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 Edit
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.
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. Foreman assured Nate that the magnetic stimulation was safe, but should treat his head pain. Nate asked for help with his other pain, but Dr. Foreman told him he was already on painkillers. Nate suggested Dr. Foreman tell his "homies" to stop beating him up.
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.
Dr. Chase went to get the mother's consent, and when she was reluctant, Nate kept pressing for them. After Dr. Cameron explained brain surgery was the next step, the mother agreed. Nate responded well and the pain disappeared. However, Nate started acting inappropriately and flashed his genitals at Dr. Cameron. However, Dr. Cameron noted that Nate had hypogonadism. A further examination showed that the rest of his secondary sexual characteristics were normal.
Dr. Cameron reported to Dr. House but although it appeared he was right about the cluster headaches, he was wrong about the cause - vasular problems in large arteries doesn't cause hypogonandism. Dr. House pointed out the hypothalmus and pituitary gland control the growth of the testicles. Dr. Cameron suggested a trauma to the hypothalmus from the patient's fighting, but Dr. House pointed out that would also cause swings in body temperature. Dr. Chase pointed out that cranial meningioma fit the symptoms. Dr. House ordered a biopsy of the pituitary.
However, Nate opposed having a biopsy so close to his brain. However, his mother was willing to consent. Nate started being argumentative and Dr. Chase went to get a sedative. However, Nate suddenly lost consciousness even though his heart rate and respiration were normal. However, Dr. Chase noted Nate was jaundiced, meaning he was suffering from liver failure.
Nate was started on sodium polystyrene sulfonate. His liver function was at 20% and falling. If he didn't improve soon, it was clear he would be dead in a few days. Dr. Chase pointed out that liver failure could explain the other symptoms, but Dr. House pointed out that the other symptoms started well before the liver started to fail. Dr. Foreman suggested Wilson's disease, but the patient's ceruloplasmin was normal. There was no enlargement of the liver or palpable mass, so cancer could be rule dd out. Dr. Chase suggesed primary sclerosing colangitis, which could be caused by alcohol abouse, but Nate tested negative for alcohol and the other likely cause acetaminophen. Dr. Chase suggested contaminated water, but then the mother would be sick. The talk turned to Nate's recent change in diet to eating meat, which meant if he had an OTC deficiency he might not be able to process the nitrogen in meat protein. He ordered that Nate be given lots of hamburger to see if his ammonia level spiked.
Nate refused to eat the hamburgers. His mother asked if she could bring roast beef from home, but Dr. Cameron said it had to be hospital prepared food to insure nothing interfered with the tests. When Nate continued to resist, Dr. Chase threatened to force feed him and called for restraints. Nate agreed to eat the food.
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.