Medical History Edit
Melinda had a history of a severe allergy to peanuts, bee stings, and penicillin. While her parents were away, she suffered a severe allergic reaction and did not have an EpiPen. She decided to try to drive herself to the hospital, but en route became dizzy and got into an automobile accident. She suffered severe trauma to the chest which resulted in her heart failing. She was given a heart transplant and put on immunosuppressant drugs.
Her parents set up a clean room in their home, refused to allow her out, and set strict limits on visitors.
Case History Edit
Melinda was in her clean room while her boyfriend was visiting. She had welts on her arm and was itching when suddenly she started having difficulty breathing. The boyfriend called for Melinda's mother who treated her with an EpiPen. She wondered what the boyfriend had done to set off the attack. Melinda was taken to Princeton-Plainsboro Teaching Hospital. Dr. House took an interest in the case when he learned that an immunocompromised patient had an allergic reaction in a clean room.
Dr. House explained to his team that Melinda lived in a clean room because she was immunocompromised from the anti-rejection drugs she was taking after her heart transplant. Dr. Cuddy reported that the patient's environment and everyone she had been in contact with had been tested. However, Dr. House ordered everything tested again.
Dr. Foreman questioned the patient and her family, and found the patient upset about her isolation in the clean room. Dr. Foreman expressed the opinion that she didn't need to live in a clean room, and Melinda's mother took him aside and told him he should have lied to her. When Dr. Foreman told the mother she was overprotective, she told Dr. Foreman about the incident leading to Melinda's heart transplant and asked who was more overprotective than she was so she could get further tips.
Dr. Chase and Dr. Cameron performed an environmental scan of the clean room. They found no allergents, but Dr. Chase determined that the boyfriend had the opportunity to secretly make his way into Melinda's room thanks to an open window next to a tree. Dr. Chase got the boyfriend to admit he had snuck in to have sex the night before the attack, but had failed to disclose the information for fear of enraging the patient's mother. He also admitted he didn't use a condom. Dr. Cameron thought it might be an allergy to semen and asked the boyfriend for a sample. However, the allergy test on Melinda was negative. Dr. Cameron reported this to Dr. House, along with the information that the boyfriend had said he took steps to keep Melinda safe. Dr. House went to question the boyfriend about what he took to keep Melinda healthy and he also admitted to recent use of penicillin as a precaution against infection. However, Dr. House told him penicillin is secreted in body fluids, including semen, and since Melinda was allergic, she probably reacted to it. She didn't react to the recent sample because it had worked its way out of his system.
They planned to release Melinda, but all of a sudden she had respiratory arrest. Dr. Foreman used his stethoscope and noted there were noheart murmors or friction. The patient started spitting out white sputem. Dr. Foreman heard crackling in the lungs two-thirds of the way up. There were welts on her neck. The mother asked why Melinda hadn't been given epinephrine, and Dr. Cameron explained that she was not having an allergic reaction, Melinda's heart was in distress.
Dr. Chase reported the patient was suffering from congestive heart failure. Dr. Cameron surmised her original attack wasn't anyphylactic shock, but was instead a toxic reaction to her anti-rejection medications causing a seizure and heart failure. However, Dr. House pointed out the original attack responded to epinephrine administered by the mother - it had to be anaphylactic shock. Dr. Foreman suggested the anaphylaxis and CHF were unrelated - the penicillin allergy explained the anaphylaxis, and the CHF could be the result of infection, coronary artery disease or tissue rejection. However, Dr. House still thought it was two symptoms of one condition, but no-one could come up with a condition that explained both. Dr. Foreman suggested it was still a good idea to investigate the heart failure. Dr. Cameron noted there was no fever, so infection was unlikely, but Dr. Chase pointed out that immunosuppressed patients won't show with a fever even if they have an infection. Dr. Foreman decided to do a CT scan and a heart biopsy.
The CT scan was clean for coronary artery disease. They planned blood tests for infections, and a biopsy to check for rejection. The patient was afraid she was going to lose her heart. Dr. Foreman told her that she wasn't going to, but the patient was aware that the average heart transplant lasts no longer than ten years. She begged Dr. Foreman to convince her mother to let her go back to school, but Dr. Foreman said they had to keep her in the hospital until they found out what was wrong with her heart. They performed surgery to get a heart tissue sample. Dr. House was still trying to find a condition that tied together anaphylaxis with heart failure. The biopsy was negative, and so were the blood tests.
While reporting the results to the parents, they discovered the patient was missing from her room. They found she hadn't taken her clothes, and must still be in the building. Dr. Foreman realized that the patient wanted to go outside and headed for the roof. He found the patient in one of the stairwells. She started saying that her mother was overprotective even before the heart transplant, and it's just been getting worse. She's now afraid even to go outside herself. Dr. Foreman noted that as they went upstairs, the patient was dragging her right foot. Dr. Foreman examined Melinda's leg and noticed the thigh muscle was twitching when she tried to bend her knee from a straight position. She had ascending paralysis. Dr. Foreman broke the news that ascending paralysis will start with the legs, then continue to spread upwards. The paralysis was spreading quickly, and the prognosis was that it would spread to her lungs in a few days.
