S8E5: The Confession

This is a preserved copy of "The Confession", originally published at politedissent.com. Wayback capture: 2012-06-18. Original URL: http://politedissent.com/archives/8171.

Chase and Taub are back on the team this week, which makes the episode much easier to watch (because the medicine sure isn’t helping)

⚠️ Spoiler warning — plot details for this episode follow.

Bob Harris, small town businessman and philanthropist collapses while in flagrante delicto with the local beauty queen. He has her bring him to the hospital where he is diagnosed with ventricular fibrillation, though there is no other sign of heart disease. He initially claims he was at his desk when the attack happened, but later admits to the affair when confronted with the evidence (fresh rug burns on his knees). The team decides to run an exercise test to see if another attack will occur. Initially, they get no results, but when Chase adds an emotional component to the stress, Bob collapses with a seizure. The team’s initial differential diagnosis is viral myocarditis, Brugada syndrome (an inherited abnormal heart rhythm), or pheochromocytoma. House suggests photic epilepsy (more commonly called “photosensitive epilepsy” — seizures brought on by flashing lights), but an EEG is negative, so he goes back to Park’s suggestion of a pheochromocytoma. While Chase and Adams run tests for the tumor, Park and Taub check out the seedy motel where Bob had his tryst. The pheochromocytoma tests are negative, but the patient now has a large mass on the right-side of his neck. Park and Taub find an abundance of pathogenic material at the hotel, including traces of fusobacterium necrophorum, which confirms House’s suspicion that the patient has Lemierre’s syndrome (an infected thrombophlebitis of the neck). The patient is started on Augmentin (amoxicillin + clavanulate) and surgery to remove the infected clot is scheduled. However, the surgery reveals no clot, but an enlarged lymph node. Adams suggests lymphoma. Chase obtains a biopsy and the patient’s vital signs plummet. Adams checks his eyes and notes yellow sclera, indicating liver failure to her.

With the new symptoms, the team formulates a new differential diagnosis. Lymphoma has been ruled out because the biopsy was negative. Alcoholism and withdrawal is suggested, but House is sure Bob still has an infection of some sort. He wants to use high doses of broad spectrum antibiotics to kill whatever infection it is. Adams is concerned that his plan will kill the patient’s already compromised liver. Chase suggests a liver transplant, and then the antibiotics. Since time is short, a partial liver transplant from a living donor is suggested. Most of the population of Bob’s small town come to the hospital to be see if they would be good donors for the liver transplant. Most leave after Bob confesses a number of sins, from cheating on his wife to ripping off customers at his car repair shop to stealing scholarship money. None of the remaining townspeople are good matches for his liver. House wants another CT of the liver, and surprisingly, this one shows that the liver is healing.

The team now suspects Bob is having an allergic reaction of some sort. He reacts strongly against the wheat sample, though he has no history of wheat allergy and blood tests don’t confirm the allergy. A latex allergy is considered but tests were also negative for that. Bob’s allergic reaction worsens, with large strips of his skin now tearing off. The team diagnoses Stevens-Johnson’s Syndrome and report that there’s nothing they can do as, according to the team, most medications exacerbate the confession. Not comfortable with leaving the patient alone, Chase sits besides him during the night. Bob tells Chase he has one last confession to make: he tells Chase he is a murderer, having killed his business partner and several others. This is over the top enough for Chase to realize that a large part of the problem is in the brain, with the patient confessing to crimes he has never committed. A brain scan shows an aneurysm. Taking this along with his other symptoms, House recognizes that Bob has Kawasaki’s syndrome, an autoimmune disease (in this case apparently induced by carpet cleaning chemicals Bob was exposed to through the rug burns). After treatment, Bob is feeling good enough to start lying to his wife.

As usual, major complaints are in red, modest complaints are in blue, and nit-picking ones in green:

A patient with a suspected systemic infection is not going to be a candidate for a liver transplant.

House’s team was bizarrely satisfied with the diagnosis of Stevens-Johnson syndrome (SJS), and never explored the all important question of what set it off?
Looked more like toxic epidermal necrolysis (TEN) than SJS to me, though admittedly most subspecialists consider TEN a very severe type of SJS.
The hallmark of SJS is the involvement of mucous membranes, none of which were involved in this patient (at least the ones we could see).
Corticosteroids haven’t been implicated in SJS, though they have rarely in TEN. In fact, they are one of the main treatments of the condition.
Narcotic pain medications are not known to cause SJS or TEN, so there was no reason to withhold them from the patient.

A lymph node biopsy, especially for something like lymphoma, takes the entire node, not just a little bit of juice from it.

Augmentin/Amoxicillin + clanulate is not the proper antibiotic for Lemierre’s syndrome.
Scanning the neck (CT scan or ultrasound) to evaluate the clot — or at least to make sure it exists – is recommended before surgery.
Patient was missing the pharyngeal/peritonsillar signs and symptoms seen before Lemierre’s.

Park complains about the length of time it takes to get culture results back (a valid point), yet she is the one who supplied the surprisingly fast results from the hotel room.

There was no good reason (other than to advance the plot, so make that no good medical reason) to repeat a CT scan of the liver so soon after the first.

You don’t confirm skin allergy test results with blood results. The skins tests are generally more definitive.

This week’s medical mystery was moderately intriguing, admittedly mostly because of its illicitness. I give it a B+. The final solution fit, but was quite a stretch, about average for the last few seasons of House. It earns a C. The medicine started out decent, but rapidly degraded. The treatment of SJS was nearly medieval. And why did it take the team so long to realize his confessions were a symptom? They were quick to consider altruism a symptom just two episodes ago. I give the medicine a grade of C-. The soap opera was much better this week — and most of that is due to the return of Chase and Taub. It’s good to have them back. A-.