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Thad was brought to Princeton-Plainsboro Teaching Hospital when he started having perceptual problems - everything looked very small. Dr. House became interested in the case and took the file. His assistant Dr. Park, suggested the JBE virus given his travel to China, but Dr. House had already checked the patient’s vaccination record. She then suggested central serous retinopathy, which is linked to type A personality, but Dr. House pointed out the funduscopic exam was normal. Dr. House enlisted the help of Dr. Adams who suggested deliberate atropine poisoning, but the patient’s pupils were normal. Dr. Park suggested thyrotoxicosis and Dr. House agreed it was a possibility. Dr. House prescribed PTU and went to give it to the patient himself.
However, when he saw the patient, he told Dr. House that when he woke up from a nap, things didn’t look small anymore, they looked huge. Dr. House realized that thyrotoxicosis was the wrong diagnosis and the patient most likely had Alice in Wonderland syndrome from a migraine. He told Thad he was lucky it was diagnosed there because in China, even doctors treat mental illness as taboo and it could have wrecked his plans for moving his company there.
Dr. Adams performed an angiogram which indicated the bleeding was coming from a site in the left lower lobe of the lungs. Dr. Park suggested hyperviscosity syndrome, but Dr. Adams pointed out the patients blood count and protein count were normal. Dr. Park then suggested Factor V Leiden deficiency, and Dr. Adams suggested myelodysplastic syndrome. Dr. House ordered human activated protein C, but Adams pointed out if it was mylar dyspstic he would start bleeding again, and Dr. Park noted if it were Factor V, he would throw a clot. Dr. House said he knew that so once one of them happened, they would have a diagnosis and since he was in a hospital, the risk was low.
However, after he was given protein C, the patient started itching, but it went away almost as quickly as it arrived. Dr. Adams turned to the patient’s wife’s death from Non-Hodgkin’s lymphoma. She suggested that she actually had a virus, HTLV-1, which can cause another type of lymphoma. He could have easily contracted it through sexual contact. Dr. House ordered radiation therapy.
Thad consented to radiation, although he was sure he hadn’t gotten any STD from his wife. However, during the procedure, he complained he had to move. Dr. Adams discontinued the procedure and found that Thad was tachycardia. He also complained of pain in his chest. She thought it was a heart attack and administered oxygen.
The patient went into ventricular tachycardia during the echo. They decided to catheterize him while he was there, but his coronary artery was clean. Dr. Park suggested an EP study, and Dr. House agreed.
Dr. Adams performed the EP study, but during the procedure, the patient’s oxygen saturation plunged to 89. Dr. Park checked, but the patient’s heart rate was 90 (well within normal) and his neck veins were flat. They couldn’t determine why the patient was having trouble getting oxygen and decided to administer oxygen again.
Dr. House decided that Thad most likely had a brain problem and went to consult a neurologist, Dr. Mark Andrews, Dr. Park’s former supervisor. After being briefed, Dr. Andrews suggested normal pressure hydrocephalus. However, Dr. Park thought autonomic dysregulation syndrome was more likely. She suggested a tilt-table stress test, but Dr. Andrews pointed out if he did have hydrocephalus, the test would put the patient in a coma. However, Dr. House agreed with Dr. Andrews and ordered a test of the cerebro-spinal fluid.
However, Dr. Park was sure she was right and Dr. Adams agreed to do the test while Dr. Park was busy elsewhere. During the test, Thad complained his heat felt hot, but Dr. Adams assured him that was normal. However, the next time she checked on him, he was unresponsive and had gone into a coma.
Dr. Adams thought it had to be normal pressure hydrocephalus, but Dr. House admitted he never liked that diagnosis - the patient had no history of edema, balance problems or mental issues. Dr. Adams realized that Dr. House manipulated Dr. Park to defy him. Dr. Adams wanted to at least test for hydrocephalus, but Dr. House wanted to do a new differential. He suggested hepatic encephalopathy, but the patient’s liver enzymes were normal. However, Dr. House hypothesized that the liver was so badly damaged that it could no longer produce enzymes. He ordered a liver biopsy.
Dr. Adams performed the biopsy, but it was normal. She also performed the test of the spinal fluid as well, but it ruled out hydrocephalus because his intracranial pressure wasn’t normal, it was elevated. She suggested HTLV again, but Dr. House felt they had already ruled it out. Dr. Adams suggested Eastern equine encephalitis and Dr. Park suggested loa loa filariasis. However, Dr. House was distracted and saw an x-ray of a bone implant. He suddenly ordered plasmapheresis.
Within an hour, Thad regained consciousness. Dr. House explained that he had hyperviscosity syndrome because the antibodies from his arthritis were thickening his blood and clogging his organs. They had ruled it out earlier because it is almost always caused by either a high red blood cell count or high levels of protein in the blood. He was expected to make a full recovery.