Lue was suffering from frequent nightmares that an elderly woman was trying to strangle him. However, after his most recent nightmare, he was in respiratory distress that proceeded to respiratory arrest. He was rushed to the emergency room of Princeton-Plainsboro Teaching Hospital. His chest x-ray was clear.
Dr. Foreman brought the case to the attention of Dr. House. Dr. House wrote it off as a stress induced anxiety attack. However, he became intrigued when he learned of the nightmares and the patient’s Hmong heritage as he was aware of the mystery of SUNDS.
Dr. House presented the case to his team, as well as a quick history of SUNDS. There were over 100 documented cases in the 1980s, and all the patients were male, Hmong and otherwise healthy. Dr. Park discounted the theory that the patient’s dreams could have anything to do with it, but Dr. Chase countered that the stress could have triggered a catecholamine surge and ventricular fibrillation. However, Dr. Taub noted the patient’s EKG was within normal limits. Dr. Adams suggested obstructive sleep apnea, but Dr. House countered that it would have not cause breathing problems after the patient woke up. Dr. Park thought it might be lung damage from inhaled toxins. Those could have continued after the patient wok up. However, Dr. Adams thought it was more likely to just be an upper respiratory infection. Dr. House ordered Dr. Chase and Dr. Park to start intravenous antibiotics in the event it was pneumonia, and ordered Dr. Adams and Dr. Taub to do an environmental scan for toxins. He also told his team to read all of the available patient files on SUNDS.
Dr. Chase asked the patient’s mother if she believed evil spirits were affecting her son because his fear alone could affect his heart function. His mother insisted she didn’t believe in such things.
During the environmental scan, Dr. Taub and Dr. Park thought they smelled mold but found no water damage. However, when they went in the patient’s room, they found a slaughtered pig and blood smeared everywhere.
Dr. Park and Dr. Taub confronted the mother, but she denied knowing anything about the bedroom. However, when they told her it was a pig, she realized it had been her father-in-law. She went to confront him, and he admitted to it, saying that she should have done it weeks ago when he started having nightmares. All of a sudden, Lue went into ventricular fibrillation and was without a pulse. Dr. Taub called for a defibrillator. He managed to shock the patient back into sinus rhythm.
Dr. Taub went to report the ventricular fibrillation, but Dr. House was more intrigued about what he found in the patient’s bedroom. Dr. Park described it as part of a ceremony. Dr. Taub explained that the grandfather was certain that Lue was suffering from the same evil spirits that had affected his father, who hadn’t just moved away - he was in prison for beating his boss to death. Dr. Adams suggested post-traumatic stress disorder could affect breathing, but Dr. Park explained the murder took place when Lue was too young to remember it. Lue believed his father had moved away after his parents divorced. Dr. Chase said that the patient most likely had a malignant arrythmia and suggested an EP study. However, Dr. House asked about the SUNDS cases and got Dr. Chase to admit that none had shown malignant arrythmias. Dr. Taub suggested acute pericarditis, which explained the shortness of breath. Dr. House went to dismiss this for not matching the other SUNDS cases, but Dr. Taub noted that pericarditis gets worse when a patient is lying down, and all the SUNDS patients had died in their sleep. Dr. House agreed and ordered an echocardiogram. He also ordered the samples from the heart scan tested for heart toxins.
The echocardiogram showed nothing wrong with the pericardium, but the patient had developed severe pain in his abdomen. They did an ultrasound, which showed no blockages, but the patient was still severely constipated. All the samples tested negative for fungus, clostridium perfringens and toxins. Dr. Adams wanted to do a colonoscopy and give the patient an enema, but Dr. Chase suggested they do a biopsy of his thyroid to test for Hashimoto’s thyroiditis. It explained the involvement of the heart, lungs and intestines, and can also cause people to die in their sleep.
Dr. Adams went to give Lue a local anesthetic for the biopsy, but he resisted. The then started getting combative and had to be restrained as he started speaking in Hmong. His mother was surprised because he had never been exposed to Hmong. The grandfather insisted it was the demon inside him telling everyone it was too late to do anything. The patient then had a seizure. Dr. Taub called for lorazepam.
The seizure ruled out Hashimoto’s. Dr. Taub was concerned that the patient spoke in Hmong, but Dr. House said they were relying too heavily on the grandfather, who probably heard what he wanted to hear. Dr. Chase said no matter what it was, it probably pointed to neurological involvement. Dr. Park suggested scleraderma, but Dr. House dismissed it because there would have been skin involvement. Dr. Adams suggested Rasmussen’s encephalitis. Dr. House ordered an MRI to confirm.
Dr. Chase told the mother that Rasmussen’s was chronic, but manageable. It even caused patietns to speak gibberish or with an accent. However, the grandfather was angry that the doctors didn’t believe that the patient had spoken Hmong. He also noted his son had suffered from the same dreams before he beat his boss to death. He denied his son suffered from mental illness and noted he was bright, caring and happy before he started having nightmares. He didn’t want the same thing to happen to his grandson. Dr. Chase asked him not to scare his grandson, because it wouldn’t help him get better.
However, the MRI was normal. Dr. House noted that this didn’t rule out Rasmussen’s.
The patient had another dream that his grandfather was trying to suffocate him to keep the spirits in the air out of him. Dr. Taub managed to awaken him and the patient complained that his grandfather had grabbed his neck. Dr. Taub examined the patient and saw what appeared to be bruises on the front of his neck covering his trachea.
