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Case History Edit
Whilst held against her will by two robbers who threatened to rape her and held her husband at gunpoint, Tracy suddenly collapsed with breathing difficulties at a diner when the patrons were being robbed. However, she had suffered no trauma that would explain her symptoms. She was taken to Princeton-Plainsboro Teaching Hospital.
Dr. Cameron presented the case to Dr. House. The patient's breathing troubles were the result of her throat swelling shut, similar to anaphylactic shock, but anaphylaxis was not the cause - Tracy's skin tests for allergies were all negative and she had been on antihistamines and steroids for four days before the swelling started to go down. She also had unexplained intense abdominal pain. Dr. House suggested an exploratory laperotomy. However, the patient already had a laperotomy and the liver, kidneys, small intestine and appendix were all clean. Dr. Chase suggested she suffered a trauma to the throat during the robbery, but there was no sign of it and, in any case, it would have completely resolved in less than four days. He also noted the thief had coughed on her, but Dr. Cameron pointed out the thief was fine except for the head trauma he suffered at the hands of Tracy's husband. Dr. Chase noted that Tracy tested positive for marijuana use and that salmonella in the marijuana would account for the abdominal pain. However, Dr. Foreman pointed out there was no fever. Dr. Chase put that down to the steroids and pointed out that marijuana smoking would also explain the throat constriction. Dr. House thought that salmonella was the best differential diagnosis so ordered floroquinalone.
When Dr. Foreman went to see Tracy and her husband Jeremy, Jeremy asked how much marijuana she would have to smoke to get throat irritation, Dr. Foreman told him it would have to be a lot. However, Jeremy irritably told Dr. Foreman they didn't smoke that much marijuana. Dr. Foreman tried to send Jeremy out of the room to talk to Tracy, but she said he was right and that she felt better when Jeremy was there. However, after she was given the floraquinalone, she started getting a rash on her arm and complained of itching.
It appeared she was allergic to the floraquinalone and Dr. Chase suggested another antibiotic. However, given her allergic reaction, Dr. House thought that it was more likely the throat swelling was due to an allergy that the tests didn't catch, most likely a food allergy. He ordered her given the same food she ate at the diner while she was on a treadmill. Dr. Foreman doubted it would work.
They put Tracy on the treadmill. She complained about stomach pain and Jeremy asked that the test be ended. When Dr. Foreman refused, Jeremy became very angry and all of a sudden, got intense pain in his stomach and chest.
Foreman pointed out that the test didn't work on Tracy. Jeremy's tests showed no myocardial infarction or aortic dissection. There was nothing wrong with his heart - the pain was non-specific. Dr. House thought it might be psychosomatic or an anxiety attack, but Dr. Cameron pointed out the pain persisted after he was given lorazepan and morphine. Dr. Foreman though their conditions were unrelated. However, Dr. House pointed out they had crippling stomach pain in common. Dr. Cameron argued they must have got the disease from each other or in the same place. Dr. House ordered tests for bacteria, viruses, fungi, radiation, prions and toxins.
Dr. Chase and Dr. Foreman went to do an environmental scan of the patients' apartment. Dr. Chase found condoms as well as the pill. It appeared that Jaremy may have an STD from cheating on Tracy. However, Dr. Foreman pointed out neither patient had symptoms in their sexual organs. Dr. House agreed it was probably an STD. Dr. Chase pointed out gonorrhea fit all the symptoms - Fitz-Hugh-Curtis syndrome explains stomach pain, and costochondritis and bladder infection would explain chest and throat pain. Dr. House ordered swabs to test for it.
However, Tracy said she knew about the condoms - they use them along with the pill to make sure she doesn't get pregnant because she was too young to have kids. Jeremy, who is Caucasian, while Tracy is African-American, thought that Dr. Foreman didn't trust him because of his race.
However, they were right - they both tested negative for STDs and showed no symptoms. Their abdominal pain was getting worse and their dose of morphine had to be increased. Dr. House ordered Tracy's steroids discontinued. If she developed a fever it would indicate infection, otherwise it would be environmental.
Tracy started to feel worse once the steroids were discontinued, and was soon having hallucinations about Jeremy's abusive father breaking his arm and threatening her. After being safely woken up from her intense nightmare by Dr. Foreman and consoled by her husband, she was soon in a delirium and coma.
Tracy's vital signs were stable, but her response to stimuli kept getting weaker. They sent her for imaging to check for masses and infections. Jeremy told Dr. Foreman that when his father caught him and Tracy together, he threatened Tracy and broke Jeremy's arm. They ran away when they were 16, and the father later committed suicide.
