S8E20: Post Mortem

This is a preserved copy of "Post Mortem", originally published at politedissent.com. Wayback capture: 2013-02-12. Original URL: http://politedissent.com/archives/8970.

Another episode with the team being mostly on their own while House and Wilson do their own thing. Not a bad episode, overall.

⚠️ Spoiler warning — plot details for this episode follow.

Dr. Treiber is the hospital’s outspoken pathologist. In the middle of an autopsy, he suddenly decides to cut his own scalp open with a scalpel and complains of being cold. He is admitted to House’s service — but House quickly runs off on a buddy trip with Wilson, so the team is left to solve the case on their own. Before he leaves, House suggests Treiber may be suffering from the Cotard delusion (a mental disorder where people believe they are dead — therefore House thinks Treiber was trying to perform an autopsy on himself), but the history doesn’t fit well. Other suggestions include liver failure due to hepatitis C, toxin exposure in the morgue (in particular, dimethyl sulfate), or blood clots. An ultrasound is obtained but shows no clots, and an examination of the lab turns up no toxins, but does reveal that Dr. Treiber is a big fan of energy drinks, the team now suspects he is suffering from stimulant psychosis, due to all the caffeine he consumes.

Treiber soon develops abdominal pain and distention, meaning that something else besides stimulant psychosis is going on. Adams still suspects the caffeine is behind most of his symptoms, except the abdominal ones, which she believes are caused by a bowel obstruction. Other thoughts are diabetes or ulcerative colitis (a type of inflammatory bowel disease). Chase finally suspects an intussusception (a collapsing of the bowel in on itself) due to cancer. They obtain an x-ray which is normal, but Treiber wants Chase to go ahead and check the small bowel surgically for the intussusception. Chase agrees to perform the surgery, but no abnormalities are found.

The team now decides that Treiber must have intermittent porphyria (an inherited metabolic disorder) and starts him on hemin (a treatment for acute intermittent porphyria). Despite the treatment, Treiber continues to decline and develops bilateral pleural effusions (fluid build up around the lungs). At this point, Treiber finally learns that House is nowhere to be found, and Foreman is brought on to the case. He immediately suspects a cardiac cause (not unreasonable, given the pleural effusions) and obtains a cardiac MRI which shows an enlarged left ventricle. Foreman takes this to mean that Treiber has an infiltrative disease of the heart (an accumulation of some substance in the heart muscle that is not supposed to be there), probably sarcoidosis, and wants a heart biopsy. Chase suspects a prion disease (a neurological disease spread by infected proteins) and wants a brain biopsy; he also wants to start him on amphotericin to treat the suspected prion disease. Unfortunately, only one biopsy can be performed and Foreman elects to go with the heart biopsy. Chase heads down to the morgue to find the source of his suspected prion disease The cardiac biopsy shows fibrosis, not infiltration, meaning Foreman was wrong about sarcoid, but Chase was also wrong about a prion cause (because no prion disease causes fibrosis in the heart). Foreman now suspects a viral infection (like a viral cardiomyopathy) and obtains cultures and starts antivirals, but Chase remains in the morgue, convinced the answer is down there. Overnight, Treiber falls into a coma, making Foreman and the rest of the team rethink their diagnosis. They come to the morgue to talk to Chase who has reluctantly decided that Treiber is too fastidious to have caught a disease in the morgue – but then he realizes it is that fastidiousness – or more specifically, the antibacterial soap he repeatedly uses – that is the source of the problem. The repeated exposure to Triclosan (an antibacterial in soap), plus a high dose of caffeine from the energy drinks, caused Treiber’s thyroid to shut down and Treiber ended up in a myxedema coma (a severe form of hypothyroidism).

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

While triclosan has been implicated in thyroid problems in bullfrogs and mice, human studies haven’t shown this effect (admittedly it was a limited study looking at triclosan in toothpaste).
Similarly, there haven’t been any studies linking high caffeine intake and hypothyroidism in humans (there is a study showing caffeine can interfere with absorption of thyroid medication, but that’s a different situation).

No one thought to check thyroid studies for an unexplained coma?

Studies have suggested that amphotericin may play a role in treating certain prion dieases, but it’s never been tested in humans.

They can’t perform both biopsies because of the amphotericin Chase wants to use because it might theoretically limit the possible prion disease the patient might have. Problem easily solved. Hold the ampho (it’s never been tested in humans for this anyway) then you can perform both biopsies.

That was simply a horrible code, but then, I think it was supposed to be one because it was supposed to be a bad doctor. Just for starters: only two people involved (not counting the patient), and one is just idly looking at IV bags. Shocking a flatline. No airway.

A small amount DMSO applied to the knees got converted to a toxic amount of dimethyl sulfate via several brief shocks to the chest?

Did no one think to ask Treiber why he was cutting his own scalp? The answer would likely have been revealing.
Despite the hypothyroidism/myxedema coma worsening, his mental status was fine in his hospital stay, despite it being his presenting complaint.

Here’s what I could get off of Chase’s whiteboard (or whiteboards) — hopefully someone got a better screenshot. In no particular order: Neimann-Pick disease, Japanese encephalitis, Creutzfeldt-Jakob disease, Q fever, impetigo (really?), typhoid, schistosomiasis, leptospirosis, gastroenteritis, neurofibromatosis, fatal familial insomnia, Tay-Sachs disease, cronobacter, syphilis, kuru, lyme, aortic aneurysm, shigelloisis, malaria, HIV, Klinefelter syndrome, yellow fever, cryptosporidiosis, dengue, German-Straussler-Scheinker syndrome, hypoglycemia.

The medical mystery was interesting, if less so once the patient was admitted. I give it a B+. The final solution made a modest amount of sense, if you accept the fact that the condition has never been seen in humans — that’s a few point off, in my book. I give it a C-. The medicine overall was thorough — on Chase’s end, at least — but missed some obvious possibilities, with myxedema coma topping that list, and easily testable. I give it a weak B. I thought the soap opera was good. The House/Wilson last fling was somewhat cliché, but Chase’s dilemma was well done. I give it an A-.