S8E21: Holding On

This is a preserved copy of "Holding On", originally published at politedissent.com. Wayback capture: 2012-08-17. Original URL: http://politedissent.com/archives/8987.

While the soap opera aspect of this penultimate episode of House was outstanding, the actual medicine left much to be desired

⚠️ Spoiler warning — plot details for this episode follow.

Derrick is a 19 year-old cheerleader who was admitted after suffering from dizziness and a massive nosebleed (and dropping his partner). A head CT was normal. Taub suggests a “mini-stroke” (though you’d think a doctor would use the correct term TIA, especially when talking to other physicians), but House tells them it is a midline granuloma and has them check a PET scan. The scan is negative for any cancer, but it does show activity in the auditory area, suggesting that Derrick is hearing to something, though no sounds are present. He denies hearing voices, but the team suspects otherwise. They suggest schizophrenia or drug use. His dorm room is searched, and though his roommate is an active participant in the drug culture, he insists Derrick is clean. A thorough exam of the room finds a picture of a young boy hidden in the back of a drawer. Confronted with this evidence, Derrick explains that the picture is of his long dead brother, and reluctantly admits to hearing his voice for the past ten years.

The differential diagnosis now consists of viral encephalitis (though, as pointed out on the show, an infection of the brain wouldn’t persist for ten years) or temporal lobe epilepsy. The team runs tests on Derrick trying to trigger a seizure, but nothing happens — except that he suffers a sudden blindness in his right eye which Adams diagnoses as a “clot in the artery behind the eye” (i.e. a retinal artery occlusion, and massage is one of the treatments supported by anecdotal evidence) and rubs out of existence. The team debates how many of Derrick’s symptoms are physical, and how many are psychological. Park is a firm believer that years of purposefully avoiding grief over the death of his brother has left Derrick with an anxiety disorder that appears as physical symptoms (though this wouldn’t explain the clot). Taub is more prosaic and believes in a physical cause. He suggests polycythemia vera (blood that is thicker than normal), Hodgkin’s lymphoma, or DIC (disseminated intravascular occlusion) due to some trauma suffered in cheerleading (I can believe this: I see more injuries due to cheerleading than any other high school activity. Basketball is second, and football a distant third.). A spinal tap is obtained. It shows no evidence of bleeding (and therefore, no trauma), but an abnormally high opening pressure (reflecting the intracranial pressure) tells them something else is going on. The suspect a “extreme” migraine as the cause. An MRI is obtained, but shows no evidence of migraine – and then the ceiling collapses due to a prank House pulled on Foreman. Before the collapse, Park noticed that he misidentified her as Adams, and that is enough for House to deduce that Derrick has a persistent stapedial artery. This is a small artery in the fetus that should fade away before birth, but sometimes it remains. In Derrick’s case, this artery has been pressing against his temporal lobe causing dizziness and hallucinations. After surgery to remove the artery, his symptoms should resolve.

Neither House nor Wilson is doing well now that they’ve learned that the chemotherapy didn’t work and the tumor remains. Wilson decides to go without any more chemo, figuring he has five months left to live. House refuses to accept this. He wants Wilson to take the chemotherapy and extend his life another couple of years. He tries a number of tricks on Wilson to get him to agree: he doses him with Propofol (a potent IV general anesthetic – what killed Michael Jackson) to mimic death, he fills a room with former patients, he has a quiet nostalgic dinner with him – but nothing he does convinces Wilson to try chemotherapy. Instead, it drives a wedge between them.

Foreman buys House season tickets to the New Jersey Devils, with seats next to his, in a bid to help House get over Wilson, but House decides to stuff the tickets down the hospital bathroom drain. This leads to a massive water overflow, ultimately collapsing the ceiling over the MRI and requiring the city emergency crew to be brought it (apparently, there is no way to shut the water off at Princeton Plainsboro).

In the end, Wilson decides to go through with the chemo for House’s sake, but House tells him not to, and they’ll just enjoy the time left. They are making plans for the next few months, when the Foreman and the hospital lawyer walk in (but why is the hospital lawyer acting as an accusing officer hear? He should be protecting his doctors, not acting like a DA), telling House his plumbing stunt was severe enough to draw police attention and his parole is being revoked and he must server the remainder – six months – of his sentence.

As usual, with a soap opera heavy show (not that I’m necessarily complaining, just noting), the patient and medicine are given short shrift. Major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

The main issue with this week’s diagnosis is what I call the “have your cake and eat it too” problem — commonly seen on House — but not usually this blatantly. In this case, Derrick has a persistent stapedial artery significant enough to cause a rise in intracranial pressure (leading to clots and bloody noses) and large enough to press against the temporal lobe causing hallucinations – yet, this large artery is not seen on CT or MRI, and the patient has none of the common symptoms such as hearing loss or tinnitus (ringing in the ears). The writers want to have it both ways — bad enough to cause extreme symptoms, but yet small enough to be missed by every exam until the last minute.

TA midline granuloma would have been seen on CT.

I see little evidence (really noevidence) in the literature of a migraine, even an extreme migraine, causing an elevated intracranial pressure. Now, an elevated ICP can cause a headache, sometimes even a migraine, but that’s the opposite of what’s suggested here.

I notice they make no effort to actually lower the elevated ICP – other than the initial spinal tap.

How did misidentifying Park as Adams lead House to the final diagnosis?

Here’s one I have no answer to, and so I’m not really calling it an error; I’m just wondering. Would an auditory hallucination light up the same areas of the brain as actually hearing something would, or would it light up different areas?

The medical mystery would be boring for any medical show, but was particularly pedestrian for House. It earns a meager D. The final solution made a little sense, but not much when you consider the so big to cause major symptoms, yet too small to be noticed paradox. I give it another D. The medicine overall was just OK. Not horrible, but not particularly brilliant. I give it a C. Once again, the soap opera was quite good. Both Laurie and Leonard deserve kudos for their scenes. I give it an A.