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- "An informant would have sold his pals out to us at the first sign of a sniffle. This guy... is a cop."
- ―House realizes why the patient won't give a proper medical history
Medical History Edit
The patient sought treatment for facial lacerations. However, he was not forthcoming as to the cause of his injuries and refused to share his medical history with the doctors or to guide them to any previous medical records. The only information he shared was that three years previously, he had suffered from back strain.
- "Yeah. Also, a lot of cops in the E.R.... Not that you care about that. So how did this happen?... Yeah, you're right. That was a stupid question. 'Cause the answer's kind of obvious. No scrapes on your hands means you didn't try to break your fall. Means either out cold or totally disoriented when you went down. No sign of trauma other than the cut means no one hit you in the head. Powder burn on your jacket sleeve means someone shot a gun."
- ―House in full Sherlock Holmes mode digs past the patient's reluctance to own up to the cause of his injuries
- Taub: "You're gonna hear a series of clicks and hisses. Sensors measure electronic activity to your auditory nerve."
- Mickey: "How long is this gonna take?"
- Taub: "An hour, maybe an hour and a half. Or you could walk away with a tumor in your ear."
- — Mickey, expressing frustration with the speed of the diagnostic process
- " I NEED THE DRUGS! Hmm... works for Jack Bauer."
- ―House questions Eddie
- Taub: "Pupils are constricted. Pulse is bounding!"
- Foreman: "Airway's clear. Need a crash cart in here!"
- Taub: "Gotta be his blood pressure. We need to get it down before he strokes out!"
- — Mickey has a bad reaction to a non-invasive test
However, during the ear test, Mickey had a seizure. His heart rate was irregular although his airway remained clear. Dr. Foreman called for a crash cart. Mickey's blood pressure started to rise and Dr. Taub realized they had to lower it before he had a stroke. Dr. Taub put him on vasodilators and got it under control. Dr. Hadley noted that Mickey got worse in the hospital, so it probably wasn't anything related to his drug dealing that made him sick. Dr. Chase thought it might be sick sinus syndrome, but Dr. Taub noted that Mickey had no chest pain or shortness of breath. He though it might be a brain aneurysm secondary to polycystic kidney disease. However, Dr. Foreman noted that Mickey's urinalysis was normal and his kidney was palpable. Dr. Hadley suggested carotid stenosis. Dr. House agreed and ordered an ultrasound of his carotid arteries to see if they were clogged.However, the ultrasound showed no obstructions or narrowing. He also kept asking to be discharged. In order to try to get a better medical history and find some drugs to test, Dr. House attempted to use a listening device in the patient's room, but he could not get it to work. However, he figured that toxins were being released by Mickey's fat cells which is why he was getting worse in hospital. Dr. Taub suggested that if it were a toxin, they should start testing him. However, that gave Dr. House an idea - he told Dr. Taub to tell Mickey the necessary tests could take several weeks. Mickey insisted on being discharged and Dr. Taub agreed. Dr. House had Dr. Hadley and Dr. Chase follow Mickey to see where he was going. However, Mickey managed to lose them.
- "Next time you're tailing someone, take two cars."
- ―Mickey gives some advice to the doctors
However, Mickey was soon back in the hospital with a fever of 105F combined with a weak and thready pulse. Eddie told the doctors that Mickey was delirious as well. They had to physically restrain Mickey to keep him on the hospital bed.
Mickey was given anti-pyretics and mild steroids. His fever dropped and he came out of his delirious state. Dr. Chase pointed out that the fact he now got worse after leaving the hospital indicated it was something environmental. However, Dr. House disagreed. Given the rapid onset of the fever, infection was more likely and it had likely spread to his brain. Dr. Chase and Dr. Taub went to do a lumbar puncture.Mickey apologized for having to lose them. He also complained that the doctors had a bad attitude about his drug dealing, alhtough it was more likely that they treated far more people with alcohol issues rather than drug issues. Dr. Taub had difficulty finding an entry point as the prior back injury seemed to have flattened out his discs. As they completed the procedure, Dr. Chase realized that Mickey's heart rate remained normal, even though it should have gone up due to the discomfort of the procedure.
- "What, are you gonna beat me up? That sounds stressful. Maybe you should pop one of your beta blockers first."
- ―House outs Mickey's drug use
Dr. Chase told Dr. House that they had ruled out infection, but that given the normal heart rate it might be an autonomic nerve disorder. However, Dr. House realized it wasn't due to his underlying problem - Mickey was taking beta-blockers. Mickey admitted that he took them to control the symptoms of the stress he feels from his lifestyle. He didn't want his friends to know. He admitted he took one the night before he was admitted. Dr. House realized the high blood pressure was merely a symptom of withdrawal. When he left the hospital, he took another beta-blocker, which allowed his blood pressure to return to normal. Dr. Chase noted his stress could be a symptom and Dr. House agreed he might have a pheochromocytoma - an insulin producing tumor. Dr. House ordered Dr. Chase to do an MRI of Mickey's adrenal glands.
