Case History Edit
Nick was brought to Princeton-Plainsboro Teaching Hospital after he could not stop making mean comments about the author he worked for and his colleagues at a dinner party. He developed a nosebleed and collapsed.
Dr. Cameron referred the case to Dr. House. The patient had an MRI, but it was clean. He thought it might be a tumor in his nasal cavities - that would have hid from the MRI and would affect the frontal lobe. He ordered an examination.
Dr. Taub explained the procedure to the patient. The patient was unable to stop insulting his wife's work or Dr. Taub's nose. However, the examination was clean. Dr. House ordered his team to look for brain damage. They did an fMRI. Dr. Foreman pointed out a spot on the cingulate gyrus that should have lit up, but didn't. A biopsy was out of the question as it was too close to the brain stem. Dr. Foreman hoped it was neurosarcoidosis, which is treatable. They decided to treat with steroids, which would show improvement within half-a-day if Dr. Foreman was right.
However, Nick soon got worse. His EKG showed that his heart was fine, which most likely meant he had a problem with his kidneys. Dr. Foreman started him on dialysis. Nick stabilized, but this ruled out systemic sclerosis. Dr. Taub thought it was chronic lymphocytic leukemia. However, Nick's white blood cell count was normal. Dr. Taub suggested diabetes mellitus. Dr. Kutner suggested a congenital metabolic disorder. Dr. Taub thought that 46 was too old for a congenital problem to present itself. Dr. Foreman also pointed out there were dozens of possible genetic conditions and they couldn't test for all of them. Dr. House suggested they test his daughter for peripheral nerve damage - they said she had an auditory processing disorder and if it were genetic she might have it too. He also ordered a glucose tolerance test in case it was diabetes.
Dr. Kutner started the nerve conduction test and explained to the daughter that she should let him know if it got too hot or too cold. Dr. Kutner wondered why she was taking so long to respond. Suddenly, she screamed. Dr. Kutner noticed she was burned and asked her why she didn't say anything. She said she thought she was helping her father.
Dr. Taub reported that Nick's blood sugar level never rose above 160. Dr. Taub admitted it wasn't diabetes, but he still thought it was an endocrine problem, perhaps the thyroid. He ordered Dr. Kutner do to a thyroid reuptake scan.
When Dr. Kutner tried to explain how his daughter got burned, the patient blurted out that his daughter didn't have a neurological problem or a disability, she was just below average. His daughter ran out of the room. All of a sudden, Dr. Kutner realized that Nick had a fever and his lungs were full of fluid. He ordered 200mg of furosemide and 2mg of morphine and started draining the fluid from his lungs. He put Nick on oxygen.
With a temperature of 103F, they figured Nick had an infection and that the steroids had allowed it to spread. Dr. Foreman noted there were several possibilities, stapholococcus, strongyloides and tuberculosis were just some of the possibilities. Dr. House wanted a medical history, but Dr. Kutner had already checked - Nick hadn't been outside the country and no one else at his home or workplace was sick. He ordered Dr. Kutner to keep asking questions.
Dr. Kutner started with a physical examination. Nick sent his wife out of the room. The only thing that he found was that there is a large dog in his house and it urinates and defacates all over the house. Dr. Kutner thought it might be Weil's disease because Nick's eyes were red as well. Dr. House agreed and ordered doxycycline.
Nick started to improve - his fever went down and his lungs started to clear. They told him the infection was gone, but the damage to his brain was probably permanent. The only treatment was to remove the damaged part of his brain, and it was too close to the brain stem to risk surgery.
Even a slight mistake could kill him and even if things went well, he might not be able to breathe on his own.
Nick spoke directly to Dr. House and told him he didn't want to be discharged when he still had the frontal lobe disinhibition. He asked Dr. House to let them operate. He said he understood the risks and the way he was, he couldn't make his wife or daughter happy.
Dr. House agreed and spoke to Dr. Chase in order to get him to try and convince Dr. Kapur to do the surgery. Dr. Chase realized that Dr. House was trying to avoid having the patient become just like him and agreed to help.
Dr. Kapur saw the surgery as a challenge and agreed to do it. Luckily, he recovered and Nick was fine with a normal heartbeat and breathing. He remembered his own name. However, it was soon clear his frontal lobe disinhibition was still there. Dr. Taub realized that although they removed the damgage, that may not have been the underlying problem. They checked his body temperature and it was low - 94.5F. Dr. Taub also thought that the surgery may have caused further damage. They bundled him up, but his temperature fell to 92F. Dr. Foreman called for heating blankets, but Nick was soon in detac and Dr. Foreman called for the defibrillator.
Dr. Foreman did an echocardiogram, which showed no structural problems with Nick's heart. However, his body temperature continued to drop. Remy Hadley realized they were wrong about the infection - he never had a fever, he had thermal disregulation and his temperature was going up and down due to some other cause. Dr. Kutner realized this meant the brain damage was spreading. Dr. Taub thought the only thing that could affect that many organs was cancer, but the patient's PSA and blood smear were all normal. Dr. Foreman, who was in charge while Dr. House was unavailable, ordered a full body scan despite Dr. Taub's protest that it would most likely just find normal meaningless anomalies.
They found a small abdominal aneurysm, but it appeared to be irrelevant. A cyst near the lungs also appeared to be meaningless. The only promissing indication was different density in the liver which could indicate arterial-venous malformation, which would explain his symptoms. To check, they would need to do targeted angiograms with contrast, a time consuming procedure. They decided to get started.
Dr. House was monitoring the situation remotely and realized that the patient's glucose levels were normal. He phoned the team to remind them that if the patient had malformations, they wouldn't be - they should be elevated because of the steroids. He had figured out the cyst they found and wrote off was actually a fibroma. Nick had Doege-Potter syndrome. The fibroma was secreting human growth hormone which lowered his glucose level to normal. When Dr. Foreman challenged it because it wouldn't cause multiple organ failure, Dr. House told them that although the fibroma was benign, his immune system must have overreacted, sending antibodies to attack it which instead damaged the other organs. He ordered that they remove the fibroma.
Nick had more surgery and was soon feeling more like himself. He started apologizing about the things he said and it was obvious he had control over what he was saying. His wife showed up and he complemented her, but it was obvious she was still upset.