Stevie was a college athlete in excellent physical shape who took care of himself with a good diet and exercise.
Stevie was driving home on his motorcycle after attending a poker party when he had an accident. He arrived at the hospital no systolic blood pressure or pulse, and because too much time had passed between the accident and the arrival of emergency crews, his lack of blood circulation meant most of his organs were not viable for transplant. However, his lungs were still viable, but when they had the transplant recipient ready for surgery, the surgical team realized the lungs had increased airway resistance. They were put in suspended animation.
With the transplant team having no ideas left after ten hours with the lungs in suspended animation and only fourteen hours left, the Dean of Medicine, Dr. Foreman, approached the Board of Directors for permission to attempt to get Dr. House, the hospital’s former head of diagnostics out of prison to work on the case. The Board reluctantly agreed and Dr. Foreman obtained an emergency court order for Dr. House’s release. Although Dr. House was reluctant to return to the hospital, he agreed once he found out about the case.
Dr. Foreman briefed Dr. House and they were back at the hospital with about 11 hours left. Dr. House was introduced to Dr. Park, a neurology resident who was on leave from her department and was available to help. They met the transplant team in the intensive care unit. Dr. Simpson advised Dr. House of the work performed to date and that that the lungs were on a mixture of 92% oxygen. There was no alveolar exudate, which appeared to rule out ARDS. Dr. House thought it might be a tick-borne disease. ehrlichiosis causing bronchitis. However, the blood smear was clear. He next suggested cocaine, but the tox screen was clean. Dr. House pointed out that if the cocaine never passed through the lungs, the tox screen would be clean as the test is for metabolites, not the actual chemical. Cocaine would also explain the motorcycle crash. Dr. Simpson wanted to treat, but Dr. House pointed out if he were wrong, the treatment would burn holes in the lungs. He called over Dr. Park and went to Stevie’s house to do an environmental scan to confirm.
Dr. House and Dr. Park went Stevie’s home. Mr. Weathers denied his son used cocaine or marijuana, and told the doctors his son was an athlete who took care of himself. They found no drugs, but Dr. House found a pair of glasses and noticed Stevie wasn’t wearing them in any of the pictures. Mr. Weathers told them he had only had them for a couple of weeks. Dr. House asked if Stevie was having headaches, and Mr. Weathers confirmed he was. Dr. House thought Stevie had a brain tumor.
Dr. House went to examine Stevie’s body. He found a mass on the right arm and took a sample. He thought it might be a rhabdomyosarcoma which caused paraneoplastic syndrome. However, on examination the mass was just coagulated plasma which had leaked into his arm through an intravenous line. Dr. Park followed up with an MRI, but found no cancer. Dr. House started to worry that the plasma may had been at fault, but Dr. Park realized that the unit of plasma had 25 donors who all needed to be tracked down. However, Dr. Foreman refused to allow Dr. House outside of the hospital. However, Dr. Park went to find some of the donors and Dr. Wilson agreed to help as well as it was his patient waiting for the lungs.
Dr. Wilson tracked down donor #3 who had eaten peanuts, which may have caused an allergic reaction in the lungs. Dr. Park found donor #6 - he had been to Thailand and a region where dengue fever was endemic. Dr. Park found one of the donors was an alcoholic who lived under an overpass where old paint was being scraped off. This pointed to lead poisoning. The lungs were started on chelation therapy.
After four rounds of chelation, the oxygen level was 98% and airway resistance was dropping. However, the lungs started to crash. Dr. Foreman increased the oxygen mixture to 100%. Dr. Park notice the saline flow was down to 10cc. She realized the chelation was making the lungs worse, meaning lead poisoning wasn’t the problem. They soon realized the problem was a vasospasm. Dr. Foreman went to get a calcium channel blocker. They used it and the vasospasm relaxed and the lungs turned pink again. However, one lobe did not improve and they realized it had died.
Dr. House planned to take a sample of the lung and asked Dr. Mike Pinto to do it. Dr. House started a new differential, based on why the lungs got worse on chelation. Dr. Park had already tested another bag of plasma from the same donors, but it was negative for all the exposures. Dr. House suggested sarcoidosis, but the transplant team has already taken an ACE level and it was normal. Dr. Park suggested the paint from the overpass might have contained beryllium or asbestos, but chelation wouldn’t have made those conditions worse. However, Dr. House hit upon another heavy metal that might have been there already - iron from hemosiderosis. The chelation attaching to an iron overload would have made the lungs worse. Dr. House ordered a stain of the dead lung tissue.
Dr. Park stained the tissue. She found no iron, but there were lots of white blood cells, indicating an infection. She couldn’t see how everyone missed it. She reported to Dr. House. He figured that if the antibiotics didn’t work, the infection was probably hiding inside the lung cells. Brucella was the most likely candidate. He ordered antibiotics and intravenous immunoglobulin.
However, a few minutes after the immunoglobulin was started, the lungs started to become discolored. They had already reached maximum PEEP pressure. Dr. Park suggested IgA nephropathy, but it had already been ruled out. Dr. Simpson suggested lupus, but Dr. House dismissed it. With no further ideas, he asked them to keep the lungs stable while he went to think.
Dr. House was almost out of ideas when he saw some smoke rise from the candles of a birthday cake. He realized that although Stevie didn’t smoke, there was almost certainly someone smoking cigars at the poker party he went to. It was a cold rainy night and there probably wasn’t much ventilation in the room. If he had eosinophilic pneumonia, any smoke he inhaled would have caused a cascade reaction of white blood cells. A large amount of smoke would have been fatal even without the motorcycle crash. This diagnosis explained both the lung symptoms and the motorcycle crash - he most likely lost consciousness from his lung symptoms. Dr. Park noted that the lungs had already been given steroids, which is the standard treatment. Dr. House felt they needed to do something more drastic and suggested radiation therapy. Dr. Park said that would destroy the good lung tissue too and she wanted to go with more steroids. However, Dr. House realized by the time the steroids worked, the transplant recipient would be dead.
Dr. Park took the lungs to the radiation lab. Luckily, the lungs responded to the treatment without suffering major damage. The transplant was a success.