The MRI was negative, meaning the stress wasn't a symptom of an underlying pathology. Dr. Taub wanted to look for environmental causes. Dr. Hadley was trying to get the listening device to work. However, she had no better luck. All of a sudden, Dr. House realized the reason the device wasn't working was because there was no open frequency. He went down to Mickey's room and asked Tommy to leave so he could give Mickey a rectal exam. However, once he left, he asked Mickey why he didn't just take Xanax or Valium to actually reduce his stress rather than beta blockers to alleviate the symptoms. He noted that actors often take beta blockers so they remain alert but have no outward symptoms of fear. He started to search Mickey's room and found a listening device he hadn't planted there. Dr. Hadley thought that Mickey might be a police informant, but Dr. House said an informant would never try to protect his colleagues and that Mickey had to be an undercover police officer. It explained why he was so hesitiant to give a full history.
Dr. Hadley went in to see "Mickey" to tell him they would find out who he was and speak to his supervisor, but he noted that they knew too little about him. He said he needed to find out who the boss was before he expanded his operation. They were only a day away and if the doctors interfered the meeting would be aborted and sixteen months of his life would have been for nothing. He asked them to keep him alive for 24 hours, then he would tell them anything they wanted to know.When Eddie returned, Mickey started having severe abdominal pain. They traced it to an digestive tract infarction due to a clot in his superior mesenteric artery. They did surgery to remove a foot of his small intestine. Dr. Foreman noted they had ruled out cancer and infection and that Mickey got worse on steroids so it probably wasn't autoimmune. It still pointed to an environmental cause. Dr. Foreman wanted to treat Mickey for the most likely environmental diseases, but Dr. Hadley pointed out that so many treatments could kill him faster than the actual disease could. She suggested that if Eddie believed he was sick, he might be more likely to talk. She drugged him and tried to convince him that he had the same thing Mickey had, but Eddie had been drugged so many times before that he realized what Dr. Hadley had done. However, he still agreed to take Dr. Hadley to where they were keeping the drugs because he was afraid Mickey was going to die.
- Eddie: "Whoa... did you drug me?"
- Thirteen: "What?"
- Eddie: "You're trying to make me think that I'm sick so I'll take you to the stash."
- — Eddie catches on to Thirteen's clever plan
- Thirteen: "Don't bother. We assumed this place was using perchloroethylene. Turns out... petroleum solvents."
- Chase: "The drug dealers are running a green drycleaner?"
- ―The team finds out the drug dealers are eco-friendly
- "The aneurysms look mycotic, but they're not. They're inflammatory. Because this is not a fungal infection. The hypertension was a real symptom. You've been unwittingly treating it with beta blockers. You stopped taking them, and your blood pressure went up. It's Hughes-Stovin."
- ―House has his epiphany
Eddie went to the big meeting at Mickey's insistence. After he left, Dr. House realized that the aneurysims may have looked mycotic, but they were actually inflammatory. The high blood pressure was a real symptom that was unwittingly being suppressed by the beta-blockers. When he stopped taking them, it wasn't withdrawal but his blood pressure returning to its actual level. He had Hughes-Stovin syndrome, an autoimmune disease. Given its advanced stage, it was terminal. He would keep getting aneurysms until one of them ruptured and he died. Dr. Hadley told him that he was probably terminal when he arrived at the hospital. He asked to call his wife. After she arrived, his symptoms continued to get worse and he finally died.
A reflection of House Edit
The patient is dedicated to his work to the point of obsession, even when his health suffers. He takes drugs to deal with symptoms rather than deal with the underlying psychological problems that cause his symptoms. He has deliberately cut himself off from his friends and loved ones for his career. He has no problem being deceptive when it suits his purpose.
Reaching the diagnosis Edit
Hughes-Stovin syndrome is very much a "quadruple zebra". It belongs to the class of autoimmune conditions (which are rare), is a form of vasculitis (which is rare and a zebra in and of itself), and is essentially a rare form of the rare vasculitis Behcet's disease. Although it was first described as a separate condition in 1959, reported cases are still rare.
Moreover, the symptom that intrigued House - noise induced dizziness - is not a common symptom of Hughes-Stovin. In increasing order of seriousness (and being a better indication of the condition), the usual symptoms are:
- Coughing, which can be caused by many conditions
- Recurrent fever, which is most commonly caused by infection
- Chills, which is another common and prosaic symptom
- Coughing up blood, which is a very serious symptom, but can also be caused by many conditions
- Multiple deep-vein thrombosis in the peripheries, which is also serious (and can be fatal), and is not immediately obvious without careful examination
- Multiple aneurysms in lungs, which is unique to the disease, but cannot be detected without radiological examination. It is the failure of these aneurysms that usually causes the patient's death.
