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Medical History Edit
Case History Edit
Lucy was brought to the emergency room of Princeton-Plainsboro Teaching Hospital when she collapsed at after-school day care with accelerated respiration. She was accompanied by her father and brother. She was diagnosed with restrictive pericarditis that had calcified and she had high blood pressure. These conditions were common in women over the age of 60, but almost unheard of in someone Lucy's age. There were no congenital heart defects. After Lucy was sent to surgery to correct the pericarditis, the case was referred to Dr. House. Dr. House knew the pathology on the heart tissue would not be ready until the following morning, so he ordered his team to test Lucy's blood for infection and to test for amyloidosis, sarcoidosis and hemochromatosis.
The team went to view Lucy's surgery and Dr. Foreman noted the pericarditis had almost reached her heart muscle, which would have resulted in death. Dr. Chase suggested coxsackievirus and parvovirus B19 and CMV, but Dr. Cameron thought it was most likely a bacteria, such as tuberculosis. Dr. Chase noted her hematocrit levels were elevated but Dr. Cameron put this down to dehydration. Dr. Foreman wanted to start testing, but Dr. Chase decided to leave for the night.
Dr. Chase went to perform a biopsy, but her father couldn't understand how Lucy could have picked up a fungus. Dr. Cameron told him it was likely someplace damp, but Lucy didn't go to pools or other moist places. However, after then finished the biopsy, Lucy exhibited double vision. There was swelling in her eyes, uveitis, which Dr. Cameron felt ruled out post-operative infection and neurological problems. The biopsy also ruled out fungal infection. Dr. Foreman felt that double vision and a bad heart suggested an autoimmune disease. Dr. Cameron pointed out that Lupus and Kawasaki's syndrome were the most common autoimmune conditions in six year olds. Dr. House wanted to know if Lucy had scars or scabs on her knees. She didn't, which indicated to him that she avoided going outside, probably because she had joint pain. He figured it was juvenile rheumatoid arthritis. He ordered an ANA test and steroids.
Dr. Foreman was with the patient and her family when he saw that Lucy was in distress. He soon diagnosed her with a stroke. After treatment with TPA, they found a clot in her middle cerebral artery. Lucy was still unconscious and they would not know if she suffered brain damage until after she regained consciousness. Dr. Cameron felt it had to be polycythemia as Lucy was fully hydrated but her red blood cell count was still too high. Dr. Foreman noted that a lack of oxygen could cause overproduction of red blood cells. Dr. Chase noted that carbon monoxide and cigarette smoke could both cause oxygen deprivation. Dr. House ordered Dr. Chase and Dr. Cameron to do an environmental scan and ordered Dr. Forman to start Lucy on Hydroxyurea to reduce her red blood cell production and to intentionally bleed her to prevent further clotting.
Dr. Foreman went to perform the bleeding and to assure Lucy's father that she was likely to make a full recovery despite her current inability to speak. Dr. Chase and Dr. Cameron couldn't find any evidence of carbon monoxide, but found a bloody t-shirt stuffed into a vent in Lucy's room. Dr. Cameron felt that Lucy was most likely being abused. Dr. Foreman thought it might be from an innocent source, such as a nosebleed, but Dr. Chase pointed out that the t-shirt was hidden. However, Dr. Foreman pointed out that there were no marks or bruises on Lucy's body. Dr. Cameron pointed out it might be sexual abuse, which required them to call social services. Dr. House wanted to perform a full physical exam, but doing a vaginal exam required the father's consent, which he was unlikely to give if he was abusing Lucy.
Dr. Foreman was given the task of getting the father's consent. He confronted the father with the bloody t-shirt and asked if he was abusing her. The father denied she was being abused and Dr. Foreman told him that if they did not allow them to examine Lucy, they had no choice but to call social services. The father agreed to the examination.
Dr. Cameron performed the examination, but the only unusual sign she saw were small cut marks around her vagina. Some had healed, but some were new. Dr. Chase suggested she was cutting herself, but Dr. Foreman pointed out such self-destructive behavior is usually only seen in much older children. However, there was no evidence of vaginal tearing, and the cuts could not account for the blood on the t-shirt. Dr. Foreman suggested that perhaps it wasn't Lucy's blood.
