S8E6: Parents

This is a preserved copy of "Parents", originally published at politedissent.com. Wayback capture: 2012-07-22. Original URL: http://politedissent.com/archives/8206.

A disappointing episode, as the ones that try to make a broad point (this time: all parents screw up) usually are. There were a few clever moments — who am I kidding, there was one, maybe two clever moments, and the rest was rushing from one imagined crisis to the next

⚠️ Spoiler warning — plot details for this episode follow.

Ben is a teenager working, quite ineptly, as a clown at a kid’s birthday party. After an altercation with one of the kids and their father, he develops the sudden paralysis of an arm and a leg and is admitted to House’s service with a diagnosis of TIA (Transient Ischemic Attack, i.e. a “mini-stroke.”) The team is puzzled why a healthy teenager would have such a condition. The initial concerns are drug use or endocarditis (an infection of the heart valves). A transesophageal echocardiogram is ordered — it shows no heart valve problems, but it does reveal a thickened pericardium (the membranous sack that surrounds the heart). The differential now includes syphilitic vasculitis, histoplasmosis, or Sjögren’s syndrome. The tests for the first two were negative, so House orders Ben started on immunosuppressants to treat the Sjögren’s.

While Taub sets up the medication, Ben develops a bloody nose, then a bloody cough. Taub reports that Ben’s platelet count is low and suggests DIC (disseminated intravascular coagulation). Park reports a low red blood cell count and suggests a retropeitoneal bleed (bleeding into the tissues behind the abdominal cavity). Adams reports few white blood cells and suggests an infection. House notes that the entire blood count (platelets, red cells, and white cells) is low and reports that Ben has aplastic anemia (a condition where the bone marrow stops production of any kind of blood cell). He has Ben started on platelet transfusions and orders bone marrow testing on Ben and his relatives to prepare for a bone marrow transplant. A short time later, Ben complains of back pain and his blood pressure drops. It turns out that he is having an allergic reaction to the platelet transfusion. House orders a more specific kind of platelet transfusion so there will be less chance of a reaction. Ben suddenly starts gasping for breath and after a perfunctory physical exam, Taub announces that he has a pleural effusion (fluid building up around the lungs). A chest tube is placed, but rather than returning blood, it drains an transudate (which to me looked more like an exudate), which Park takes to mean our old friend liver failure is back. The team now has a prolonged and mostly pointless argument about whether the liver failure is due to a failure of protein synthesis or high ammonia levels. House suggests feeding Ben a high protein diet to purposefully worsen the liver, and his symptoms (heart failure or coma) will let the team know which problem he had (because this is so much quicker and easier than running a ten-minute blood test).

Of course, things quickly go from bad to worse. Ben’s left eye starts bulging out and needs steroid injections to resolve. The team now suggests angioneurotic edema, anasarca, or Burkitt’s lymphoma. House suspects that later is the most likely, so starts Ben on chemotherapy. While receiving his therapy, Ben crashes and develops multiple organ failure. The team initially suggests multiple aneurysms or cholesterol emboli as potential causes. But then Ben’s estranged and in-fact-thought-dead father stops by, and House recognizes the abnormal gait of someone with tabes dorsalis, a sign of syphilis. This causes him to realize that the father sexually abused Ben as a youngster and infected him with syphilis, which is what caused his current symptoms — well, that plus the antibiotics causing a Jarish-Herxheimer reaction (severe symptoms caused by multitudes of bacteria dying off and releasing toxins into the bloodstream).

This week’s episode was particularly weak in differential diagnoses. After the first round, they quite trying, and the newer diagnoses just explained the latest symptom and not the previous ones, so the original admitting symptoms were usually left unexplained. As always, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

Once again, House is starting chemotherapy on a patient without even confirming the patient has cancer, let alone what type he has. There is no generic chemotherapy; it is specially tailored to the specific cancer.

A few simple blood tests would determine the likely cause of the liver failure, though it is quite possible if not very likely to have poor synthesis and high ammonia livers. Despite what House says, it would be quicker too than feeding the poor patient protein and waiting for it to be processed by the liver and have an effect.

Worst diagnosis of the episode: retroperitoneal bleed. How does that even come close to explaining the TIA symptoms?

A pleural effusion is not “bleeding into the lung.” It is bleeding around the lung, a not unsubtle difference.

I have my doubts that the syphilis tests (likely an RPR or VDRL) would be negative in Ben’s case. Those tests are known for their false positives, not false negatives.

If Ben’s white count is so low as to suggest aplastic anemia, why was he not placed under neutropenic precautions?

The effusion should have been clear, not cloudy (and I’d expect it to be a little bloody as a result of the brutal chest tube placement as well).

This week’s medical mystery was a little interesting, but not terribly compelling. I give it a C. The more I think about the final solution, the less it makes sense. Ben had latent syphilis that suddenly, in the space of a minute, exploded into neuro- or at least cardiosyphilis? Really? And the Jarish-Herxheimer symptoms are a poor match as well. It earns a D. The medicine was poor as well, and was more reactive than actually thought out. I give it a C-. The soap opera, at least among the patient and his family, and among the team was interesting, though Taub surely knows that House cares nothing for his daughters’ well-being. The House/Wilson/Foreman aspect, though at times amusing, just reminded me of what a sad defeated man Wilson really is. I give the soap opera a B.