The dizziness, seizures and high blood pressure suffered by the patient are not typical symptoms of the disease. As such, the House medicine blog Polite Dissent was of the opinion that the final diagnosis was not a good fit for the symptoms shown in the episode.
Given the dizziness, a brain tumor or a toxin were obvious and likely choices. However, when those were ruled out and given the seizure, carotid stenosis was not a good fit. The most common symptom of that condition is transient ischemic attack.
However, when carotid stenosis was ruled out, return to a toxin was still a good idea and the team spent a great deal of time looking for some likely ones. The fever didn't rule out a toxin, but put infection on the table. When infection was ruled out by a lumbar puncture, they came up with autonomic nerve dysfunction which was ruled out quickly as his lack of response to the clumsy LP was traced to the beta blockers.
The clot in the superior mesenteric artery was the first good clue for Hughes-Stovin. Although it too could have been caused by a number of conditions, combined with the fever it may have rung some bells. However, as Mickey hadn't improved on steroids, Thirteen thought they should rule out autoimmune conditions. She wanted to focus on toxins and that meant doing an environmental scan. The dry cleaners was a good lead, but turned out to be a dead end.
However, by the time she came back, Mickey was coughing up blood, another classic symptom of Hughes-Stovin. This at least led them to do a VQ scan which showed the aneurysm, another classic sign. However, as it appeared to be isolated, the cause was still unclear. They only became concerned again when a second scan showed more aneurysms. A fungus was the first guess, but it was later clear that it was inflammation which suggested the final diagnosis.
The episode also explores the importance of obtaining a full medical history even though, unfortunately, it probably would not have been of much use here except to rule out some of the incorrect diagnoses more quickly. Concurrently, it also explores House's favorite maxim everybody lies. As House has tried to explain on numerous occasions, people lie for all kinds of reasons and, quite often, those reasons are very good. Mickey emphasizes the point House made in Three Stories - "What you're willing to die for. What you're willing to lie for."
Explaining the medicine Edit
- House makes a nice Holmesian deduction about Mickey's injuries, but it's based on good medicine. A conscious person will instinctively protect their head when falling, so lacerations, scrapes and bruises on the hands and forearms in a fall are almost universal. He made a similar observation in Locked In.
- Cocaine is almost certainly healthier for you than most of the things that are mixed in with it to "cut" or dilute it to the strength that street dealers sell. Unfortunately, just about anything cheap, white and water soluble will do. Lidocaine is common because it causes the same numbness and will fool a customer into thinking the cocaine is purer than it actually is. However, it has numerous adverse effects, even at non-lethal doses. Another common adulterant is skim milk powder which can trigger allergies and breathing problems. Powdered sugar is not uncommon, but can be a problem for diabetics and can also cause lung inflammation. Lastly, levamisole has become common because it has the same appearance and makes the cocaine look purer. However, it causes serious problems up to and including Levamisole Induced Necrosis Syndrome.
- Vasodilators lower blood pressure by relaxing the smaller arteries, resulting in a lower diameter which allows a higher volume of blood to flow through the vessels. They are commonly used as an ongoing blood pressure medication.
- Toxins generally come in two forms - fat soluble and water soluble. Water soluble toxins are usually more potent, but can also be removed by the kidneys through urination so can be eliminated by dialysis or forced diuresis. They also respond to antitoxins because they tend to be water soluble as well and can reach the toxin through the body's fluid systems like blood vessels and the lymphatic system. Fat soluble toxins are more problematic to remove. Although they are generally less potent, they are released when the patient loses weight and can't be reached merely by circulating anti-toxins. This was one of the plot points in Detox.
- Beta-blockers are one of the most useful class of drugs in the physician's toolbox. They are very effective in treating many conditions such as high blood pressure and arrhythmia. However, they have some interesting side effects and they are sometimes prescribed solely for this purpose. Although they don't affect anxiety directly, they do eliminate the "fight or flight" response that results from it without having any sedative effect. Actors and other performers often use them to deal with stage fright. They are also effective in eliminating social phobias and can turn a wallflower into a conversation artist. However, one of the most common side effects is erectile dysfunction and loss of libido.
- The episode does get one thing very wrong. Unlike many drugs that treat chronic problems, beta-blockers do not cause physiological dependence. However, many drugs used to treat high blood pressure, like the vasodilators used by this Wiki's humble administrator, cannot be discontinued quickly without the chance of the symptoms getting very much worse very quickly - often in a matter of days. This is a problem with many drugs used to treat chronic conditions, most notably antidepressants and antipsychotics
- One of the nice things about treating diseases of the small intestine is that humans appear to have far more than they need. When the small intestine is damaged, a resection is the usual procedure - cutting out the damaged tissue entirely and then stitching the ends back together.
Character relationships Edit
- Married to Mickey's Wife
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