Tommy was taken to the emergency room of Princeton-Plainsboro Teaching Hospital. However, he had not suffered a heart attack - his EKG, cardiac enzymes and cardiac catheterization were all normal. Dr. Foreman brought the case to Dr. House, but Dr. House dismissed it as an anxiety attack. Dr. Foreman dismissed this suggestion as the patient’s wife had been interviewed and there was nothing out of the ordinary in Tommy’s life either at work or at home and he had been fine. To rule out anxiety, Dr. Foreman ordered treatment with alprazolam and lied to the patient he had a minor respiratory infection that was easily curable in order not to increase his anxiety. The patient did not improve even though alprazolam treats anxiety. Dr. House was suitably intrigued enough to take the case.
Dr. House convened his team. Dr. Park suggested shingles, which could cause chest pain before a rash, but Dr. House pointed out the pain would be restricted to one dermatome. Dr. Taub suggested an asthma induced pneumothorax, but the patient had no medical history of asthma. Dr. Adams suggested chlorine gas poisoning, and Dr. House thought a toxin was likely, so he ordered that the patient’s urine by alkalinized, an environmental scan of the home and to proceed on the assumption that the wife had tried to poison him and ask her what she used.
Dr. Taub asked the wife about who might want to poison her husband, but she said that Tommy was well respected in his office and even by the people he prosecutes. She also told him that poisoning him would be difficult as he only eats and drinks things he brings from home. Dr. Taub wondered why Tommy was so careful, and his wife told him that Tommy has worked in the health department. Dr. Chase talked to the patient, but Tommy told him that due to his kids, they don’t keep poisons at home. Dr. Chase asked about the possibility of deliberate poisoning, but Tommy dismissed the idea that his wife would try to kill him. His wife assured Dr. Taub as well.
Dr. Adam and Dr. Park did the environmental scan. They found no fuel, pesticides, fertilizer, or anything else that could be poisonous. However, as they went to leave, Dr. Park noticed one of the rooms was smaller than it should be. She searched and found a secret room that was full of guns and ammunition.
They confronted the patient, who admitted to adding the gun room during a recent renovation. The team reported to Dr. House, who had already surmised the patient was afraid the government was going to fail. Dr. Chase suggested that the paranoia was a symptom, perhaps of cocaine abuse. However, Dr. Park dismissed the idea that it was a symptom. Dr. Adams thought the paranoia might indicate Fahr’s syndrome. Dr. Park noted there were no hallucinations, but Dr. Adams thought they may have just missed them and suggested a mental status examination and a CT scan of the basal ganglia. However, Dr. Park thought it was more likely to be atrial fibrillation brought on by hyperthyroidism or sleep apnea. Dr. House ordered the CT scan and a hair sample to check for cocaine use. He also ordered a test of TSH levels and a sleep study.
The patient’s hair sample was clear for cocaine, and there were no calcifications in the basal ganglia. Dr. Park started the sleep study. However, she noticed a bleeding sore on his leg. Tommy didn’t feel any pain or sensation at the site.
Overnight, the patient also developed a fever. Dr. Adams thought it might be tuberculosis. However, there was no sign of atelectasis or chest infiltrates on the x-ray. Dr. Taub suggested systemic sclerosis, but Dr. Park pointed out that it takes longer than a few days to develop skin ulcers after the first symptoms appear. Dr. Adams pointed out his paranoia started over a year ago, but Dr. Park once again didn’t think the paranoia was a symptom. Dr. Taub wanted to biopsy the skin lesion and start the patient on enoxaparin immediately, but Dr. Park thought it would be better to wait for the biopsy results before starting treatment. Dr. House ordered the biopsy and the treatment.
However, soon after, Tommy started to get very aggressive, getting out of bed and throwing a chair through the glass panel of his room. Dr. Taub, Dr. Chase and an orderly managed to subdue him. Tommy was put in restraints and it was determined he was hallucinating about being attacked by bears, which once again pointed to paranoia as a symptom. Dr. Park thought this paranoia was new and pointed to tularemia, but Dr. Adams thought the paranoia was consistent with his past behavior and pointed to GAD autoimmune disease. However, Dr. Chase thought the consistently normal blood tests pointed to a mental illness like schizophrenia. However, Dr. Park noted that didn’t explain the fever or skin ulcer. Dr. Chase suggested the patient might have tried to dig things out of his skin, causing the ulcers and an infection. However, Dr. Park thought an infection was far more likely and suggested broad-spectrum antibiotics, but Dr. Adams noted those would be fatal in a patient with GAD autoimmunity. Dr. House ordered steroids and intravenous immunoglobulin for GAD.
Tommy’s fever got worse. Dr. House came to the conclusion that they had, perhaps, started treatment too late and ordered the dose of steroids increased. Dr. Park objected saying more steroids would be fatal if it were an infection, but Dr. House noted with the neurological symptoms getting worse so fast, it was unlikely antibiotics would help even if it was an infection. Dr. House agreed, but noted broad-spectrum would be useless. He ordered DNA assays for sporotrichosis, meningococcemia and anything else they could think of. He ordered the steroids discontinued.
The patient went into respiratory arrest. He had stridor, but no obstructions. It appeared to be anaphylaxis. Dr. Chase prepared for an emergency tracheotomy. However, the obstruction was blocking Tommy’s entire trachea. Dr. Taub ordered more racemic epinephrine. They restored the patient’s breathing and realized the cause was tracheal edema. Since they weren’t treating him, it had to be a symptom. However, it ruled out both GAD and a systemic infection. It also appeared to rule out an allergy because the patient couldn’t get worse three days after he was admitted. Dr. House turned back to toxins, but the doctors were at a loss as to who could do it as the wife left due to a fight over the guns in the house. Dr. Park suggested squamous cell carcinoma, with the hallucinations being the result of paraneoplastic syndrome. Dr. House ordered a biopsy.
However, Dr. House finally realized the tracheal blockage wasn’t edema, but a pseudomembrane. He wasn’t clinically paranoid, but his symptoms were largely caused by a toxin. He removed the patient’s tracheal tube to examine his throat and found the pseudo membranes indicative of diptheria, which explained all the symptoms. He ordered antitoxin from the CDC. The patient was treated and was expected to make a full recovery.