Dr. Cuddy confronted Dr. House about not reporting possible abuse, but Dr. House noted that the father's consent ruled him out as a suspect. She told him to report the matter anyway.
Dr. Foreman tested the blood - it was Lucy's, but it was full of endrometrial cells - menstrual blood. That meant Lucy had entered puberty. This was traced to a hormone imbalance - too much estrogen and testosterone for a person of her age. They had to find the source. However, Lucy had started talking again.
The bloody t-shirt was from her trying to soak up the menstrual blood when she had a period and didn't know what it was. A friend her age suggested it. The cut marks were from taking her father's razor to shave off her pubic hair when they started to grow. Dr. Foreman thought the excess hormones were from a tumor, most likely a pituitary adenoma. However, Dr. Cameron thought it had to be an environmental source - estrogen is overused in agriculture and manufacturing. Dr. House thought a tumor was more likely, so he ordered an MRI of her head and reproductive tract. However, he allowed Dr. Cameron to look for an environmental source. However, the MRI showed a growth on her left ovary.
Surgery was scheduled to remove the ovarian tumor. During surgery, Lucy developed an arrhythmia, although they defibrillated her and stabilized her. Dr. Chase thought that the arrhythmia was due to the hydroxyurea and wanted to stop it. However, Dr. Cameron pointed out that this meant they would have to keep bleeding her. Dr. Chase felt that the removal of the tumor would result in her red blood cell production returnign to normal. However, the biopsy showed the tumor wasn't an adenoma at all, just a harmless benign cyst. Dr. Cameron pointed out that the extra hormones had to have come from an environmental source. Dr. Foreman left Dr. Chase and Dr. Cameron to test the samples Dr. Cameron collected.
While Dr. Cameron and Dr. Chase were talking during a late night break, Lucy's brother saw them together and attacked Chase, threatening to kill him and biting him on the arm hard enough to draw blood. They reported Dr. Chase's injury to Dr. House at home, who at first brushed it off as irrelevant. However, he soon called back to point out that Lucy's symptoms and the brother's aggressiveness were being caused by the same problem.
The brother tested 100 times the normal level of testosterone for an eight-year-old male. The tests on the environmental sources ruled out any environmental source of the testosterone. Dr. Chase thought it might be genetic, and it was all the more likely given the family history of brain tumors. However, their mother didn't have any symptoms of hormone overproduction and the brain scans of both patients were clean. Dr. Chase thought that perhaps the mother's doctors overlooked what they felt were irrelevant symptoms. Dr. House ordered the team to review the mother's medical records.
Lucy complained that her stomach hurt and started screaming. They did scans and found cysts in her pancreas, kidneys and lungs. The cysts were obviously the result of the increased hormones and if they spread to her brain or heart, they would kill her. The mother's medical record was clean until she was diagnosed with the brain tumor. Dr. Cameron felt it had to be a pituitary adenoma despite the lack of any indication on the scans. She recommended removing Lucy's pituitary gland despite the side effects. Dr. House still thought it was most likely environmental given that both siblings developed it at the same time and wondered if they had missed a source. Dr. Cameron went to get the father's consent to remove the pituitary. Dr. House felt that they had no evidence, but Dr. Cameron pointed out they had eliminated every other condition that could cause hormone overproduction.
Dr. Cameron talked to the father, but Dr. House showed up to argue against the procedure and started asking the father about other possible sources. The father noted they went to the same after-school day care, but none of the other kids there were sick. Despite Dr. House's opposition, the father consented to the procedure. Dr. House asked how the father knew none of the other kids were sick and the father said he would have been told.
Dr. House went to the day care to speak to the supervisor. He told her that he thought she was dating Lucy's father, because that's the only way he could have known no-one else was sick. However, she denied ever going to the house. Dr. House noted that she had just had a lip wax, but had no other care procedures. He figured that she was growing a mustache - another symptom of testosterone exposure. He figure the father had to be the source and called to cancel the pituitary surgery.
Dr. House asked the father if he was using any testosterone supplements. He admitted to using testosterone cream because the day-care supervisor is much younger than he is. However, he kept it at his gym. Dr. House pointed out that he would have excreted it in his sweat, exposing his children every time he touched them. That's why Lucy didn't get better in the hospital. He agreed to stop using it. Lucy and her brother were soon well enough to be released from the hospital.