The patient has been blind since birth, and has diabetes mellitus.
Will became disoriented while crossing the street when the sound in his environment became overwhelmingly loud to him. He was taken to the emergency room at Princeton-Plainsboro Teaching Hospital. His blood sugar was tested and was normal, as were his ketones. His tox screen was clean. Suspecting schizophrenia, he was sent for a psych consult, but his mental status was normal.
The patient told the doctors that he had not eaten and he was sure he had just fainted. He also denied ever having a seizure before. Dr. Chase noted that seizures can often present as a muscle tremor or even a lack of concentration. His girlfriend said she hadn’t noticed anything like that, but admitted she hadn’t seen him in about five months. Will told them that he and Melissa were on a break to ensure that they wanted a permanent commitment. Will insisted that he had to be constantly on vigil about his body, otherwise he would be falling all the time. However, he agreed to the EEG.
During the EEG, he seemed to have a seizure at 300 Hz, but Dr. Taub didn’t see anything abnormal on the EEG and realized he was choking. Dr. Adams examined his mouth and saw blood, but no blockage. Dr. Taub gave Will the Heimlich manouvre, and three teeth popped out of his mouth. Will started breathing again.
Dr. Chase thought the tooth loss indicated heavy metal poisoning or radiation sickness. Dr. Taub noted that none of his co-workers were sick. Dr. Park suggested the girlfriend had poisoned him deliberately. However, Dr. House thought it was merely periodontitis, exacerbated by his diabetes, explaining the auditory hallucinations and disorientation as well. Dr. Taub noted the tooth infection could have become systemic, spreading to Will’s brain. Dr. House ordered broad-spectrum antibiotics and treatment by a periodontist.
Dr. Taub told the patient he needed better oral hygiene, and Dr. Park told him periodontitis is more common in diabetics. When his girlfriend left the room, Will asked them to put the engagement ring he was holding in a safe place in his apartment, and at the same time retrieve his laptop and Braille writer. He couldn’t get his girlfriend to do it because he didn’t want her to know about the ring.
While they were at the apartment, Dr. Taub and Dr. Park decided to do an environmental scan, but found nothing dangerous.
Dr. Adams thought the seizure pointed back to epilepsy, but Dr. Chase argued epilepsy didn’t explain the lost teeth. Dr. Taub pointed out the periodontal could be unrelated to the seizures. Dr. Park started suggesting illegal drugs, such as LSD. When she was asked why, she said that there must have been something at the patient’s apartment because she was hallucinating. Dr. House examined Dr. Park and found that her pupils were dilated and her pulse was elevated. She then described Dr. Chase and Dr. Adams as rabbits and Dr. Taub as a tooth fairy. Dr. Taub told Dr. House that Dr. Park had eaten a few things at the patient’s apartment. Dr. House ordered the rest of his team to re-do an environmental scan to find the drugs, to ask the patient where they came from, and to do an MRI of the patient’s brain to see if there were any infections, masses or plaques.
The patient admitted to LSD use five or six times in an attempt to generate visual hallucinations. He admitted he had another girlfriend who he met on his break from Melissa who had given him the drugs. He also admitted the ring was for his other girlfriend. He was planning on telling Melissa, but got sick. He gave the doctors the cell phone number for the other girlfriend, but asked them not to let her know he was in the hospital. He admitted he hadn’t told Melissa because he didn’t want to be alone in the hospital.
The MRI showed a dark spot on the brain which seemed to indicate brain damage. However, Dr. House thought it was a large clot - cerebral venous sinus thrombosis. However, it was unusually large. Dr. Taub noted that progression of the clot would explain why the symptoms started with disorientation and then proceeded to seizures. They realized that, if untreated, it would lead to cerebral edema and death, but Dr. Chase didn’t think they could tie the clot to the tooth loss. Dr. Adams started suggesting hypercoagulative diseases, starting with lupus. However, Dr. House thought it was more likely to be Behcet’s disease. Dr. Taub noted that Behcet’s always presents with color blindness and abnormal visual fields, but realized that the patient’s eyes had been ignored due to his blindness. They realized that he needed an eye exam, heparin to break up the clot and steroids and interferon for the Behcet’s.
The eye exam showed fresh scaring and swelling in both eyes, and bleeding in the left eye consistent with Behcet’s. They explained that despite his blindness, the tissue in his eyes would still respond to light and they had to wrap them to keep them dark and to reduce the swelling. Dr. Adams wrapped his eyes in a dressing.
However, Will soon started coughing up blood. He soon stabilized. Dr. Taub examined him, but couldn’t find anything out of the ordinary. Dr. Adams thought it was just another symptom of Behcet’s, but Dr. Taub pointed out that he should have improved on steroids, not developed another symptom. Dr. Park suggested that the clot they were breaking up could have dislodged and wound up in an artery in the lungs. She wanted to increase the dose of heparin. Dr. Adams argued that if the patient did start to bleed again, the heparin would make it impossible to stop. However, Dr. House realized another large piece of the clot could cause a heart attack or stroke. He ordered a lung CT scan to confirm, followed by an increase in heparin.
Dr. Adams was beating herself up for not having thought that the patient’s eyes could have issues merely because he was blind. The CT scan confirmed the clot in the lungs and they realized blood thinners were the appropriate course of action.
However, soon after they increased the dose of heparin, Will started screaming in pain and that his eyes felt like they were on fire. They removed the dressing and found his eyes had become extremely swollen and inflamed, signs of necrosis.
They realized Behcet’s couldn’t have caused the necrosis. Dr. Chase thought it was streptococcus pyogenes but Dr. Adams countered they had given him antibiotics. Dr. Chase thought it was drug resistant and wanted to remove the patient’s eyes before gangrene set in. Dr. Adams though it was more likely a virus, but there were no viral markers in the necrotized tissue. Dr. House asked to look at the lung clot and realized it was the center of a fungal infection, mucormycosis. It spreads quickly in diabetics. Dr. Park quickly confirmed the diagnosis from tissue sample. Dr. House ordered amphotericin B, but Dr. Adams quickly noted that they had already treated Will with gentamicin and the medicine interaction between the two would probably cause deafness at the dose of amphotericin B required.
Dr. Adams explained the side effects of the treatment to Will, who said he would rather be dead. Dr. Adams said there was still a small chance he might retain some of his hearing, but he refused treatment.
However, Melissa came back. She said he was fine with his decision if that’s what he wanted. However, she also told him she came back because she loved him and wanted to be with him as long as she could. Will asked if she would still love him if he was deaf, and she said she would love him no matter what. Will agreed to treatment and started to improve.
After several hours, it was clear Will could not hear anything, although his improvement continued. Melissa came to see him. Will asked her to marry him, and she shouted out yes. Will said she had heard her say yes and embraced her. His prognosis was excellent.