Tracy had generalized edema and traces of increased signal in several spots of her brain near her brainstem which could indicate a number of things. Dr. House asked for a new differential. Infection was ruled out because she hadn't developed a fever. Toxins didn't make sense either because her liver was fine and there were no other illnesses among her neighbors and co-workers. Dr. Foreman suggested once again it was two different diseases, but Dr. House dismissed the idea - he suggested sarcoidosis. However, Dr. Chase pointed out that the only environmental causes of that disease were firefighting and living in a pine tar forest. Dr. House thought it might be another unknown environmental cause. He pointed out Jeremy's hylar lymph nodes were slightly enlarged. Sarcoidosis would explain the symptoms, and why it continued to get worse when they discontinued steroids. However, Dr. Cameron pointed out it didn't explain throat swelling. It also causes lung scarring in the vast majority of cases. Dr. House asked Dr. Wilson for his opinion, but he said it was non-specific and could be granulomas or plaques. He didn't think it was sarcoidosis. However, Dr. House ordered methyltrexate. He also wanted to order a biopsy to be sure, but Dr. Chase pointed out that a biopsy of the brain stem would almost certainly cause brain damage. Dr. Cameron pointed out that they would need Jeremy's consent, but he was in a conflict of interest. Tracy needed a guardian ad litem. She went to Dr. Cuddy, who agreed. Dr. House argued there was no conflict and no time. Dr. Cuddy argued that if she was brain damaged, the hospital would be sued out of existence. Dr. House asked that Dr. Wilson ask for consent, but Dr. Cuddy agreed on the condition that Dr. House apologize to a patient he humiliated.
However, Jeremy refused consent - Tracy was a straight A student. Instead, he asked that they let him get worse and biopsy his brain. Dr. House admonished Dr. Wilson for not getting consent, but he was unrepentant. Dr. House ordered Jeremy's morphine discontinued, but his team refused. Dr. House suggested that instead they inject Jeremy with naloxone, an opiate blocker, but they refused that too. However, Dr. House fooled his team and went to inject Jeremy. He started having severe stomach pain and Dr. House started arguing with Jeremy about the biopsy. Finally, Dr. Foreman found a tranquilizer and injected Jeremy with it. However, Jeremy was adamant he would rather be in pain so they could biopsy him.
Dr. House asked Dr. Cuddy to get him a court order for the biopsy, but she refused.
Tracy's coma got worse. Jeremy's lactic acid rose to 45 and he started vomiting. Dr. Cameron thought Jeremy might have small cell vasculitis, but this has no environmental cause. Dr. Foreman thought it might be two diseases - vasculitis for Jeremy, porphyria for Tracy. Porphyria fit her symptoms and caused comas too. Dr. House ordered hemotin for Tracy and a bowel resection and biopsy for Jeremy.
However, Jeremy's bowel wasn't dead - it was general edema and swelling, most likely from the stress of his illness. Dr. Cameron said that allergies just didn't fit now. Dr. Chase thought it might be a different STD like Syphilis. Dr. Foreman put sarcoidosis back on the table. However, when Dr. House learned they had run away together he asked why. Dr. Foreman told him it was to get away from his racist dad. Dr. House asked how they knew he was racist. Dr. Foreman told him that he had beat up Jeremy for seeing Tracy. Dr. House said that didn't necessarily mean he was racist, maybe he just didn't like Tracy. He noticed that the patients had the same eye color. He started considering genetic diseases and one that causes general swelling and edema is hereditary angioedema. Dr. Foreman realized that Dr. House was suggesting they might be related, and Dr. House thought they were half-siblings with the same father. This would explain the father's behavior when they started dating. The father probably also had angiodema, which would explain why he took a lot of pills. As it would take too long to check for the genetic marker or to see if they were related, he ordered them to treat Tracy for it and hope for the best.
However, Tracy's response to stimuli didn't improve. However, she suddenly woke up when Dr. Foreman replaced the pulse detector on her finger. She was responding normally to stimuli.
Dr. Foreman resisted telling them, but Dr. House told him it was only a matter of time before they found out, and it could be a disaster if they had children of their own.
Dr. Foreman explained the treatment to the patients - they needed to take pills for the rest of their lives, but it was very treatable. The stress of the robbery most likely set it off even though they had both had it all their lives. When they asked how they could both possibly have it given it is genetic and rare, Dr. Foreman told them they should take a DNA test because they may have the same father. Tracy realized he was probably right as people always said they had the same eyes and she was lighter than both of her parents. Dr. Foreman tried to assure them they weren't really siblings because they didn't grow up together, but Tracy rejected his assurances and asked for her own room.