Note: The sequence of events in this case study have been altered from the sequence of events as presented in the episode and have instead been placed in chronological order. They have also been edited to remove the problem with House's unreliable narration of the behavior of his fellows.
Phillip came to the Rutgers Student Medical Center with severe coughing. He was diagnosed with acute bronchitis, but his blood and sputem cultures were negative. He was transferred to Princeton-Plainsboro Teaching Hospital and was assigned to Dr. House when all the other common diagnoses were ruled out. His O2 stats were dropping.
Phillip complained he was having difficulty breathing, and was developing pain in his chest. He then started coughing up blood. Ms. Masters suggested a chest CT scan, and Dr. Foreman agreed. The patient was given antibiotics in the event he had a lung infection that was missed on cultures.
The patient stabilized, but he soon developed a severe cough and started coughing up blood again. Ms. Masters thought this indicated that whatever infection he had, it was drug resistant. His O2 stats started to plummet. Dr. Taub wanted to put him on bronchodilators before he went into respiratory arrest. Dr. Foreman called for suction. Phillip then coughed up a piece of his lungs.
Ms. Masters couldn’t even explain how the patient managed to cough up a piece of his own lung. Dr. Taub suggested that the patient had primary squamous-cell carcinoma, which could cause the lung to disintegrate. However, cancer had been ruled out because Phillip’s bronchoscopy was normal. Infection appeared to be ruled out because the patient had been treated with broad spectrum antibiotics with no effect on his symptoms. Dr. Foreman theorized that a amoebic liver abcess might have ruptured through the diaphragm into the thorax. Ms. Masters noted the patient’s roommates were developing computer chips and may have been using toxic solvents. Dr. House took Dr. Foreman to do an environmental scan and ordered a thoroscopic lung biopsy and a C-ANCA, because he thought it might be sarcoidosis.
Dr. House and Dr. Foreman performed an environmental scan of Phillip’s dorm room. There were no insecticides or toxic cleaners, and the bathroom was checked and no toxins or molds were found.
Dr. House thought it might be a foreign body in the lung and ordered scanning. However, despite using x-rays and the MRI, no foreign body was found. Dr. House wanted to do more scans, but that would risk radiation sickness. The biopsy and C-ANCA were negative. Dr. Foreman suggested a pneumonectomy, but the patient had no sign of drug or alcohol abuse, didn’t smoke, and didn’t work in a coal mine or with pottery. Dr. House ordered methyltrexate and steroids for sarcoidosis. Dr. Foreman objected - if the patient did have an infection, this treatment would make it worse and would most likely result in the patient’s death. However, Dr. House pointed out that the patient was dying in any event.
A PET scan was also negative for sarcoidosis and the rest of the patient’s lung started to collapse, and Dr. Foreman had not started the treatment. Dr. House ordered treatment for sarcoidosis despite the negative test result as sarcoidosis is a diagnosis of exclusion.
However, Dr. House finally realized something soft and small, a pea for example, would be a foreign object that would not show up on scans, would be small enough to get into an airway and too big to be washed out in a bronchial lavage. It would also explain what appeared to be chronic obstructive pulmonary disease and wouldn’t respond to steroids or antibiotics. Dr. House ordered exploratory surgery. The obstruction was found, removed, and the patient started to improve immediately.