The patient had engaged in recreational heroin use until about six months ago when she embraced Hassidism.
Roz was brought to Princeton-Plainsboro Teaching Hospital from her wedding reception, where she had collapsed. She had lost control of her bladder, had blood in her urine and broke her leg in the collapse. Dr. Hadley brought the case to Dr. House, but he put it down to a simple urinary tract infection. He ordered abbocillin for the infection and a cast for the leg. However, the blood cultures were negative, there was no history of trauma and her STD panel was negative. Dr. House thought it must be kidney cancer, but the CT scan had shown no tumor or kidney stones. However, her sodium level was low which led Dr. Hadley to think it might be endometriosis in her bladder. However, Dr. Taub noted that low sodium could be due to fasting, which Hassidic Jews do on their wedding day. Dr. House thought the sodium may have been removed from the bloodstream by a toxin and Dr. Kutner suggested carbolic acid. Dr. Foreman noted that much carbolic acid could only be the result of deliberate poisoning, and Dr. House suggested that the bride had done it herself in a suicide attempt. Dr. Hadley still thought endometriosis was more likely. She wanted to put her on anti-inflammatories and do a cystoscopy to confirm. Dr. House allowed it, but also ordered an environmental scan for carbolic acid.
Dr. Taub and Dr. Foreman went to the patient's home. All the cleaners were organic and none contained carbolic acid. However, Dr. Foreman found a number of gold records for hard rock albums which listed Roz as the producer, and Dr. Taub found some sexy lingerie. This led Dr. Taub to the conclusion that Roz was a drug user.
When confronted about her past, Roz admitted that she gave up drugs six months ago when she became Hassidic. However, she also told them that she had revealed her past to her new husband, who never asked for details. Dr. Hadley explained she may have suffered long term damage from her drug use. They had to test her hair for latent toxins.
The treatment for endometriosis had no effect, and her hair sample was negative for drugs. Dr. Taub suggested cryoglobular anemia, but Dr. House felt that the patient's sudden change to a strict religious life indicated altered mental status. He thought she had porphyria. Dr. Kutner pointed out that the personality changes associated with porphyria are much more severe - all Roz did was go to a temple. Dr. House pointed out that she didn't just become religious, she chose the strictest religion available. Dr. House ordered hematin and a phlebotomy.
Jonatan asked why they had suddenly jumped to a rare genetic disease when nothing showed up in the tests. Dr. Kutner was forced to admit Dr. House believed that Roz's religious conversion was a symptom. Jonathan went to see Dr. Cuddy to have Dr. House removed from the case. Dr. Cuddy thought it was cryoglobulin anemia as well, but Dr. House insisted the religious conversion didn't fit anemia. Jonatan left insisting on a new doctor. Dr. Cuddy ordered indomethacin for anemia.
Roz was given oxygen overnight and stabilized, with her O2 stats rising to 95%. The lung problems ruled out porphyria. Dr. Foreman pointed out Wegener's disease would explain her elevated sed rate, but Dr. House pointed out it wouldn't explain her altered mental status. Dr. Hadley admitted that the rest of the team was ignoring that "symptom". Dr. House suggested lupus, which would cause a heart problem. He ordered a stress test - if the patient had a heart attack during the test, that would confirm it. Dr. Taub said he would make sure the crash cart was handy.
Roz had trouble getting her heart rate up during the stress test. Jonatan was worried that if they treated her, whe wouldn't be interested in him anymore. There were no problems on the EKG so Dr. Taub ended the test. However, when Roz got up, she collapsed again, complaining of intense pain in her right leg.
Dr. Foreman reported the test results to Dr. House because they ruled out lupus and altered mental status as a symptom. Dr. House countered that the leg pain ruled out Wegener's. Dr. Foreman thought the pain was from nerve entrapment, probably from a blood clot. Dr. House ordered an MRI on the leg and an fMRI to look for neiroschemic stroke in post-ischemic parts of the brain.
Dr. Foreman and Dr. Hadley performed the MRI, but found nothing out of the ordinary. Dr. House came by and ordered them to stick an intravenous needle into her to see if she reacted positively to pain, indicating masochism. When Dr. Foreman stuck in the needle, her pleasure centers in her limbic system lit up. However, when they asked Roz about it, she said that just before Dr. Foreman put the needle in, he said he was sorry, and she started praying because she knew something bad was about to happen. Roz started to get up off the MRI table when her heart rate and blood pressure dropped precipitously. She collapsed into Dr. Foreman's arms and he realized she was crashing. However, when they laid her back down on the table, she stabilized. Dr. House ordered Dr. Foreman and Dr. Hadley to get her on her feet again, and when they did, she crashed again, only to stabilize when she was laid back down on the table.
