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Medical History Edit
Spencer has a history of fatigue and two years before had a retinal vein occlusion caused by a venous anomaly. It was surgically repaired. Occlusions are usually caused by diabetes mellitus or low blood pressure but she had no history of either.
Her father had needed cardiac bypass surgery.
Case History Edit
Spencer was brought to the emergency room of Princeton-Plainsboro Teaching Hospital accompanied by Dr. Hadley after she suffered a tonic-clonic seizure for about three minutes. Dr. Cameron admitted Spencer and reassured her that she would be allright as she was conscious but unresponsive. Dr. Cameron asked Dr. Hadley if she had a history of epilepsy but Dr. Hadley admitted she didn't know the patient that well.
Dr. Cameron attempted to consult Dr. House but he was not initially interested in the case. Dr. Cameron though the seizure was the result of dehydration or a neurological problem, but Dr. House pointed out that the patient had tested positive for Ecstacy. However, Dr. Cameron informed Dr. House that Dr. Hadley had reported that the patient had taken the Ecstacy at least five hours before the seizure. When Dr. House realized that Spencer and Dr. Hadley had been together at 3 a.m. he agreed to take the case.
Dr. House took the case to his team, but Dr. Hadley assured him that it was merely dehydration from a combination of alcohol and Ecstacy. Dr. Foreman thought that the previous occlusion may have been caused by a blood problem rather than an eye problem. That would explain the fatigue and seizure as well. However, Dr. Hadley had reviewed her medical records and Spencer had been to four other doctors who found nothing out of the ordinary. Dr. Hadley thought she was a hypochondriac. Dr. Kutner pointed out that clotting would also explain her symptoms. Dr. Taub pointed out that could be explained by excess platelet production by the bone marrow. Dr. House ordered Dr. Hadley to perform a bone marrow biopsy.
Dr. House supervised the biopsy and the patient realized who he was. Spencer realized Dr. House was curious about her relationship with Dr. Hadley and started talking about it to him.
Dr. Hadley was suspicous that Spencer recognized Dr. House. She went through his correspondence and found several letters from Spencer asking him to take her case. She admitted she learned Dr. Hadley was on her team and followed her to the bar where they met. However, she said it was only her intention to talk to Dr. Hadley to see if Dr. House would take her case. Instead, Dr. Hadley had aggressively pursued her sexually. Dr. Hadley told her she believed Spencer faked the seizure. Spencer denied it, saying faking a symptom would just make diagnosis harder, but Dr. Hadley had the results from the biopsy and they were negative. Dr. Hadley wanted to discharge her, but Spencer insisted that she was tired all the time, and often suffered from hypersomnia. None of the other doctors could help her, but Dr. Hadley countered they couldn't because there was nothing wrong with her. However, suddenly Spencer had trouble breathing. Dr. Hadley thought she was faking, but her vital signs monitor showed she was crashing. Dr. Hadley told her to lie back and relax, then ordered a defibrilator realizing she was on the verge of cardiac arrest. Spencer's blood oxygen level fell to 90%, with a blood presure of 98/66 and a heart rate of 82. Dr. Hadley realized she must be really ill.
Dr. Hadley managed to stabilize the patient and reported to Dr. House. Dr. House admitted he only was treating Spencer to bother Dr. Hadley as he agreed with her at the time that she was a hypochondriac. However, the heart attack meant she was really ill. However, all the symptoms could still be explained by heavy drug use. Dr. Hadley realized that since Spencer's seizure happened at her apartment, they had to do an environmental scan of it. Dr. House ordered Dr. Hadley to do an ultrasound for atherosclerosis and allowed Dr. Foreman to accompany him on the environmental scan.
Dr. House and Dr. Foreman went to Dr. Hadley's apartment. Dr. House ordered Dr. Foreman to check the patient's purse. It was clean. Dr. House found an asthma inhaler. He also found a brown recluse spider in the bathroom, a venomous spider which can cause seizures and heart problems.
The ultrasound was negative. Dr. Hadley admitted the inhaler was hers. She had asthma as a child and it started acting up when she moved to her current apartment. Dr. Kutner realized that if the spider was responsible, they would have to examine her for a bite. Dr. House ordered Dr. Hadley to do the examination.
Dr. Hadley went to do the physical examination. Spencer thought she would have felt a spider bite, but Dr. Hadley assured her that people don't often feel the bite. Dr. Hadley admitted she was angry with Spencer because she didn't intend to see her again. Suddenly, Dr. Hadley realized Spencer couldn't feel her hand on her hip.
Dr. Hadley checked Spencer's potassium level - it was low, which explained the numbness. However, this ruled out the spider bite as a cause. Dr. House realized the low potassium meant the heart problem was only a manifestation of a kidney problem and asked Dr. Hadley what that could be. She thought it might be IGA nephropathy, but there was no blood in her urine. Dr. Hadley suggested PSAGN, but the patient's blood pressure was normal. Dr. Hadley suggested renal tubular acidosis - a failure of the kidneys to remove acid. Dr. House thought that was possible and ordered a CT Scan to look for the calcifications in the kidney that are typical of the disease. If they were right, she would only need sodium bicarbonate and surgery to remove the calcifications.
The CT was positive for calcifications and Dr. Chase started surgery with Dr. Taub assisting. Dr. Hadley and Dr. Foreman observed the procedure, but Dr. Hadley left early. As they were starting to close, Spencer's oxygen stats started dropping. They realized she wasn't breathing and needed intubation.
