|First Appearance||The Jerk|
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Medical History Edit
Nate was a vegetarian most of his life, but has recently started eating meat. Since reaching adolescence, he has become very obnoxious with everyone, including his mother. He is constantly getting into fights with other boys his age and has many scrapes, bruises and aches from these encounters.
Case History EditNate was brought to Princeton-Plainsboro Teaching Hospital when, during a speed chess tournament, he suddenly struck out at the other player, then collapsed with a severe headache.
- Chase: "Your head still hurt?"
- Nate: "You a moron?"
- — Nate, before pointing out he's obviously clutching his head
Dr. Chase referred the case to Dr. House, and wrote the first symptoms on the whiteboard - rage and head pain. Dr. Allison Cameron noted that Nate had other pain, but Dr. Chase put this down to numerous bruises from fighting. There was no sign of head trauma, the scans showed no frontal lobe tumor, and his tox screen was clean. Dr. Foreman suggested an adrenal gland tumor, which could account for the symptoms. However, Dr. House said the adrenal gland tumor wouldn't explain his personality. Dr. Foreman put down Nate's personality down to being a teenager, but Dr. House thought the personality issues were too extreme. He suggested cluster headaches, and that Nate had probably suffered from them for years. However, they still had to find an underlying cause, but it was most likely a vascular problem. Dr. Foreman said cluster headaches would cause swelling around the eyes, but Dr. House countered that the swelling would have gone down if he had taken ibuprofen for the headaches. Dr. Cameron pointed out that cluster headaches are usually treated with steroids, and that Nate had already been given those with no improvement. Dr. House believed another approach was called for and ordered blood thinners and transcranial magnetic stimulation. Dr. Foreman agreed to treat the patient.
Dr. Chase examined Nate, who still had head pain although it was less severe. Dr. Chase asked Nate if he had any problem concentrating in school, but he denied it. Dr. Chase suggested a parasite and asked if Nate ate sushi, but his mother said he didn't eat much fish, but had recently started eating meat. She described no recent changes in his behavior, but noted that he had developed an obnoxious personality since he became a teenager.
- "This isn't gonna turn me into some, like, drooling vegetable wets his pants, is it?"
- ―Nate, worrying aloud about the procedure
Dr. Chase informed the mother that the treatments could improve Nate's personality as the cluster headaches could be the cause of his disposition.The treatment had no effect on the head pain. Dr. Cameron suggested Nate might have haemochromatosis, but Dr. House pointed out this wouldn't explain the personality disorder. Dr. Chase suggested a thyroid disorder, but this would make Nate lethargic, not rage-prone. Dr. Cameron suggested a ruptured dermoid cyst, but there was no fat the ventricles. Dr. House still thought it was cluster headaches, but Dr. Cameron pointed out that only remaining treatment was brain surgery and there was no guarantee that would work. However, Dr. House wanted to try a non-approved treatment - hallucinogenic mushrooms. He went to Dr. Cuddy for approval - the psylocybins can treat the cluster headaches. Dr. House was aware the patient could suffer a fit of severe paranoia. Dr. Cuddy approved as long as the dose was kept below 10 mg, it was done in a controlled setting, and the mother consented.
- Chase: "New research shows that a chemical component in the mushrooms can be..."
- Nate: "Yeah, lots of technical medical stuff. So, when do I get 'em?"
- ―Nate looks forward to magic mushrooms
- "[points at Chase] You don't touch me, all right? [points at Cameron] You can touch me. Just not my brain."
- ―Nate objects to the pituitary biopsy
- Chase: "Either you start eating, or I'm gonna strap you to this bed and shove these down your throat one-by-one, got it?"
- Nate: "Can't get mad at me. I'm sick. [feigns coughing] You're supposed to feel bad for me."
- Chase: "Nurse, full set of body restraints."
- — Chase exercises his bedside manner
The hamburger test was negative. Nate easily converted the ammonia to urea, ruling out OTC deficiency. Dr. House thought it might be diabetic steatosis. He ordered all food withheld to see if Nate's blood sugar spiked. The risk was that his fluctuating glucose levels could set off another rage attack.
As Dr. Chase predicted, withholding food from Nate sent him into a rage attack. He held off the doctors with an IV stand while they tried to get a urine sample and he demanded food. To mock them, Nate decided to urinate on the floor, where the doctors saw blood in the urine. Dr. Chase told Nate he had to get back in bed immediately, and Nate complied.
The chem panel and urinalysis showed that the bloody urine was caused by kidney failure. He would probably need dialysis for the rest of his life, although given his condition, that might not be very long. Dr. Cameron thought the multiple organ failure pointed to primary HIV infection, bu Dr. Chase was not convinced anyone would agree to have sex with Nate. In addition, his serology was negative. Dr. Foreman pointed out his uric acid level was slightly elevated, but Dr. Chase pointed out that was common in males. When Dr. House asked if they should dismiss the symptom, Dr. Chase also raised the fact that the high level could be caused by all the meat they gave him and/or his kidney failure. Dr. Foreman thought it might be a genetic disease, like hepatic fibrosis or MCAD. Dr. House agreed to the tests, but directed Dr. Foreman to focus on treatable conditions.
