Case History Edit
Ted was brought to the emergency room of Princeton-Plainsboro Teaching Hospital when he found himself unable to speak at his wedding to his fiance Nicole, then found himself unable to breathe properly and collapsed. He was seen by Dr. Chase got Dr. House to see the patient, and they found Dr. Taub waiting for them. They had already ruled out infection, vocal cord damage and stroke. Dr. House examined the patient. They had already ruled out hypoglycemia and low blood pressure as well. Dr. House realized that the patient had developed the symptoms at the altar. Dr. House instructed him to roll on his side and lift up his gown. He then stabbed Ted with a needle, and Ted cried out in pain, expressing surprise that he could talk. Dr. House thought he was just faking the symptoms so he wouldn’t have to go through with the wedding. However, Ted denied this.
Dr. Taub didn’t think Ted was faking. However, Dr. House wouldn’t listen to him.
Outside the hospital, Ted and Nicole were waiting for a ride when Ted started coughing and Nicole called for help. A nurse rushed to her aid.
Dr. House was upset about the patient returning to the hospital, but Dr. Foreman reported that Ted now had a pleural effusion - he clearly wasn’t faking. There was 200cc of fluid in the space. Dr. House was willing to admit the new symptom was real, but wondered how the original symptoms disappeared without treatment. Dr. Foreman thought the symptoms could be explained by any systemic illness. They had already done an eosinophil count to rule out parasites. Dr. House felt the patient may be hiding something. Nevertheless, he decided to double check the ER’s conclusion that it wasn’t an infection by ordering a lung tap, blood cultures, cytology for cancer and a test of his blood pressure while talking about the wedding. He also ordered an environmental scan. Dr. Hadley noted that Ted had only been living with Nicole for three months, so Dr. House ordered a scan of both his current residence and his old residence.
Dr. Hadley and Dr. Taub checked out his old place. Dr. Taub noted the house was about 40 years old and he suspected lead paint, but Dr. Hadley pointed out it was unlikely Ted had pica. Dr. Hadley noticed the ceiling was suspended and found old acoustic tiles underneath, a possible source of asbestos exposure. However, the existing resident found them both there, but calmed down when they explained why they were there. He asked if Ted was okay and advised them he already had the tiles checked and they didn’t contain asbestos. He also told the doctors that he had been Ted’s boyfriend for three years.
However, Ted denied being gay or bisexual. He claimed Cotter had a crush on him and he left over it. They told Ted he had tested positive for mononucleosis, which would explain the pleural effusion and why the symptoms came and went. Mononucleosis is rare in men Ted’s age unless their immune system is compromised, and AIDS is the most common cause of that. Ted still denied he ever had sex with Cotter. When Dr. House asked if he could test Nicole for AIDS, Ted finally admitted he had some intimate contact with Cotter but that he was still straight. He finally agreed to be tested as long as they didn’t tell Nicole. Dr. Hadley said that wasn’t her business.
However, when discussing it with her colleagues, Dr. Hadley thought Ted was being dishonest with Nicole and that it would affect their relationship at some point. However, Ted tested negative for HIV. However, Dr. Hadley thought that perhaps Ted had done something to himself to make himself straight. He went to confront him about how he “turned his life around”. She got him to admit that he had undergone a course of conversion therapy, a controversial procedure where men are shown gay porn while being given emetics to make them nauseous. Ted didn’t know which emetic he was given. He was also given male hormones. This could have caused the pleural effusion. After that, he was given electroshock therapy which would account for the aphasia. Dr. Foreman objected that ESP doesn’t cause nerve damage, but Dr. House pointed out it most likely wasn’t performed in a hospital setting. Dr. House ordered an EEG.
However, Ted’s EKG showed no abnormalities. Dr. House reviewed the three ways a heart attack can occur - electrical problems, restricted blood flow, and bleeding. The EP study had ruled out shocks as a cause. Dr. Foreman went to do an angiogram.
Dr. Taub and Dr. Hadley came in to prepare Ted for the angiogram, but when he sat up in bed, he immediately collapsed backwards and lost consciousness. They checked his heart rate, but it was normal. He regained consciousness immediately. However, when he sat up again, he fainted again. When they reported this to Dr. House, he though it was POTS. They realized they had only checked his blood pressure when he was lying down - it was plummeting every time he stood up or sat up. Retracted hypertension would explain both the heart attack and the fainting. It would also explain the aphasia and why his voice returned when he lay on his side - it wasn’t the needle. Both bacterial and viral infections, including mononucleosis, can cause POTS so Dr. House ordered fludrocortisone.
