Morgan came to the clinic and was assigned to Dr. House. She complained of having colds all winter and feeling run down, like some serious illness was coming on. She had no sore throat or runny nose. She asked Dr. House to run a CBC and thyroid panel, then collapsed and had a seizure. Dr. House called for Dr. Cuddy for a consult. Dr. Cuddy examined the patient while Dr. House asked that the patient’s file be sent up to his office. Dr. Cuddy noted that the patient’s urine was green.
Dr. House told his team that the patient was a 35 year old head nurse in an old age home and was suffering neurological problems and had green urine. Dr. Foreman suggested pseudomonas, but the patient had no fever. Dr. Hadley suggested a toxin. Dr. Taub thought it was merely late-onset epilepsy and the green was from digesting too much food coloring. Dr. House ordered an environmental scan, but Dr. Taub protested - the patient’s neuro exam was normal and she hadn’t had another seizure - the case obviously wasn’t life threatening.
Dr. Kutner and Dr. Taub performed the environmental scan at the patient‘s office. Dr. Taub found methylthioninium chloride which explained the green urine. He argued that Morgan had faked the seizure because she has Munchausen’s Syndrome. However, Dr. House dismissed the suggestion. That drug is used to treat Alzheimer’s disease and would be commonly found in an old age home and deliberately urinating on oneself is difficult. Dr. House also thought the seizure was real. He figured the problem was phenol from an antiseptic throat spray that she used for her colds. Dr. House sent Dr. Taub to the patient’s home to show she was abusing the throat spray. He ordered Dr. Kutner to start charcoal hemoprofusion. However, when Dr. Kutner went to leave, Dr. House called him back to say not to bother - he just wanted to get Dr. Taub out of the way so he could test if the patient was faking seizures.
Dr. House went to see the patient to tell her the head CT Scan was normal. She asked for a thyroid uptake test and abdominal ultrasound, but Dr. House said he was going to try to induce another seizure. She agreed and when Dr. House used the strobe, she started seizing. However, Dr. House tested her by trying to drop her hand on her head and she reflexively stopped before her hand hit her, showing the seizure was a fake. She insisted she didn’t have Munchausen’s and that she would die if he didn’t help her. She told him about a cat at the old age home that predicted her death. Dr. House went to process her discharge.
However, Morgan came back with the cat. It lives in the nursing home and has slept next to ten people, all of whom have died. The cat started sleeping next to her. Dr. House tried to ignore her, but she had a news video about the cat’s ability to predict death. She then started having trouble breathing. Dr. House figured she was faking, but Dr. Foreman rushed to her aid and with his stethoscope determined she was having a bronchospasm, something that couldn’t be faked.
Even Dr. Cuddy though that Morgan may have mental health issues, but Dr. House agreed to take on the case again, even though he thought the story about the cat was ludicrous and he agreed that Morgan had faked her earlier symptoms. However, Dr. Cuddy said that Dr. House had to prove the patient wasn’t faking symptoms or else she would discharge the patient in 24 hours.
Dr. Foreman suggested the patient might have bronchitis, but the patient had no cough or fever. Dr. Hadley suggested emphysema, but her lung CT scan was clear. Dr. Foreman focussed on the cat. Dogs could be trained to sniff out diabetes mellitus comas, oncoming seizures and cancer, so it was possible that the cat was picking something up from the dying patients. However, Dr. House thought it was just a coincidence, but Dr. Hadley noted that even Dr. House didn’t think Morgan was sick, but the cat seemingly did. Dr. Foreman suggested the cat may have caused the deaths - cat scratch fever or visceral larva migrans. Dr. House ordered the team to scope the patient looking for worms.
Dr. Hadley did the examination and found no worms. Dr. Foreman suggested severe acid reflux, but there was no inflammation of the esophagus. Dr. House went to the coma ward with the cat to test the theory that it could predict death. Dr. Foreman went back to Morgan’s case and suggested an airborne allergen. The scratch tests were negative, but the lungs might be more sensitive. Dr. Taub suggested that it wasn’t a bronchospasm at all, but a laryngospasm typical of a panic attack. However, both Dr. House and Dr. Foreman heard a bronchospasm. The cat went to the bed of Mr. Limpert. Dr. House ordered a methacholine challenge because he thought an airborne allergen was the best fit.
The methacholine challenge was normal and Dr. Cuddy told Dr. House to discharge the patient. Dr. House told her the bronchospasm was real and could happen again if they released her. Dr. Cuddy was unmoved and told Dr. House either he would have to discharge the patient or she would get security to do it.
