S8E9: Better Half

This is a preserved copy of "Better Half", originally published at politedissent.com. Wayback capture: 2012-06-18. Original URL: http://politedissent.com/archives/8571.

An unfortunately average episode of House where the most interesting question is left unanswered.

⚠️ Spoiler warning — plot details for this episode follow.

Andres is a man with early onset Alzheimer’s disease. He is being evaluated for possible inclusion in a drug study when he develops bloody vomiting. He is admitted to Princeton-Plainsboro Hospital and assigned to House’s service. The team’s initial thought is that the patient has a gastrointestinal bleed which is causing the bloody emesis. An EGD (upper endoscopy) is performed and it shows a Mallory-Weiss tear (a rip in the esophagus of those who vomit frequently or forcefully), but that is a consequence of vomiting, not a cause. Andres is also noted to have elevated liver enzymes, and the diagnoses of gallbladder disease and steatohepatitis (fatty liver) are mentioned. House favors the latter and decides to start the patient on statins (a class of cholesterol drug as high cholesterol is almost always seen with steatohepatitis) and double check the liver (initially a biopsy, but overruled by Foreman to an ultrasound examination), but before they can perform the testing, Andres becomes more violent that ever, punching his wife, and requires sedation. At this time, the team also notices bloody urine. The differential diagnosis now consists of rhabdomyolysis (severe sudden muscle damage) and TTP (thrombotic thrombocytopenic purpura). House thinks TTP fits best, and orders Andres started on plasmapheresis.

Overnight, Andres elopes (the medical term for a patient, especially a demented one, who leaves the hospital). In the middle of a snowstorm, the team tracks him down to an old soccer field, but by the time they find him, he is hypothermic and pulseless. CPR is started, because, as Chase reminds Adams, they’re not dead until they’re warm and dead (sudden hypothermia can sometimes be protective of a patient, though this is more common in children than in adults, so it’s medical tradition not to declare someone dead until they’re back to normal temperature). Andres is brought back to the hospital, sent to the ICU, and started on extracorporeal warming of his blood. As he warms up, his brain function returns, then his heart. He’s initially in ventricular fibrillation, but he returns to a normal rhythm after some amiodarone (a medication used to suppress heart arrhythmias) and defibrillation. Unfortunately, he seems to have lost his ability to speak English and now only murmurs in Portuguese, his native language. He also develops a fever, but is this a symptom of his original admitting disease, or a consequence of being hypothermic? Looking over Andres’ symptoms, House sticks with the diagnosis of TTP and wants to resume plasmapherises. Foreman, instead, favors a viral infection that has spread to the brain to cause encephalitis. House relents, and has the patient started on interferon.

Andres is not doing any better. He falls back into ventricular fibrillation and this time requires three shocks to correct (apparently they neglected the amiodarone this time around). Foreman maintains it is a viral infection of the brain, such as encephalitis or meningitis, while House now favors toxin exposure. This week, it is Foreman who has the Eureka! moment while talking with some hospital donors. Seeing a flower bouquet still looking fresh despite being over a week old, he recalls that aspirin in the water can prolong the life of cut flowers, and this leads him to diagnose the patient with Reye’s syndrome. Some corticosteroids and Andres is back to normal (well, as normal as someone with early onset Alzheimer’s can be.)

Meanwhile, Wilson is treating a patient with a bladder infection (which he apparently diagnoses by palpating her neck). In the course of his discussion with her, he learns that she and her husband are self-proclaimed “asexuals”, completely disinterested in sex. House finds this head to believe and wagers $100 that he’ll find a medical cause for the lack of sex. He runs tests on the patient’s blood, but everything is normal. He eventually lures the husband in for an exam and discovers a pituitary tumor (a “macroprolactinoma“) that is suppressing the normal sexual urges. With some treatment, the high levels prolactin can be treated and the patient’s symptoms (in this case his nonexistent sex drive) corrected.

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

Pet peeve here: Defibrillation does not “shock the heart back into rhythm.” The shock from defibrillation momentarily stops the conduction of the arrhythmia, allowing (hopefully) a normal rhythm to take over. The shock itself does not “jump start” the heart or start the normal rhythm, it just stops the bad rhythm — an important distinction.

TTP (thrombotic thrombocytopenic purpura) -– none of three parts (the T, T, or P) fits. There was no mention of low platelets (though other lab abnormalities were mentioned), no clotting, and no purpura. (In fact, there was no mention of rash at all, and rash is almost always seen in Reye’s).

In regards to his symptoms, Reye’s syndrome is quite a stretch with few of Andres symptoms matching well, but then again, Reye’s in adults is quite a stretch in-and-of-itself.

Symptoms of death in the hypothermic do not resolve that predictably (“Ah, 93 degrees, must be time for the ventricular fibrillation”), and frankly, the patient usually remains dead.

Interferon is not a treatment for encephalitis or meningitis.

Cortciosteroids are used in Reye’s to treat swelling of the brain — something they never bothered to look for, despite the more-than-expected behavioral changes.

Third episode so far this season where there is debate whether societally atypical behaviors are symptoms or not. Charity, paranoia, and now aggression.

Before starting statins in a patient with elevated liver enzymes, I’d want to make sure the cholesterol is indeed high and require treatment, as the statins themselves can elevate liver functions.

While there is debate over the use of “chemical restraints” (sedation in aggressive patients), diazepam is unusual for a first line agent. Haldol seems the more common choice. On the other hand, diazepam can be more easily reversed if something goes wrong.

The medical mystery this week was OK, but not great — but that still makes it better than most episodes this season. The big mystery was why Andres developed Alzheimer’s so young, but answering that was outside the scope of the episode. I give the medical mystery a C+. The final solution kind of more or less fit, if you ignored the usual time course of Reye’s Syndrome. I give it another C+. The medicine was uninspiring this week, with diagnoses thrown around that could be easily tested, but never were. Plus Foreman, a neurologist, was using meningitis and encephalitis interchangeably. I give the overall medicine a C. The soap opera was enjoyable this week from the pathos (Chase), to the humorous (the yellow cards, Park and her “tapping”), to the unethical (House and Wilson). It deserves an A-. (Bonus points for the Spider-Man allusion. And what manga was House reading when first talking to Wilson? Maybe someone should tell him they’re read right-to-left, not left-to-right.)