clearly one on the x-rays. Dr. House thought it might have been a tapeworm, but Dr. Taub noted that the fecal smear they did would have shown eggs, and the patient would have systemic eosinophilia. Dr. House suggested a detached cyst, but Dr. Foreman insisted it could not have moved that far in just an hour. Dr. House finally hit upon an intermittently swollen lymph node. Ms. Masters realized that this would be caused by an infection and the only was to confirm was with a lumbar puncture. However, given the patient’s recent injuries, a lumbar puncture could dangerously increase his intra-cranial pressure causing a herniation of the brain. Dr. Chase suggested a ventricular puncture instead and Dr. House agreed.
The patient was confused about the request for the ventricular puncture given the fact the mass had disappeared, but agreed. Dr. Taub performed the procedure with Ms. Masters assisting. However, the cerebro-spinal fluid was clear. However, the patient started having trouble breathing and his O2 stats started to drop. Dr. Taub called for intubation, but they could not insert the tube. Ms. Masters called for a tracheotomy and Dr. Taub made the incision to his trachea to get him breathing again. However, Nurse Anne noted a peculiar smell. After confirming the patient had not defecated, the smell was traced to his feet.
The smell on the feet could be explained by diabetes mellitus, athlete’s foot or gangrene, but none of those diseases explained the other symptoms. Dr. House thought that another fungus had started ulceration between the toes and spread through the patient’s body, which also caused intermittent abcesses (which appeared to be masses) which explained the bleeding. The infection would have to be in the heart or brain. Despite the conductive rod in his ribs, they decided to do an MRI on his heart. Although it would heat up and be painful, it would cause no permanent damage. Dr. Taub suggested injecting ice water in his abdominal cavity to keep the heat down.
Dr. Taub and Dr. Masters explained the procedure to the patient. He started feeling severe discomfort. His rib temperature rose to 158F and he started smoking. They finally ended the scan and Ms. Masters applied ice packs. However, the scan showed no abnormalities in the heart or its major vessels.
This appeared to indicate the infection was in the patient’s brain. Dr. House wanted to do a CT scan, but Dr. Foreman objected as the plate and screws in the patient’s skull would make a scan useless. Dr. House suggested removing the plate, but Dr. Taub noted that the patient’s skull had multiple hairline fractures and would most likely be irreparable if they removed the plate. Dr. House noted that the patient was dying and he could still live with a damaged skull. Dr. Foreman argued it was too risky given that the patient’s symptoms kept disappearing every time they tested for them. All of a sudden, Dr. House suggested that the symptom that hadn’t disappeared may never have been there in the first place. Dr. House asked if the patient was slow to answer questions and Ms. Masters confirmed that he was. Dr. House realized the patient’s hearing was fine - he was just having momentary short blackouts, probably from a something like a complex partial seizures. The first one happened after the bull ride, but the rest happened afterwards and the patient didn’t notice them. Dr. Chase noted the patient’s EEG didn’t indicate any seizures, but Dr. House said it wasn’t really a seizure, just something that resembled one.
Dr. House came up with a simple diagnostic test. He asked the patient to sing while he was being timed by a metronome. The patient started singing normally, but suddenly paused between the words without realizing it. Lane was surprised that he wasn’t singing normally. They planned the surgery to remove his skull plate.
However, after removing the skull plate and doing a CT Scan, there was still no trace of an infection or any other problem with the patient’s brain. Dr. House wanted to increase pressure on the aorta until it ruptured, indicating where the infection had weakened it, but Dr. Foreman opposed the plan. They had performed a trans-esophageal echocardiogram on the heart which, together with the MRI, showed no swelling, vegetations or masses. Dr. Chase reminded Dr. House how dangerous that was, but Dr. House argued the infection would have the same effect over time and once it ruptured, it could not be repaired in time. Dr. House went to get the patient’s consent.
Dr. House explained to Lane that he probably had a bartonella infection which had caused a mycotic aneurysm in his aortic wall and that they planned to increase his blood pressure until it ruptured, hoping that they could repair it before he bled to death. The patient agreed to the procedure. However, Dr. Cuddy objected. She accused Dr. House of not being objective due to his recent personal problems. However, Dr. House insisted he was still the best doctor in the hospital and that he planned to do the procedure with his team unless she physically stopped him. She finally agreed to let him try.
Dr. Chase opened up the patient’s heart and exposed the aorta. Dr. Foreman started to increase the blood pressure and noticed the bleed that confirmed Dr. House’s suspicions. Dr. Chase started to switch the patient to heart-lung bypass, but the hole in the aorta got much larger and started squirting blood. With no time to get the patient on bypass, Dr. Chase managed to clamp the hole and called for suction and sponges. Dr. Chase then started to suture the hole and managed to stop the bleeding. The patient’s heart rate returned to normal.
Lane was taken to recovery and Ms. Masters monitored him. Lane soon regained consciousness and was fully lucid. He was warned not to get his heart rate too high for a little while.