Dr. House took Morgan outside and talked to her about her medical history. He had figured out from her varicella vaccination that she had once had a child. She told him she had a step-son who had died from choking. Dr. House told her that turning to superstition was irrational. He deliberately blew cigar smoke into her face to set off another bronchospasm and he also noticed a rash on her neck. He called over another doctor to confirm it.
The patient complained that her urine had turned brown. Dr. Hadley pointed out the brown urine didn’t fit any diagnosis. There was no blood in the urine and her kidneys and liver tests were normal. Fecal matter from the fistula had also been ruled out. Dr. Foreman supposed that the urine merely looked brown - it may have been leftover green dye mixed with something purple to make brown. Dr. House realized a streptococcus bovis infection from colon cancer would fit. Paraneoplastic syndrome would explain the bronchospasm. However, they had already scoped her colon when they checked her fistula and found no tumor. Dr. House told them to use a pill camera instead.
Dr. House took Morgan to see Mr. Limpert, the person the cat slept next to for the last two days. He was still stable. She thanked him, but thought the cat might be confused. She was convinced something terrible was going to happen to her.
The pill camera results were normal. Dr. Hadley thought they were wasting their time looking for cancer. The patient was still very healthy and the problem was probably minor. Instead, Dr. Kutner suggested it might be skin cancer that had mestastisized to the colon - it wouldn’t show up on the pill camera. He ordered Dr. Kutner to check for melanomas.
That night, Dr. Kutner called Dr. House to advise that the patient had developed spider veins on her back, which appeared to rule out cancer. Cushing’s disease explained everything except the bronchospasm, but that could be explained by Cushing’s myopathy. In addition, Dr. Kutner advised Dr. House that Mr. Limpert had just died after being stable for eighteen months.
However, the cat had escaped. Dr. House and his team started looking for it because even Dr. House realized it had to have some reason for picking on nearly dead people. Dr. Kutner pointed out that a cat has an excellent sense of smell and could pick up on kidney or liver failure. However, Dr. House had already reviewed the nursing home records and none of the dead people had liver or kidney problems. Dr. Foreman had done an MRI looking for a cause of Cushing’s but had found nothing. Dr. House suggested he check the patient’s ACTH, but Dr. Foreman had done so and the level of 11.7 did not point to either the adrenal glands or the brain as the problem. Dr. House admonished Dr. Kutner for leaving the office door open. Dr. House finally ordered a venous sampling of the brain. If they found nothing there, the problem had to be in her adrenal glands.
Dr. House did an autopsy on Mr. Limpert. Dr. Chase came to report that Morgan suffered a cardiac arrest during the venous sampling, but they managed to stabilize her. The ACTH was still high, so Dr. House wanted to remove the pituitary gland. Dr. Chase pointed out the patient was in good shape - no central body obesity typical of Cushing’s. He ordered Dr. Foreman to speak to the patient to get her consent to the removal of the pituitary. Dr. Wilson wanted to know why Dr. House was doing the autopsy when he had a living patient to deal with. He thought Dr. House was too obsessed with trying to explain how the cat predicted death to deal with his living patient.
Dr. Chase explained Cushing’s to the patient. It could be treated with drugs, but it wouldn’t be permanent and might come back. Surgery on her pituitary would cure the condition, but was dangerous, particularly in her current condition. She opted for the surgery, fearing the disease would kill her if she wasn’t treated. Dr. Chase scheduled an operating room.
The patient was taken to the operating room and prepared for surgery. Dr. House once again started reviewing the nursing home records and the videotape from the news item when the cat returned to his office and jumped on his laptop computer. He realized the cat just liked being places that were very warm. When he reviewed the videotape and records again, he realized that all the dead patients either had a fever or had heating blankets on them. He realized that in addition to her other symptoms that resembled Cushing‘s, she was also overheating. He went to Dr. Wilson, who also realized if that was the case, she had to have an intestinal corticotropin producing carcinoid tumor. The fact that it wasn’t found by the pill camera meant it was in the one place the camera didn’t go - the appendix. Dr. House rushed to the phone to cancel the brain surgery.
The appendix was removed and Morgan quickly improved. Dr. House wondered why the patient was so eager to undergo brain surgery just because a cat said she was going to die. The patient wondered why the cat sat on House’s laptop just before she went in for surgery.