|Diagnosis||Atypical presentation of breast cancer|
|First Appearance||It's a Wonderful Lie|
Maggie Archer is the patient in the episode It's a Wonderful Lie.
Medical History Edit
The patient had a family history of breast cancer and inherited the BRCA mutation and underwent an elective mastectomy as a preventative measure. She did not opt for the use of reconstructive breast implants.
Case History Edit
The patient was brought to Princeton-Plainsboro Teaching Hospital when she lost her grip on a safety rope holding her daughter during rock climbing. The daughter suffered a broken arm as a result. The patient was unable to move her fingers.
The patient was treated by an orthopedist, two neurologists and an immunologist without success. Her hands had become paralysed and the numbness was spreading into her arms. She was referred to Dr. Gregory House. The patient denied having a history of drug use. Despite the double mastectomy, Dr. Taub pointed out that paralysis is a symptom of paraneoplastic syndrome, indicating cancer. Dr. House ordered an MRI of her chest to confirm. Dr. House spoke to the patient's daughter who admitted that her mother was somewhat promiscuous. However, the patient had already admitted her sexual history.
Dr. Wilson reviewed the MRI and saw no sign of tumors or cancer. Dr. Hadley had already tested for STDs. Dr. House sent Dr. Foreman and Dr. Taub to interview her sexual partners. One of her partners admitted to giving her ecstacy and they took a sample. Dr. Kutner started hemodialysis. Dr. Hadley tested the drugs. During the treatment, the patient suffered from rapid onset blindness.
The ecstacy only contained ecstacy and it could not account for the blindness. Dr. Hadley believed the blindness could be the result of the hemodialysis, but Dr. Kutner noted the results were within range. Dr. House ordered an environmental scan. Dr. Forman thought it might be Kearns-Sayre syndrome, but Dr. House noted there was no family history of the disease. Dr. Taub thought it might be multiple sclerosis or a vascular problem. Dr. House agreed to perform an MRI to test for MS and ordered a fluorescein angiogram of her eyes to determine if they missed bleeding. He also insisted on the environmental scan and asked his team to bring the computers of both the patient and her daughter.
Dr. Taub performed the angiogram. It ruled out any vascular problems. The MRI was normal as well. Dr. Foreman thought it might be conversion disorder. Dr. House agreed and over Dr. Hadley's objections enlisted the daughter to mislead the mother about a placebo treatment. He convinced the daughter that anti-depressants would be dangerous if it wasn't conversion disorder. Dr. Taub administered the placebo and told the patient that her reaction would be nearly immediate. However, the patient did not improve and was soon suffering from respiratory distress when her lymph nodes swelled up and blocked her airway. Dr. Taub intubated the patient. They then used alcohol to shrink the lymph nodes and the patient started breathing on her own again. However, the swollen lymph nodes ruled out any psychosomatic cause. Dr. Kutner thought it might be a fungus from her gym, but the patient had no fever and her white blood cell count was normal. However, Dr. House had studied the patient's computer and believed she had sarcoidosis because she was selling exercise equipment and avoiding exercise. It appears she had been suffering from joint pain for about two years. However, Dr. Hadley pointed out her ACE levels were too low for sarcoidosis. Dr. House argued that the disease could be in an inactive phase. Dr. Foreman pointed out there was no lung involvement. Dr. Taub suggested a broncheal-alveolar lavage to confirm.
Dr. Taub, Dr. Kutner and Dr. Hadley performed the lavage. However, when the test was completed, they noticed the patient was bleeding into her eyes. Her platelets were tested and found to be dropping, showing her blood had stopped clotting. Dr. Taub suggested splenic sequestration or tuberculosis. Dr. Hadley suggested Gaucher's disease and TTP. Dr. Kutner suggested hemolytic uremic syndrome, lupus and sepsis. Dr. House ordered a bone marrow aspiration to see why her platelet count had dropped.
Dr. Chase performed the aspiration. However, while he was drilling, Dr. Foreman noticed that the bone was smoking, showing it was harder than the steel tipped drill they were using for the procedure. Dr. Kutner performed a full body bone scan, but it showed no hot spots. Dr. Hadley suggested that the tracer had not circulated, and Dr. Taub thought the procedure had been done incorrectly. However, Dr. Kutner insisted the test had been performed correctly. Dr. Foreman suggested the lack of hot spots merely showed the density was consistent throughout the body - all her bones had turned hard - osteopetrosis. Dr. Kutner suggested carbonic anhydrase type 2 deficiency because all other causes of osteopetrosis are untreatable. Dr. House ordered Dr. Kutner to test for it and hope for the best.
Dr. Taub informed the patient and told her that if it was type 2 deficiency she would require a bone marrow transplant. However, the patient refused consent to test her daughter. Dr. Taub checked the donor registry and found a 5/6 HLA match. However, the test for type 2 deficiency was negative so a bone marrow transplant would not help. The best they could do was palliative care. Dr. House agreed to advise the patient, but ordered his team to keep working until they discovered what was wrong with her. Dr. House realized the patient's daughter was adopted (which is why she refused to let her daughter be tested) and recommended that she tell her before she died. However, she refused.
However, after talking to Dr. Wilson, Dr. House realized there was one other treatable cause of osteopetrosis-breast cancer. He realized breast tissue can often be misplaced in the developing fetus. He injected the patient with risperidone which makes breast tissue swell. He found swelling below her knee. Dr. Hadley thought it was a fat deposit, but Dr. House drew out milk, the production of which is also stimulated by respiradone. He ordered surgery to remove the tumor and chemotherapy. The prognosis for recovery was excellent.