S8E15: Blowing the Whistle

This is a preserved copy of "Blowing the Whistle", originally published at politedissent.com. Wayback capture: 2012-06-17. Original URL: http://politedissent.com/archives/8863.

Trying to mirror some current events (relatively current, anyway), House delivers an episode that in underwhelmingly average.

⚠️ Spoiler warning — plot details for this episode follow.

Brant, a young soldier being escorted by the military police, has a seizure and ends up admitted to House’s service. A previous head CT and EEG were normal. The initial diagnosis includes typhus (caused by lice; discarded because the patient is bald), leishmaniasis, or factitious disease (the patient is faking it). Park and Adams try to fool the patient with a placebo — and it seems to work — but then he develops abdominal pain and bruising. The differential diagnosis now includes esophageal rupture with a subsequent compartment syndrome, a ruptured abdominal aortic aneurysm, or pancreatitis caused by a gallstone. The team proceeds with an abdominal ultrasound which shows no gallbladder problems, but does reveal an enlarged spleen. About this time, Brant starts bleeding everywhere and Chase announces the patient is sequestering platelets in his spleen and he’ll need to have his spleen squeezed in the OR to release these platelets. The surgery goes well and the patient begins to improve, but Chase notices the spleen is abnormally lumpy.

Given these new symptoms, the differential consists of extramedullary hematopoesis (the production of blood cells outside the outside of the bone marrow), tuberculosis, brucellosis, lymphoma, or sarcoidosis. The last seems the most likely, so the team starts the patient on steroids. His symptoms don’t improve, and now he complains of foot pain and is found to have a cyanotic (blue from lack of blood flow/oxygen) foot. A cholsterol embolism and methemoglobinemia are suggested, but the team ultimately settles on DIC (disseminated intravascular coagulation) due to Bernard Soulier syndrome. The patient is started on Heparin. Later, House talks to the patient and learns his hair turned gray in three days. This makes House suspicious of an autoimmune disorder, particularly Grave’s disease. He wants to start him on antithyroid medication, but the team ignores his suggestion.

Brant takes another turn for the worse. He is now running a high fever and has a high white count (a sign of infection). Legionnaire’s disease, dengue, and malaria are all discussed, with House suspecting malaria. The patient is started on anti-malarial medication without success. He continues to have a high fever and high white count, only now his kidneys are failing as well. Gonorrhea is suggested, but House realizes the patient has typhus, not from his own hair (which, because he is bald, is why the diagnosis was abandoned initially), but from the animal skin furniture he used to sit on overseas.

In the B plot, the team has decided that House is sick. A tumor, dietary problems, refsum disease, and serotonin syndrome are all mentioned, but in the end, they settle on hepatic encephalopathy (brain damage caused by a malfunctioning liver) from his Vicodin use (in addition to a narcotic, Vicodin contains acetaminophen – i.e. Tylenol – which in high doses can be toxic to the liver). In the end, House was never sick, but just pulling one over on the team.

I found tonight’s differential diagnoses — both of the patient and House — more maddeningly illogical and superficial than usual. For an example, here’s a good list of differential diagnoses to consider when suspecting typhus. How many of them were actively pursued, let alone mentioned?

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

I realize it’s been quite a while since I’ve done a surgical rotation, but it was my understanding that the treatment for symptomatic splenic sequestration was a splenectomy, not just “squeezing the spleen.” If you leave the spleen in there, the problem is just going to recur.
If Chase noticed the abnormally lumpy spleen while performing surgery, why not take a second and get a biopsy?

A ruptured esophagus is going to cause compartment syndrome in the thigh?

I don’t seen any indication in the literature that DIC is associated with Bernard Soulier syndrome. And it didn’t bother the team that they were diagnosing two different causes for the patient’s low platelets?
Honestly, I was confused by the resolution of the cyanotic foot. They seemed to just brush it under the table. Was it caused by a clot/embolus that resolved, or a vasospasm, or something else? Park seemed to suggest both a vasospam and clot, but then the patient was started on heparin, an anticlotting agent. (And none of it fits Bernard Soulier)

Methemoglobinemia would be systemic, not just one foot.

Extramedullary hematopoesis is going to cause an enlarged spleen? I guess it’s possible if so much blood is being produced that it’s clogging up the spleen, but that would have been easily visible on a standard and routine blood count.

Starting Graves treatment with potentially nasty antithyroid medication without performing the quick and easy confirmatory tests?

The medical mystery was slightly above average this week, but would a new onset seizure really be admitted to House’s service? That’s hardly an unusual symptom. I give it a C+. The final solution kinda fit, if you ignored symptoms that should have been there, and overlooked some ones that shouldn’t. It earns a C. The medicine was painfully illogical — they’re not looking for zebras, they’re looking for non-existant dinosaurs. I give it a D+. The soap opera was just OK. Once again, Chase is the one who comes closest to getting House, even more than Wilson. I give it a C.