Medical History Edit
The patient has an extensive history of worldwide travel.
Case History Edit
The patient was admitted to Princeton-Plainsboro Teaching Hospital after suffering visual hallucinations during a business meeting. Dr. House agreed to take the case. The patient had no fever, which seemed to rule out tropical diseases. Dr. Kutner suggested abuse of amphetamines as the patient worked long hours. However, her tox screen was clean. Dr. Taub suggested Vitamin B-12 deficiency from a diet of airline food. However, Dr. Hadley thought it was an insulinoma in her pancreas causing hypoglycemia. However, Dr. House noted that the patient had hypersegmented polys which indicated a B-12 deficiency. He ordered the patient be given Vitamin B-12. Dr. Hadley went to administer the B-12, and found the patient very active trying to plan a trip for her boss. She thought her symptoms were merely due to fatigue and dehydration, but Dr. Hadley told her she needed rest and to get back into bed. All of a sudden, the patient complained she had accidentally had a bowel movement (diarrhea being a common symptom of B-12 deficiency), but when Dr. Hadley looked, she found the patient had rectal bleeding.
Dr. Hadley tried to report the rectal bleed to Dr. House, but he was busy. Dr. Hadley and Dr. Taub decided to perform a colonoscopy. Dr. Hadley wondered why the patient's heart rate had slowed when it should have sped up because of the bleeding. However, they could not find any bleeding in the colon. They also performed an endoscopy, which was also clear. They planned a CT Scan, but Dr. Hadley doubted it would show anything different. They reported to Dr. Foreman. However, Dr. Kutner arrived and explained one of her routine blood tests showed a hormone imbalance that could effect heart rate and blood flow - pregnancy. The patient had not had sex for 2-3 months, but Dr. Kutner could not find the fetus with the ultrasound.
Although the patient's B-12 levels were normal, her heart rate was still slowing. Dr. Hadley thought it might be choriocarcinoma, but this would have shown up on the sonogram. Dr. Kutner suggested immunoglobulin A deficiency, but there was no blood in her urine. Dr. Taub thought her Beta-HGC injections might have had a cross-reaction. However, Dr. House was sure the patient was actually pregnant. He went to do the ultrasound himself and found the fetus had dropped through the uterus and latched to the intestines, drawing blood from them and causing the bleeding; a rare complication. The fetus was also most likely pressing on her vegus nerve, slowing her heartbeat as well. He ordered surgery to remove the fetus. Dr. Hadley protested that the patient might want to keep the baby, but Dr. House noted the surgery they were planning was already very high risk, and saving the fetus was likely impossible. Dr. House accused Dr. Hadley of letting her positive test for Huntington's Disease color her judgment and reminded her that everyone dies. When Dr. Hadley went to get consent for the surgery, she readily agreed to it.
Dr. Chase performed the surgery, but had trouble with bleeding once the placenta was removed from the large intestine. The patient's blood pressure started to drop. Dr. Chase ordered administration of calcium chloride. He ordered someone to squeeze her spleen to encourage clotting despite the risk of rupture. He managed to stabilize the patient and remove the fetus.
However, after the surgery, her heart rate stayed low and the patient started blinking continuously, indicating a neurological problem. The pregnancy may have just been a coincidence. The patient's heart rate dropped to 39 bpm and she was given the maximum dose of atrophine. Dr. Hadley started to install a pacing wire, but the patient went into cardiac arrest. Dr. Foreman performed CPR as they tried to contact Dr. House, but he could not be reached.
The team managed to stabilize the patient and insert the pacing wire, but her heart rate remained low. In Dr. House's absence, Dr. Cuddy assured the team she had full confidence in them. However, they had no differential diagnosis. Dr. Hadley thought it might be a complication of the surgery, but Dr. Taub noted the surgery was no-where near her brain. Dr. Kutner noted that anxiety, stroke and Tourette syndrome could all account for the blinking. Dr. Hadley thought it might be multiple sclerosis. Dr. Foreman agreed to start the patient on interferon. Dr. Hadley assured the patient that Dr. House thought she had MS. All of a sudden, the patient started to shiver and presented with a slight fever. This ruled out MS.
The team reviewed a video of the surgery. Dr. Hadley still thought it was a complication of surgery, perhaps an infection that had reached the brain, such as streptococcus. However, Dr. Kutner spotted something he thought was a ganglioma, although Dr. Taub thought it was a harmless hematoma. Dr. Foreman realized a ganglioma could explain the symptoms and realized they needed to perform more surgery to perform a biopsy. However, Dr. Chase refused because he didn't think it was a ganglioma, the patient was unlikely to survive anesthetic for a second time, and if the biopsy was positive she would need another major surgery which she likely wouldn't survive either.
However, Dr. Kutner came up with an alternate plan - go in with a lighted scope up her rectum until they find the ganglioma, then push it to the surface and take out the biopsy sample where they see the light. Dr. Hadley explained to the patient that they could not anethestize her during the procedure, and she wanted to talk to Dr. House. However, Dr. Hadley insisted that they knew what they were doing. They performed the procedure and took a biopsy in her abdomen. However, it was not a ganglioma and it ruled out the surgery as a cause of the patient's symptoms. Dr. Hadley thought it might be amyloidosis, but they had to find the cause which could be rheumatoid arthritis, familial Mediterranean fever or lymphoma. However, Dr. Taub pointed out that there was no joint pain (ruling out arthritis), the patient no longer had abdominal pain (ruling out Mediterranean fever) and had no palpable lymph nodes (ruling out lymphoma).
Dr. Foreman went to Dr. Wilson for a consult and he thought it might still be lymphoma despite the lack of palpable lymph nodes. Dr. Foreman started the patient on chemotherapy. The patient started to feel better. She thanked Dr. Hadley for thinking of lymphoma. However, Dr. House came to see the patient - he noticed that the patient looked older, more like her age. The previous week, she had looked under 30. He asked if the patient had bruising, but Dr. Hadley put that down to her reaction to the hallucinations. However, Dr. House examined them and found the bruises were actually micro-bacterial lesions. The young skin and lesions indicated lepromatous leprosy. The chemotherapy had killed some of the bacteria, making her feel better. However, if they had continued it, it would have destroyed her immune system, allowing the bacteria to run rampant. He ordered antibiotics and prednisone. The patient tested positive for leprosy. Her pregnancy had triggered erythema nodusum leposum, a complication of leprosy which inflammable the nerves to her heart, made it difficult for her to absorb vitamins and scarred her fallopian tubes, explaining all of her symptoms.