Medical History Edit
Lupe has held a number of short term jobs - pet store clerk, telemarketer, retail clerk and dogwalker. She had also been unemployed between those jobs. She became pregnant at 15, but her child died of SIDS.
Case History Edit
Lupe was brought to Princeton-Plainsboro Teaching Hospital when she panicked after being unable to pick any card in a game of three-card monte and collapsed. She was examined by Dr. Foreman who told her the symptom was called aboulia, the inability to make a decision or exercise will. It was the result of a transient ischemic attack - a lack of blood flow to the frontal lobe. Dr. Foreman asked Lupe what drugs she had been taking, but she denied having taken any. Her medical history seemed to rule out any exposure to toxins.
Dr. Foreman brought the case to Dr. House. He suggested that a clot may have caused the TIA, but her arteries were clear. Dr. Cameron thought the clot may have dissolved, but that it most likely came from her heart. She suggested a bubble study. However, Dr. Foreman thought a clot was unlikely in a woman Lupe's age who was not on the pill. He thought it was a vascular spasm caused by drugs. Dr. Chase suggested that her pattern of going from job to job indicated attention deficit disorder, but Dr. Foreman put it down to her being a scam artist - being employed just long enough to qualify for unemployment benefits. Dr. Chase suggested an infection, but Lupe's lumbar puncture was clear, she had no fever and her white blood cell count was normal. Dr. Chase and Dr. Foreman started arguing as to whether drugs or toxins were more likely. However, when the tox screen came back, it was clean. Dr. House ordered the bubble study and an environmental scan to look for toxins.
Dr. Chase and Dr. Foreman searched Lupe's apartment, where Dr. Foreman found a crack pipe. Dr. Chase pointed out the clean tox screen had ruled out drugs as a cause of the TIA, but Dr. Foreman pointed out that the drugs may have been laced with a toxin that did stay behind, like arsenic or rat poison. He planned to test for them, but Dr. Chase volunteered to do it.
The arsenic test showed only trace amounts, not enough to damage her lungs. She was given an MRI and they found a mass just outside the left lung. A biopsy showed white blood cells in the walls of the blood vessels. This indicated an autoimmune disease - her white blood cells were attacking the body's own tissues. Dr. Foreman wanted to start her on steroids, but Dr. House wanted a definitive diagnosis. However, Dr. Foreman pointed out that whether it was a disease of the large blood vessels like giant cell arteritis, one affecting the small blood vessels like lupus, steroids was always the appropriate treatment. Dr. House agreed.
Lupe admitted using the crack pipe a couple of times, and she was still coughing. She also started showing signs of jaundice, indicating liver failure. She needed an immediate liver transplant. Dr. Chase suggested they choose a more targeted immunosuppresant and add methotrexate. Dr. Foreman argued it wasn't an autoimmune disease despite the white blood cells attacking the body. The failure of the heart, lungs and liver all in the space of two days was too fast for an autoimmune disease. He thought it was cancer - lymphomatoid granulomatosis, a very rare form of the disease. This would explain why she wasn't improving on steroids and why she had poor fingernail growth. He suggested total body irradiation. Dr. Cameron protested because of the danger of the treatment, but Dr. Foreman pointed out that the immunochemistry tests to confirm would take at least a week and Lupe wouldn't last that long. He also pointed out that if it was an autoimmune disease, the main side effect of the radiation would be immunosuppression. Dr. House told Dr. Forman to get the patient's consent and start the radiation treatment. Dr. Foreman didn't feel he had the appropriate rapport with the patient, so Dr. House agreed to get the consent himself.
Dr. House went to see Lupe and told her the other side effects of the treatment. However, she once again started exhibiting ebulia and lapsed into unconsciousness. The nurses ran into the room to deal with the emergency and Dr. House told them to increase her dose of blood thinners and take her to radiology for treatment.
Lupe did well after her first radiation treatment, although she felt weak and was sleeping a lot. She also complained of nausea. All those symptoms were typical of radiation treatment, but Dr. Foreman detected a heart murmer, and when the blood pressure cuff inflated, Lupe cried out in terrible pain.
Dr. Foreman and Dr. Cameron reported the pain to Dr. House. Dr. Chase realized this ruled out cancer, but made it likely that Lupe was suffering from sepsis. Although a lower level of pain could indicate a lot of conditions, this much pain narrowed it down. They realized that Lupe had an infection, but they had disabled her immune system with the radiation. The lack of fever and the clean lumbar puncture most likely indicated the infection was in the heart. Dr. House had to tell the patient that their treatment would result in her death, but Dr. Foreman volunteered to do it.
Dr. Foreman went to Dr. Wilson for advice. Dr. Wilson told him not to try to minimize the hurt, not to temporize, give her time to process the news, then comfort her. He also told him not to be afraid of freaking out and to let the patient see that.
Dr. Foreman broke the news to Lupe - that she would be dead within the next 24 hours. He told her that they misdiagnosed her with cancer when she had an infection and that radiation was the wrong treatment. A heart transplant would not help because the infection had spread to her entire body. She became very angry and told him to leave.
However, when Dr. Foreman realized that Dr. House was planning to do an aspiration to identify the infection, he stopped him because the knowledge would not have helped the patient. Dr. House said he needed to know where they went wrong, but Dr. Foreman told him he could wait for the autopsy. Dr. Foreman also ordered that Lupe be moved from intensive care back to her room so she could have more privacy. He then went back to ask for forgiveness, but then decided to stay with the patient. Eventually, Lupe's heart stopped beating and Dr. Foreman called time of death at 3:35.
Dr. House performed the autopsy and found a small scratch on Lupe's back from her bra hook. This allowed a Staphylococcus infection which spread into her body and led to the sepsis.