Roz was given fludrocortisone and ephedrine. Dr. Kutner pointed out that Roz's reaction to standing was the opposite of what was supposed to happen - blood pressure and heart rate are supposed to rise when you stand up. Dr. Foreman thought it might be a pheochromocytoma. However, Roz had low catecholamines in her urine, ruling that out. Dr. Hadley suggested systemic sclerosis, but this would not cause altered mental status. Dr. Kutner thought it might be an electrical problem in the heart, an arythmia affecting blood flow, blood pressure and altered mental status. Dr. House ordered an EP study.
Dr. Kutner and Dr. Taub performed the EP study, but there was no abnormality. Dr. Kutner thought it might be a problem with the autonomic nervous system and Dr. Taub suggested Riley-Day syndrome, which is rare, degenerative and incurable. Dr. Taub scheduled a thermoregulatory sweat test.
The sweat test takes place in a warm room. This should cause her body temperature to rise and the sweat turns powder they put on her body purple. If she doesn't sweat, it shows damage tot he central nervous system. However, instead of making her body temperature rise, she started shivering and had a seizure.
Dr. Kutner thought an infection had caused her hypothermia, but her white blood cell count was normal. Dr. House thought that Roz's opposite reactions were the result of something that was missing. Dr. Kutner suggested an enzyme or hormone. Dr. Foreman suggested Addison's disease, which Dr. House realized fit the symptoms. Dr. Hadley went to run a cortisol stimulation test.
Roz felt better on cortisol, but was still tired. Dr. Hadley noticed her abdomen was swollen. When Roz sat up to see, Dr. Hadley realized she was going into shock. She ordered more saline and two units of blood for transfusion. Dr. Hadley inserted a syringe into the swollen abdomen and drew out blood, indicating internal bleeding. Jonatan realized that Roz was saying a prayer people say when they think they are going to die.
They did an MRA which confirmed internal bleeding, but didn't show the source. Dr. Chase came by for a consult and told her that given the quantity of the bleeding, they could not keep her stable for long on transfusions and that exploratory surgery was her best option. He told her that even if they found the source of the bleeding, they may not find what disease she had, but it would keep her alive long enough for Dr. House to find a diagnosis. However, Roz refused to have surgery until after sunset (8 hours later) as she had never had a sabbath meal with her husband. Jonatan and her rabbi both asked her to go ahead with the surgery, but she was adamant.
Dr. Hadley suggested they x-ray her ribs to find if they were causing arterial twisting, but Dr. House pointed out that would not cause bloody urine. However, Dr. Chase had an idea - black out the corridors. This fooled her and she taken to a room to have her sabbath meal with her husband.
Dr. Kutner did some research and suggested a hydadid cyst could affect the lungs, but Dr. House pointed out it wouldn't affect the bladder. Her white blood cell cound was still normal. Dr. Taub pointed out that volvulus of the small intestine could cause bleeding, but Dr. Hosue pointed out it would also cause constipation. Dr. Kutner suggested polycythemia vera, but her red blood cell count would be higher. Dr. Kutner suggested thrombocytopenia, but her ANA was normal. Dr. Kutner suggested Parkinson's disease would explain the hypothermia, but it would not explain the bloody urine. They started to discuss whether her religious beliefs were interfering with her treatment, and when Dr. House suggested that thinks aren't the way they are because they want them to be, he suddenly realized that things aren't always where they're supposed to be either.
Dr. House rushed to the patient, who was on a gurney getting ready for surgery. He demanded that Dr. Hadley get the patient on her feet. Roz stated to collapse again, but Dr. House grabbed her back and applied pressure. She suddenly sabilized. He let go the pressure and she collapsed again. Dr. house instructed Dr. Hadley to press on the patient too, and Roz stabilized again. He realized she had nephroptosis, a hanging kidney. The kidneys are loosely attached to their blood supply and in some persons, the connection is very weak. When a patient is shaken, such as during her wedding celebration, connections are broken, causing the bleeding and other symptoms. The scans didn't pick it up because shen she was on her back, the kidney returned to its normal position. They just needed to an ultrasound with her standing up and lying down to confirm, then it could be surgically reattached. The bleeding was most likely near the kidney.