Dr. Foreman sedated Nate to take the blood sample, and his mother objected. However, Dr. Foreman insisted that he needed a break from the patient's behavior.
Dr. Chase and Dr. Cameron tested Nates' blood, but found no genetic markers for either hepatic fibrosis, MCAD or Von Gierke's disease. However, Dr. Chase did find a partial HPRT enzyme deficiency, which could indicate Kelly-Seegmiller syndrome. However, although this would explain his aggressiveness, Kelly-Siegmiller patients are also self-destructive and Nate showed no indication that he was cutting himself or banging his head against walls. Dr. House thought Dr. Cameron was opposed to the diagnosis because it is a degenerative, untreatable, terminal illness. Dr. Chase pointed out that Kelly-Siegmiller patients only self-mulilate under stress and his previous vegetarian diet could have lowered his purine level enough that the disease didn't affect him until he started eating meat. Dr. House suggested putting the patient under stress and directed Dr. Chase to distract Nate's mother.
Dr. House injected Nate with adrenaline and challenged him to a game of speed chess to stress him. Nate resisted at first, but eventually agreed to play. Nate played a good game and Dr. House soon conceded when Nate explained how he could not get out of the position he was in without losing. Although Nate was clearly under stress, he didn't self-mulilate and instead had a seizure. Dr. House ordered the nurse to administer 4 mg of intravenous Lorazepam.
Dr. Cameron pointed out Kellly-Siegmiller could not have accounted for the seizure. Dr. Foreman suggested amyloidosis, but it would not account for Nate's personality problems. Dr. Cameron thought it might be multiple conditions. Dr. House thought it was a single disease, but Dr. Chase said they had exhausted all the possibilities based on the symptoms they had. He though Nate was lying about medications or hiding something else. At that point, Dr. House agreed to consider that the personality problems were not a symptom. If that were the case, it could be amyloidosis. His team objected, but Dr. House ordered that Nate be given immunosuppressants, that they find a bone marrow donor for a transplant, and they get a biopsy to confirm.
They gave the news to the mother and took the biopsy. Nick wanted an anesthetic, but they couldn't give him one because they needed to make sure he would be ready for surgery later on. However, the biopsy showed no sign of amyloidosis. In addition, Nate now had a fever, which indicated an infection. Dr. Foreman wanted to start him on antibiotics, but Dr. House wanted to double check for amyloidosis and ordered a second biopsy and continuation of the immunosuppressants.
However, while talking to Dr. Chase and noticing how he grasped a chess piece, he remembered something about Nate - he wasn't bending his thumb when he moved the chess pieces. Dr. House went to test his theory by grabbing and bending Nate's thumb which caused him pain. He figured Nate was unable to bend it because it had formed abnormally. Together with all the other symptoms, haemochromatosis was the likely diagnosis. The iron built up in his system and interfered with bone growth and organ function. Even his aches and pains attributed to the fighting were a symptom as well. Dr. House discontinued the immunosuppressants and started bleeding Nick to drain his blood along with the iron in its hemoglobin. Unfortunately, the personality issues were not related to the disease, alhthough his switch to eating meat contributed to the excess iron in his bloodstream. Although he would continue to need regular dialysis and bleeding, he would live a normal lifespan.
A Reflection of House Edit
Nate is extremely intelligent, expresses himself well, and plays chess at a high level. Unfortunately, he has no respect for authority figures, routinely insults and demeans people, and is constantly acting out.
Reaching the Diagnosis Edit
Chase's first theory is a parasite, but he rules it out quickly as there does not seem to be a dietary source. A concussion was ruled out by the MRI. The MRI also ruled out a tumor on the frontal lobe, which would explain rage and lack of inhibition. A tox screen ruled out illegal drugs. House rules out an adrenal gland tumor as it would not explain the patient's behavior. House thinks that rage, behavior and head pain together point to cluster headaches and orders transcranial magnetic stimulation and blood thinners. He explains away the lack of swelling by the fact the patient received ibuprofen and the fact that steroids had no effect on unusual presentation.
However, the treatment has no effect. Cameron suggests hemochromatosis, but House rules it out because it wouldn't affect personality. She suggests hypothyroidism, but House rules it out because it would cause lethargy. Her next selection is ruptured dermoid cyst, but House notes there is no fat in the ventricles. House still things it is cluster headaches because it is the only disease that fits all the symptoms. However, the only treatment left is dangerous and doesn't always work - surgery. However, House has another idea - psilocybin mushrooms. Cuddy reluctantly agrees. Nate responds well to the mushrooms, which seems to confirm the diagnosis, until Cameron notes he has hypogonadism. Although this doesn't rule out cluster headaches, it does rule out a vascular cause. Cameron suggests that a blow in one of Nate's fights might have affected the hypothalamus, which does control testicular growth. However, the hypothalamus also controls body temperature, which isn't fluctuating. Chase suggests a craniopharyngioma and House agrees to a biopsy of the pituitary gland, which would confirm the original diagnosis.