Cotter came to visit Ted and when Cotter lay his hands on the sleeping Ted, Nicole saw it as a gesture of affection and asked him to leave.
Ted finally awoke and was told he was improving. Nicole asked him who Cotter was and he said they were old roommates. When she pressed him, he admitted they had sex while he was drunk but it was a mistake. He denied he was gay, although he admitted he thought he was. However, when he intended to tell his parents, he said he realized he was disgusted about being gay and he went to get help. He admitted the head trauma the doctors told her about was part of the therapy that cured him. However, Ted started to develop a severe headache. They thought it might be a cerebral infection, or a fungus that had spread to the heart. Dr. House ordered a lumbar puncture to test the cerebro-spinal fluid.
However, the cerebro-spinal fluid was negative for infection, but Ted’s headaches just kept getting worse. This ruled out POTS as the cause of his problems. The patient was maxed out on morphine for the pain. Dr. House realized that the headaches may have gotten worse because of the lumbar puncture. He suspected a fluid leak from the site of the puncture. Dr. Chase pointed out this wouldn’t explain why he got the headaches. Dr. House realized that something in the patient’s brain had caused the POTS instead of the POTS causing the brain issues. He ordered that the leak be fixed and that he be given artificial cerebro-spinal fluid.
Dr. Chase fixed the leak. However, right after the procedure, it appeared that Ted was having a stroke - his face contorted. However, Dr. Chase ruled out a stroke by noting both of Ted’s pupils were responding to light. Ted was also able to respond to questions.
Dr. Chase informed Dr. House that the new symptom clearly ruled out POTS and they had no idea what was wrong with Ted. They had done an MRA which showed no problems with blood flow to the brain, ruling out a transient ischemic attack. Dr. Taub suggested acidosis, but the chest x-ray showed no hilar masses. He suggested scleroderma, but the patient’s skin was fine. He suggested histoplasmosis, but the EIA was clear. Dr. Chase suggested MELAS, but the lactate levels were stable. They seemed out of options, but Dr. House realized they couldn’t trust Ted to give an accurate medical history. He told them to call Cotter and question both him, Nicole and Ted together.
They re-did the medical history with all three participants. There was no history of dizziness or seizures. When they started talking about blackouts, Nicole said the only time was at the wedding, and Ted denied it, but Cotter remembered an incident where Ted had fallen over even when he was sitting on the couch. Ted put it down to drinking on an empty stomach. Nicole complained of occasional erectile dysfunction, but Cotter said it was never a problem with him. Dr. Taub thought it might be a vascular problem despite the normal MRA. Acute ischemia might have caused all the symptoms. They decided to do a penile plethysmograph to see how blood flowed into his penis when he had an erection. Ted declined the porn he was offered, choosing instead to receive an injection into his penis to induce the erection. However, the test was normal. They noticed Ted seemed to be sweating, but on closer examination, he was lactating.
Dr. Chase put down the lactation to the hormones he was given during his conversion therapy. However, Dr. Foreman pointed out male hormones don’t cause lactation. Dr. Chase thought they may have affected the thyroid gland, but Dr. Foreman pointed out that the hormone treatment ended three months before. Dr. Chase thought it was something else affecting the thyroid, such as Grave’s disease or Hashimoto’s disease. However, Ted’s TSH panel was normal. Dr. Taub suggested a benign pituitary tumor - it would cause all the symptoms and would not have shown up on the cancer screening. Dr. House ordered a test of Ted’s prolactin level and an MRI of the pituitary.
However, when Dr. House started talking to Dr. Wilson about what you can change, he realized something. He guessed the pituitary MRI was normal. He asked the patient how the headaches were, and he said they were still bad. Suddenly, Dr. House grabbed Ted by the neck and placed pressure on the jaw line. Suddenly, Ted felt much better. However, when Dr. House released him, the pain returned. It went away again when Dr. House applied pressure. Dr. House realized Ted had a Chiari malformation - a narrowing a the base of the skull that cut off the flow of cerebro-spinal fluid. Dr. House handed Dr. Taub a neck brace to relieve the pressure. The electroshock therapy caused his brain to swell, closing off the smaller opening and bringing on the symptoms. The brain was also pressing up against the pituitary, causing the other symptoms and mimicking POTS. Unfortunately, treating a Chiari malformation like POTS only made the problem worse, and Dr. House apologized for that. He needed surgery, and was told it was congenital.
After surgery, he recovered quickly. Cotter tried to tell him he was making a mistake by marrying Nicole, but Ted wouldn’t accept that. However, Nicole came in to see him and told him that although she still loved him, that she thought he still loved Cotter. He told her that he had chosen how to live his life, but she said she had to make a choice too and told her she was leaving him.