S8E8: Perils of Paranoia

This is a preserved copy of "Perils of Paranoia", originally published at politedissent.com. Wayback capture: 2013-03-26. Original URL: http://politedissent.com/archives/8261.

What started out as an intriguing courtroom thriller ended up a barely mediocre episode of House

⚠️ Spoiler warning — plot details for this episode follow.

Tommy is a forty year-old prosecutor who develops sudden severe chest pain in the middle of a court case. He is admitted to the hospital where a heart attack and anxiety are ruled out — with no clear cause of chest pain remaining, he is admitted to House’s service. The team’s initial differential diagnosis includes shingles, asthma-induced pneumothorax (a collapsed lung) or poisoning (particularly chlorine poisoning). House thinks poisoning seems the most likely, so has the team alkalinize the urine, and then interview his wife and search the house. No poisons turn up in the search, but Park and Adams find a hidden bunker filled with guns. Now Chase and Adams think that this is a sign of paranoia, but Park doesn’t think he’s paranoid. Taub, wisely, sits this one out. The new differential diagnosis consists of cocaine abuse, Fahr’s disease, or atrial fibrillation due to hyperthyroidism or sleep apnea. House has all the suggestions checked, but everything comes back negative.

Park notices a bleeding sore on Tommy’s leg, which he tells he didn’t know about. He starts running a fever as well. The team thinks tuberculosis is possibility, as is systemic sclerosis (better known as scleroderma, an autoimmune disease). House decides to go with Taub’s suggestion of sclerosis; he orders a skin biopsy and starts Tommy on enoxaparin (a blood thinner). The treatment doesn’t help and Tommy starts having hallucinations and suffers a psychotic break. Park thinks he has an infection like tularemia and Adams thinks he has GAD autoimmunity. Chase thinks all of the patient’s symptoms are psychiatric or self induced. House favors Adams, and starts Tommy on immunoglobulin and corticosteroids. Tommy continues to get worse with his fever getting higher. Adams wants to up the steroid dose, but this time House agrees with Park and has Tommy checked for a number of infectious diseases, including sporotrichosis and meningococcemia.

Without warning, Tommy goes into anaphylactic shock. Chase performs a tracheotomy, but it doesn’t help because the airway blockage is below the cricothyroid membrane. There are some tense moments (as least I assume they were tense, all we got was a commercial break), but Chase and Taub manage to open the airway and get him hooked up to a ventilator. The team is at a loss for a cause when Park suggests that Tommy’s symptoms are the result of squamous cell carcinoma (a type of skin cancer) along with paraneoplastic syndrome. The team is getting ready to obtain a skin biopsy when House has one of his Eureka! moments and realizes that Tommy has severe diphtheria. One of the classic symptoms of the disease is a pseudomembrane which blocks the airway, and this explains the respiratory arrest. His other symptoms have also been associated with the disease, albeit very rarely. Some antitoxin, and he should be as good as new (though still paranoid).

As usual, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

A patient with non-cardiac non-anxiety chest pain is not a big mystery; they’re a dime a dozen. Once the patient’s chest pain is determined to be non-cardiac, there’s no reason to admit the patient (unless something life threatening is going on, which is not the case with Tommy – at least at this point). The rest of the work-up can be done as an outpatient.
There are many common causes of chest pain that are non-cardiac and non-anxiety (gastrointestinal and musculoskeletal are common, for starters). An ER of that size would see at least a dozen such patients a day. There is no reason House would be intrigued by such a pedestrian complaint.

Notice how, for once, House held off starting broad spectrum antibiotics (or any antibiotics) and waited for tests to come back first – only because if he had given the antibiotics earlier the case would have been solved too quickly. Acting out of character in order to advance the plot is not the sign of a well written mystery.

Do they intend to biopsy the entire chest looking for this squamous cell cancer, or is there a suspicious lesion on the chest just asking to be biopsied – and if that’s the case, why didn’t someone spot it or mention it sooner?

Severe enough diphtheria to cause fever, pseudomembrane formation, skin lesions, chest pain, and hallucinations, but somehow there are no upper respiratory symptoms or swollen lymph nodes?

Giving someone Xanax and noting no chest pain, even when lying to the patient, does not rule out anxiety. For instance, what if they only have anxiety in high-stress situations like a courtroom? What does giving them Xanax in the artificial surroundings of the hospital accomplish?

It was not anaphylaxis, it was respiratory distress/arrest. They are not synonymous. You’d think the team would notice there were no other symptoms of anaphylaxis.

The main symptoms of Fahr’s syndrome are disorders of movement, none of which the patient had.

Once the airway blockage has been cleared, why is Tommy on a ventilator? There was never any indication or any reason given why he was unable to breath for himself.

Someone with a bad infection may worsen on corticosteroids, but giving someone with GAD autoimmunity antibiotics is not going to kill them.

If the EKG was normal and the cardiac enzymes were normal, why proceed with a cardiac catheterization?

Schizoid and schizophrenia are not the same thing.

As I mentioned above, the medical mystery this week was routine, boring even. Chest pain is exceedingly common and this case would not pique House’s interest. I give it a D. The final solution fit, but really only if you accepted the fact that the doctors on the team are idiots and borderline incompetent. I give it a C. The medicine diagnoses seemed more random than logical with many of them fitting the patient poorly, if at all. And did I mention House acting out of character? I give it a weak D The soap opera was better this week with all three storylines (Foreman, Park, House/Wilson) clicking. I give it a B+.