However, when they try to perform the biopsy, Cameron notices that Nate is jaundiced. Chase notes that liver failure could explain all the symptoms, but House thinks they would have noticed liver failure the previous day and believes something else caused the liver failure and the other symptoms. Foreman suggests Wilson's disease, but House notes the patient's ceruloplasmin is normal. Chase suggests primary sclerosing cholangitis, but House thinks that a lifestyle cause is more likely. Foreman suggests alcohol, but Chase notes the tests were negative and Cameron notes the clear tox screen, which excluded acetaminophen as a cause. His drinking water supply is ruled out as a source as his mother isn't sick. However, when his diet comes up, House realizes that if the patient has Ornithine Transcarbamylase Deficiency, his inability to metabolize nitrogen would lead to liver failure.He decides on a diagnostic trial of force feeding the patient hamburger to see if his ammonia levels rise.
However, Nate's ammonia levels don't change. House thinks it might be diabetic steatosis, which would also affect the liver. He orders them to stop feeding Nate to see if his blood sugar level spikes. A change in blood sugar levels would also explain the rage attack. However, when blood appears in his urine, they realize his kidneys are failing too, and the tests confirm it. Cameron suggests primary HIV infection, which can cause multiple organ failure, but he has already tested negative for it. They focus on his raised uric acid levels, which could mean hepatic fibrosis or MCADD. House orders genetic sequencing tests.
Most of the tests are negative, except one suggests it could be Kelley-Seegmiller syndrome. This fits the aggressiveness, but Kelley-Seegmiller also causes self-harm. House decides to put the patient under stress, which would exacerbate the symptoms. He chooses to inject Nate with adrenaline to play speed chess with him, but despite the pace of the game Nate keeps his composure and his intellect, telling House that he's sure to lose. However, he soon suffers a seizure.
The seizure rules out Kelley-Seegmiller. After Cameron suggest the patient may suffer from more than one condition, House starts to concede that the patient's personality, which long pre-dates his other symptoms, may not be a symptom of his condition. If it isn't, amyloidosis explains the remaining symptoms. He orders steroids and a biopsy to confirm.
However, the biopsy shows no signs of amyloidosis. However, Nate has developed a fever and congested lungs. Foreman suggests an infection, but House still believes amyloidosis is a better fit. He orders another biopsy to look for the suspect proteins. However, he later realizes Nate's unusual way of grasping the chess pieces - instead of picking up a piece using his thumb and first finger, he lifted them between his first and middle finger - he can't bend his thumb. That indicates abnormal bone growth. That could be caused by iron overload, which also explains the organ failure. It also explains his complains about body aches. The most common cause is hemochromatosis, which would have been made worse by eating meat. .
Explaining the Medicine Edit
- Although the role of iron deficiency in decreased brain function is well understood (iron is a necessary part of such brain function) the role of iron overload in mood swings is poorly understood, although there is a clear relationship between the two. Experiments on rats show clear increases in aggressiveness and anxiety when iron levels in the blood are raised compared to control groups. Nate's rage and lack of emotional control is common in hemochromatosis patients.
- Transcranial magnetic stimulation is another treatment that clearly works in clinical trials, but no-one is sure why. Although TMS is generally used to treat depression that is not responsive to other treatments, it has also shown promise in trials with cluster headache patients.
- Nick's grasp is often called "bronze fist" - the first and middle fingers in the fist aren't even with the other two fingers as they would be when someone else makes a fist. It is very specific to iron overload. Although many conditions can cause arthritis in finger joints, where the arthritis is limited to the first two joints of the first two fingers, it's almost certainly iron overload.
- Patient's who have used psilocybin to treat cluster headaches have reported that it prevented an attack in about 80% of cases. However, because of the legal status of the drug, no-one has been able to perform clinical trials. Effective doses appear to be much smaller than those needed for recreational use.
- Another thing iron overload can do is interfere with the production of sex hormones, which explains the hypogonadism. It can also cause erectile dysfunction and loss of sex drive.
- Jaundice is the result of an accumulation of bilirubin which is created when red blood cells die. The liver normally processes the bilirubin but when the liver isn't functioning properly, it's yellow color shows clearly on white parts of the body such as the skin of Caucasians, the gums, and the whites of the eye.
- Sodium polystyrene sulfonate binds to potassium in the digestive tract, making it impossible for the ions to be taken up in the intestines and keeping blood potassium levels low. The bound compound then passes in stool.
- As the body metabolizes protein in meat by breaking it down into it's constituent amino acids one of the by products is ammonia. In normal metabolism, this is converted through a number of steps into urea or uric acid, which are much less toxic. However, in patients with any of a number of enzyme deficiencies, excess ammonia can't be processed quickly and, when a person eats a diet rich in protein, it's level in the blood quickly rises.
- In a patient with kidney failure, inflammation in the kidneys cause microscopic bleeds as red blood cells leak through the barrier that usually separates blood products from waste products. The worse the inflammation, the more blood leaks in.
Character Relationships Edit
- Son of Enid