As the breathing problem started after they fixed her kidney, the acidosis wasn't her underlying problem. There were no masses or infiltrates in her lungs. Dr. Kutner thought it might be a problem in her airway. Dr. Taub realized it could be a type of dystrophy or an autoimmune condition. Dr. House ordered a methacholine challenge.
Dr. House found out that Dr. Hadley was found in the clinic giving herself intravenous fluids. Dr. House managed to convince Dr. Cuddy not to give her a drug test, but instead fired her for leaving the surgery before it was over and missing a differential.
Dr. Foreman found Dr. Hadley in the radiology lab reviewing Spencer's scans. He told her about the methacholine challenge. They discussed a small dark area on her lungs. Dr. Foreman thought it was just overexposed, but Dr. Hadley thought it could mean that her diaphragm was flat and her lungs were hyperinflated. If that were the case, she could have a pulmonary obstruction, such as cysts on her lungs. Dr. Hadley realized that cysts would not show up on the x-ray. She realized if that were the case, the methacholine challenge would make her cysts expand and rupture.
Dr. Hadley rushed to the examination room where she found Dr. Kutner and Dr. Taub with an unconscious Spencer. Dr. Kutner was dumbfounded as to what was wrong because her airway was clear, but Dr. Hadley informed them the test had ruptured one of the cysts, causing her lungs to collapse. Dr. Taub said there were still breath sounds on both sides, but Dr. Hadley grabbed a syringe and after noting her trachea was deviating to the left, plunged it into Spencer's chest. Air rushed out of the space surrounding her lungs and Spencer started coughing and breathing again.
A CT Scan of the lungs confirmed multiple cysts, including the one that burst. Dr. Hadley thought it might be amyloidosis or pulmonary fibrosis, but Dr. House reminded her she had been dismissed from her job. He ordered a biopsy of one of the cysts. Dr. Foreman asked Dr. House to reconsider the firing, but Dr. House noted that if Dr. Hadley had shown up for the differential, she could have spotted the problem before proceeding with the methacholine challenge.
The lung biopsy indicated that Spencer had LAM a terminal illness which meant she had no more than ten years to live. Dr. House asked Dr. Hadley to break the news to Spencer as Dr. Hadley's own experience with her Huntington's disease would most likely be helpful in helping Spencer deal with the news. Dr. Hadley agreed that it would be better if she, and not Dr. House, broke the news. Dr. House reminded her that this would not get her her job back.
Dr. Hadley explained to Spencer that the biopsy showed smooth muscle cells and told her that indicated LAM. Although she could have surgery to remove the existing cysts, new ones would grow replacing healthy lung tissue until the lungs stopped working.
Spencer underwent surgery to remove the cysts and Dr. Hadley went to see her when she returned to her room. Dr. Hadley told her what happened to her when she confirmed her Huntington's and that she had about as long to live as Spencer did. However, as she was about to leave, she noticed Spencer was bleeding from her stitches.
Dr. Hadley ran blood tests that showed both her red blood cell and white blood cell counts were low - aplastic anemia. She reported this to Dr. House who reminded her she was fired, but she said this was a new symptom. Dr. Hadley asked to at least be allowed to work on the case. Dr. Foreman agreed that if they didn't address the new symptom, Spencer would be dead in a few days. Dr. Taub said any alternatives to LAM were even worse, such as PNH with a respiratory infection, which would give her 12 years to live. Dr. Kutner suggested Langerhan's cell histiocytosis, which would only give her months to live. Dr. Foreman said it might be mastocytosis which could be fatal in days. Dr. House ordered his remaining team to test her.
Dr. Foreman quickly ruled out Langerhan's cell histiocytosis, but when Dr. Chase (who was in the lab as well) said that was good news, Dr. Foreman told him the patient was so sick that even cancer would be an improvement. Dr. Hadley went to spend time with Spencer.
Dr. House reported to Dr. Hadley that all the tests were negative, but he was recommending a bone marrow transplant because it was clear she had some sort of blood disorder and he had found a matching donor. However, he didn't want to give her radiation therapy to kill her remaining marrow because it was almost dead already and she seemed too weak. Dr. Hadley objected - any remaining marrow would be attacked by the donor marrow leading to a massive autoimmune response. Dr. House told her to get consent.
Dr. Hadley reported that Spencer had consented to the transplant. Dr. House agreed to hire her back on the team. He told her she did good work and that given her previous behavior, he wanted to insure he could bond with another human being. Suddenly, Dr. House noted that Dr. Hadley had cracked lips. She admitted she had been using her inhaler for allergies. Dr. House asked her if Spencer had cried when she was told about her terminal diagnosis. Dr. Hadley realized that Spencer had gotten upset, but there were no tears.
Dr. House went to see Spencer and cut an onion in front of her face. He started crying, but Spencer didn't. He realized she had Sjogren's syndrome, a fairly common autoimmune disorder that prevents tears and saliva from forming. It also commonly causes lung cysts and tubular renal acidosis. The bleeding was merely an unusual presentation. Dr. Hadley wondered how it would cause her own dry lips - it isn't contagious. However, the dry mouth is a perfect breeding ground for fungus like candida. Dr. Hadley's inhaler had dried out her mouth too, and she caught the fungus from Spencer. Spencer needed methylprednisilone but she would live a normal lifespan.