Dr. House dismissed the bruises as being the cause of the bad dream, not the result of it. Dr. Adams suggested a coagulopathy from lung problems, but Dr. Park noted that the bruises wouldn’t just be on his neck, but everywhere. Dr. Taub continued to argue that thoughts during sleep could manifest as physical changes. Dr. Adams pointed out that bruise can have many causes - anemia, vitamin C deficiency or even leukemia. Dr. House suggested liver failure could cause a patient to spout gibberish from an encephalopathy, constipation, bruising and breathing problems. Dr. Adams agreed that hepatic fibrosis was a possibility in an 8 year old. Dr. House ordered a liver biopsy.
Dr. Adams and Dr. Taub performed the biopsy as they reassured the mother. She was afraid she might be wrong about spirits because the doctors always seemed to be wrong about what was wrong with Lue. However, the biopsy was negative for fibrosis.
A nurse called in Dr. Adams and Dr. Taub, who swore they saw the patient floating about six inches above his bed. However, when they reported this to Dr. House, he figured that they misinterpreted something they saw. Even Dr. Chase thought it was more likely the patient was arching his back. Dr. Park agreed and noted that tetanus can cause muscle rigidity. Dr. House noted that tetanus wouldn’t cause breathing difficulties. Dr. Chase suggested hypocalcemia. The enema that they gave the patient had a high phosphorus load. Dr. House thought it was unlikely, but agreed it fit the symptoms. He ordered electrolytes and beta blockers.
However, the mother was resistant due to the previous incorrect diagnoses. Dr. Chase implored her by noting a further seizure could cause permanent neurological damage. However, the mother wanted to let her father-in-law try the exorcism ceremony. Dr. Taub said there was no way they could allow that, but the mother threatened to have the patient discharged. Dr. Chase questioned her change of heart, but she noted that her husband’s actions weren’t typical of his personality either.
Dr. House went to Dr. Foreman to ask him to forbid the ceremony. However, Dr. Foreman was unsympathetic. He felt as long as the grandfather didn’t try to feed Lue, or place anything on his skin that wasn’t harmless, it wouldn’t affect their treatment plans. Dr. House said that the mother’s beliefs were irrational and they might as well get a popular singer in to dance for the boy. Dr. Foreman said that was fine by him as long as the mother gave consent. Dr. Foreman said the mother’s request was no different from having a congregation leader lead a prayer vigil. It might even be helpful for the mother’s state of mind. Dr. House threatened to quit if Dr. Foreman put superstition over science. However, Dr. Foreman knew Dr. House wasn’t about to quit, and he said allowing the ceremony wasn’t the same as saying it had more power than medicine - it was just showing respect. However, Dr. House told Dr. Foreman about the pig that was involved in the previous ceremony. Dr. Foreman finally relented and agreed to speak to the mother.
The mother explained she had no objection to treatment, but she wanted to try everything that she could. Dr. Foreman reminded her that they couldn’t act the same way in a hospital as they would in a temple. The mother threatened to have her son discharged, but Dr. Foreman countered he was too sick to leave. However, the mother had spoken to her lawyer, who informed her that Dr. Foreman couldn’t refuse her the observation of her religious beliefs as long as she agreed to treatment. Dr. Foreman asked that the mother allow them another 24 hours.
However, Lue became unresponsive. Dr. Adams treated him with one ampule of dextrose and started cardiac massage. When Lue didn’t respond, the mother went to call the boy’s grandfather.
The grandfather started the ceremony, which largely involved gongs and items placed around the room around the patient. The tests for the genetic conditions Brugada syndrome and Long QT syndrome came back negative. Dr. Taub thought it might be a carotid artery aneurysm that clotted and wanted to do an angiogram. However, the patient’s carotid pulses were normal. Dr. House didn’t want anything more to do with the case, partly because he figured if he did manage to successfully treat the patient, the ceremony would most likely get all the credit. Dr. Chase asked him to consider Kawasaki disease - it explained the irregular heartbeat, respiratory distress and seizures. Dr. Adams wanted to do coronary bypass surgery, but Dr. House pointed out that Kawasaki’s would have shown up on the echocardiogram. However, he realized a patent ductus arteriosus would not show up on an echo. Dr. Taub argued it couldn’t be a PDA because he hadn’t had any symptoms for the first eight years of his life. However, Dr. House noted that if the ductus had harboured an infection, it would have kept the hole closed. When they treated him with antibiotics, they opened the hole and caused all the new symptoms. Dr. Adams noted the odds were about a billion to one against it. Dr. House countered that by that logic, at least seven people in the world had this problem at the present time. Dr. Taub countered that even SUNDS was far more common than that. Dr. House noted that perhaps PDAs are more common than are believed and were the root cause of the illness. Dr. Adams insisted that the diagnosis had to be wrong, but conceded that since surgery was not an option given the patient’s condition, the alternative was a type of ibuprofen that was harmless and would allow the ductus to repair itself. However, Dr. House didn’t want to treat the patient because of the mother’s belief that faith would cure her son. When his team agreed that his diagnosis was obviously wrong, he prohibited treatment.
However, the patient’s blood pressure suddenly dropped again and he crashed. Dr. Adams asked the mother to stop the ceremony, but she refused. At that point, Dr. Adams went against orders and gave the patient intravenous ibuprofen. They managed to stabilize the patient.
After that, the patient’s vital signs started to improve. The doctors realized that the patient would recover. Dr. Adams tried to explain that the ibuprofen was what repaired Lue’s heart, but his mother would not believe that such a simple treatment could explain her son’s recovery and gave the credit to the grandfather. Dr. Taub rationalized by saying one of two impossible things happened, and they could never know for sure which one.