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Case History Edit
Lee was brought to the hospital emergency room in Middletown, New York, after suffering a catastrophic bicycle crash. He remained unconscious and he had negligible EEG activity. As such, he was judged to be brain dead by his attending physician and plans were made to harvest his organs for transplant. He was kept on life support. However, Dr. Gregory House, who was also at the time a patient in the emergency room, believed that the EEG showed real brain activity and believed the patient's eyes were tracking people in the room. He diagnosed locked-in syndrome. He brought this to the attention of the attending physician and soon convinced him that the patient's eye movements were deliberate. The patient was soon responding to questions by blinking. The attending soon changed his diagnosis to locked-in syndrome caused by damage to the brain stem from the bicycle crash. However, Dr. House noted that the patient's other injuries were inconsistent with a conscious person falling from a bicycle. There was no evidence that the patient attempted to protect himself in the fall. He believed the locked-in syndrome was caused by another underlying condition, such as stroke, cancer or infection. However, the attending rejected the diagnosis and planned to put the patient on a regime of physiotherapy.
Dr. House called his team to Middletown for a consult. Dr. Foreman believed the most likely causes of rapid onset locked-in syndrome were vascular artery stroke and brain hemmorhage. However, Dr. House had reviewed the patient's CT Scan and found no abnormalities. Dr. Kutner suggested a heart problem, but the patient was an active bicycle rider and was unlikely to have a faulty heart. Dr. Hadley suggested a brain tumor, which would only show up with a contrast MRI. Dr. House surreptitiously ordered the MRI.
The MRI detected a lesion in the central pons. The attending physician insisted it was an infection and treated it with anti-viral medication. However, Dr. House believed it was a tumor causing paraneoplastic syndrome, in which case the anti-viral would be dangerous. The patient soon suffered a seizure. His spouse insisted he be transferred to Princeton-Plainsboro Teaching Hospital.
The patient was transferred and put on plasmapheresis to treat the cancer. However, Dr. Taub noticed that the patient had blood in his urine. The patient was asked if he used alcohol or street opiates, but denied it. Dr. House arranged to biopsy the lesion.
Dr. Chase prepared the patient for surgery and put him under anesthetic. The patient was revived during surgery to test his mental faculties. He answered the first two questions correctly but soon stopped blinking altogether. Dr. Foreman surmised that the biopsy damaged the brain functions that control blinking, but Dr. House pointed out that the surgery may have caused enough swelling to kill the brain outright.
The biopsy showed damage to the myelitis sheath. This could be caused by several conditions including coronavirus, Epstein-Barr virus, malaria, and rotovirus. Dr. House realized they needed a better medical history in order to see if he had other symptoms consistent with those diseases. Dr. Taub suggested a brain computer interface and put the patient on the equipment and instructed him to keep thinking "up". After several hours, the brain interface finally responded and the patient was once again answering questions.
The patient denied having bloody diarrhea, ruling out rotovirus. He also denied having joint pain, ruling out Epstein-Barr. He also denied leaving the country. However, when he denied any travel inside the United States, his answer was inconsistent with his wife's recollection that he had been to St. Louis recently. Dr. House suggested the patient had cheated and may have neurosyphillis. However, the patient denied it. Dr. House soon learned the patient had been staying with a friend. He talked to the wife and found out where the patient was staying. He sent Dr. Taub and Dr. Kutner to the house for an environmental scan. They learned the patient was the only person staying in the basement of the house. They also traced a place of employment - a factory that made rechargeable batteries. An environmental scan done there found cadmium and cadmium poisoning would explain all the symptoms. They started chelation therapy. They also had to irrigate the patient's eyes because he could not blink. However, as Dr. Hadley went to close the patient's eyes so he could sleep, she noticed that his epithelium was torn. She put fluorescent stain in his right eye and examined it. She found ulcerative keratitis, which ruled out cadmium poisoning.
The loss of myelitis pointed to an infection, possibly varicella, but the previous treatment would have affected that. It could also be an autoimmune condition such as Bichette's disease. When Dr. Cameron came to treat Dr. House's injuries, she suggested a lumbar puncture. This could result in a positive result for either varicella or Bichette's. Dr. Foreman was preparing to perform the LP when the patient had a cardiac arrest. Dr. Foreman called a code and Dr. Kutner managed to revive the patient. As the doctors were arguing, they realized the patient was trying to bring something to their attention. They soon realized the patient had a problem with his right foot - it was itching. This indicated liver failure. It was likely that enzymes from the failing liver led to nerve damage which caused the locked-in syndrome. Dr. Foreman believed the condition that would explain the most symptoms was sclerosing colingitis. Dr. House ordered a biopsy to confirm. As they prepared for the biopsy, Dr. Hadley mentioned that some of the patient's urine had gotten on her wrist when she changed the catheter. She had a rash that could be caused by leptospirosis, which is carried by rats and transmitted through urine. Those could have been in the basement the patient had stayed in. They found a scratch on the patient's finger that could have let in the leptospirosis. They found rats in the basement that tested positive for leptospirosis and they started treating the patient for it. The patient soon began to exhibit voluntary movement again. He eventually started speaking again.