Dr. Cameron pointed out that tick paralysis would cause all three symptoms, but Dr. Foreman pointed out that although it can cause anaphylaxis, it was more likely the penicillin allergy. Dr. Chase pointed out the patient had two full physical examinations, and showed no tick or tick bite. Dr. Foreman wanted to focus on the paralysis, and the clean scans ruled out stroke or aneurysm. It was too quick for ALS or multiple sclerosis and too slow for leukemia. Dr. Foreman thought it might be Guillain-Barre syndrome, but it doesn't affect immunocompromised patients. Dr. Chase suggested botulism, but paralysis from botulism descends, it doesn't ascend. Dr. Cameron suggested a virus such as West Nile Virus or polio - those would be likely to affect an immunocompromised patient. Dr. House ordered a lumbar puncture and a PCR test for viruses. He also ordered an EMG in the event it was Guillaine-Barre. The only positive result was that the EMG showed increasing muscle weakness above the knee. That seemed to indicate Guillaine-Barre and Dr. Foreman suggested plasmapheresis to the parents. They consented and the treatment was started. However, the patient's reflexes got weaker. When the patient fell asleep, the mother told Dr. Foreman that Melinda had stopped fighting, she was afraid she had given up.
The patient went into respiratory arrest again. Dr. Foreman listened and found that she was losing control of the accessory muscles that control breathing. Her blood oxygen level was at 90%. Dr. Chase checked for a swollen tongue. The patient was soon cyanotic and Dr. Foreman realized they had to intubate. Dr. Chase administered Lorazepan and they managed to put her on a ventilator. However, they had to report the paralysis had finally reached her lungs.
The quick progression of the paralysis ruled out Guillaine-Barre. Dr. Cuddy suggested an MRI to rule out spinal lesions. Dr. House wanted to know why Dr. Cuddy had suggested anything, and he was told the parents wanted the team off the case. Dr. House realized why the parents had done so.
The next morning, they started a new differential. Dr. Foreman said the symptoms were similar to what happens when someone is poisoned with a nerve agent. Dr. Cameron suggested glue inhalation, which the patient would most likely not disclose. However, Dr. Foreman thought it unlikely that a middle-class kid would turn to glue when she tested negative for marijuana use. Dr. Chase thought it might be pesticides, but they are rarely used this time of year. However, Dr. House asked what else the patient might have gotten from the boyfriend, and they realized she was on a special diet. This brought botulism back into play as the boyfriend may have brought her outside food. They realized the patient never admitted to anything, even the sexual encounter. Dr. House ordered his team to inject the patient's blood into a lab rat to see if it developed botulism as well. However, Dr. Foreman once again pointed out the paralysis was not descending.
Dr. House went to confront the patient. Melinda denied eating any outside food, even when confronted with the sexual encounter. However, all they found out was that the antibiotic that the boyfriend took wasn't penicillin - the patient was concerned about her allergy and checked the bottle herself. They realized that the anaphylaxis must have been caused by something else. Dr. House realized that Dr. Cameron's explanation of tick paralysis was now likely. He asked if the boyfriend had to come through tall grass to see her, and the patient confirmed he did. Dr. House started looking for a tick. He explained to Dr. Cuddy and the parents that because of her allergies, the tick bite may have resulted in anaphylaxis. The toxin then attacked her heart and the muscles in her legs. However, Dr. House had taken her off the respirator, and her heart rate dropped to 47, and her blood pressure dropped as well. Dr. Cuddy figured it was the stress of the situation, but Dr. House argued it was the tick venom. Dr. Foreman administered atrophine. Dr. Cuddy called off the tick hunt so they could arranged to insert a pacing wire. However, Dr. House argued that if was tick paraylsis, it would just get worse. The tick produces more toxin the longer it feeds - she wouldn't last an hour even with perfect care. Dr. Cuddy was unconvinced - in the patient's state, her heart would be gone in 20 minutes. She called for a cardiology team.
She asked Dr. Wilson for help, but he did not feel the patient could be treated where she was in radiology. He didn't think dopamine would be enough - the patient needed amrinone lactate. Dr. Cuddy worried about the risk of arhythmia and thrombocytopenia, but Dr. Wilson thought the risk of death was greater. He recommended taking her to the intensive care unit.
However, on the trip to the ICU, Dr. House managed to isolate himself in the elevator with the patient and Dr. Foreman. Dr. House pulled the emergency stop and tried to convince Dr. Foreman to look for the tick. Dr. Foreman agreed to give the patient his last vial of atrophine and look for the tick for three minutes or until her heart rate fell to 35. A thorough search failed to find a tick and her heart rate fell to 35. Dr. Foreman restarted the elevator. Finally, Dr. House asked the patient the night with her boyfriend was the first time she had sex. He examined the patient's vagina and found the tick just as the elevator door opened. As the father attacked him, he showed him the tick. He ordered nor-epinephrine and the patient's prognosis was that she would recover by the next day. Her symptoms quickly improved as she was rushed to the ICU.
By the following day, her reflexes and heart were back to normal. They released her from ICU and planned to release her the next day. Her mother announced she was going to have to go to school the following Monday.
Despite the protective nature of the patient's mother, she has since allowed Melinda to return to school.