S8E7: Dead & Buried

This is a preserved copy of "Dead & Buried", originally published at politedissent.com. Wayback capture: 2012-07-29. Original URL: http://politedissent.com/archives/8224.

A promising episode derailed by a story decision more suited to Grey’s Anatomy or Chicago Hope than House. The B storyline was better.

⚠️ Spoiler warning — plot details for this episode follow.

Two cases this week: the team tackled the case of a moody teenager, while House looked into the death of a four year old boy.

The team takes on the case of Iris, a fourteen year-old girl who was admitted to the hospital with an idiopathic anaphylactic reaction. The first thoughts are hereditary angiodema (a genetic condition leading to swelling of the face and airways), systemic mastocytosis, pheochromocytoma (a tumor that secretes stress hormones, like adrenalin), or an anaphylactoid reaction to opioids. They start out by checking a catecholamine panel (high in cases of pheochromocytoma) and an expanded opioid screen. Taub learns that Iris’s mother has been secretly slipping diazepam (Valium) to her daughter to calm her down, telling her they were vitamin pills. When Iris suddenly begins throwing up, the team starts to rethink their diagnoses. A quick exam reveals some mild abdominal pain and breast tenderness. They run a pregnancy test, even though she insists that she’s never had sex. About this time, she develops numbness in both arms. The pregnancy test comes back positive, explaining away many of the symptoms. To work up the paresthesia (numbness), the team considers the possibilities of a cerebral tumor, vasculitis (inflammation of the blood vessels), multiple sclerosis, or HIV-related mononeuritis mutiplex. The tumor and HIV seem the most likely, so a blood test and MRI are ordered, but both are negative.

In the meantime, Iris’s paresthesia has resolved, but she now has bruises on her upper arm. The team investigates the possibility of clotting disorders such as thromobocytopenia (low platelet count), vitamin K deficiency, or scurvy (severe vitamin C deficiency). The tests for these conditions are negative, but a search of her room at home turns up a hidden stash of love letters and hardcore pornography. When confronted, Iris admits to having a boyfriend and reports that the porn is his. She also explains that he snuck into the hospital and beat her the night before, explaining the bruises. In the middle of the conversation, she develops a sudden attack of tunnel vision, which resolves spontaneously. Chase suggests a TIA (transient ischemic attack — a “mini-stroke”) and an MRA is ordered. House, stopping by, has a moment of inspiration and tells Iris her boyfriend was hit by a car. She angrily tells House that he’s lying because she is the boyfriend. It turns out that she has dissociative identity disorder (multiple personality disorder, to the layperson), and the boyfriend is just one of her personalities. Hypnosis reveals the trauma that split the personalities was the car accident when she was two that killed her father. Snips of memory from that accident (strawberries, an eight ball) caused her initial allergic symptoms — in one personality at least. It seems each personality was exhibiting different symptoms, and that’s why they would come and go so quickly. When she develops severe vaginal bleeding, the team realizes that she still has an unexplained medical ailment. They find that the symptoms that are consistent across all three personalities are the pregnancy, the high blood pressure, and the vaginal bleeding. Bearing this into account, the differential now consists of preeclampsia or an ectopic pregnancy (a pregnancy outside the uterus), but an ultrasound reveals no embryo. She is ultimately diagnosed with choriocarcinoma, a cancer of the placenta (or rarely, very rarely, a choriocarcinoma can be found in other reproductive tissue).

Meanwhile, House is obsessed with discovering the cause of death of a four year-old who died five years before of an unexplained kidney disease. Berger’s disease is suggested initially but when House learns that the lungs were also involved, he considers lupus and Wegener’s granulomatosis, but those avenues of inquiring prove pointless. Next he focuses on heavy metal poisoning, particularly arsenic, lead, and mercury, but his tests are negative. In the end, after a confrontation with the dead boy’s grandfather, mother, and mother’s new-husband — combined with an earlier comment from the boy’s father said — House realize that the boy had been partially deaf and was suffering from Alport syndrome, a genetic condition affecting kidneys and hearing.

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

As far as I was concerned, the episode was going along fairly well, but then lost all momentum and semblance of coherence when the diagnosis of dissociative identity disorder (DID) was introduced. It introduced more questions and generating more handwaving than it solved. For example:
What trauma caused the boyfriend personality?
Nobody noticed Iris’s changes in personality? Not just no one at home (explained away by the Valium), but no one at the hospital noticed a change in personality with a change in symptoms?
Iris’s main personality was aware of the boyfriend much more than she should have been if it were a true case of DID.
DID in young patients is not unheard of, but very rare. But a two year old? You can’t blame the Valium for Mom missing a decade of symptoms unless she started Iris on Valium as a toddler.

Three positive HCG tests and no one ran a quantitive test (tells how much HCG there is. Can be helpful in dating the pregnancy, or discovering if something else, like a choriocarcinoma, is going on), or checked an ultrasound for dating. How far along the pregnancy is is an important topic, especially when considering preeclampsia, ectopic pregnancy, or even morning sickness.

I don’t think pregnancy is a “symptom” of a condition. A positive HCG test may be, but that’s not what they were discussing during the differential. They also forgot to mention all the symptoms they explained away by blaming that same pregnancy (vomiting, abdominal pain, breast tenderness, abnormal periods).

Another House episode this season overcome by real world events, in this case the recent news that the most famous of all multiple personality cases, Sybil, was faked – casting doubt (more doubt, anyway) on many of the more extreme DID cases.

A patient taking diazepam would not have a “clean tox screen,” she would be positive for benzodiazepines.

An expanded opioid screen is not better at telling if a person is on opioids or not, it just shows which opioid they are taking. If the initial tox screen was negative for opioids, then the expanded screen would be too.

It was more of a symmetrical neuritis than a mononeuritis multiplex.

For the second week in a row, Park suggests the most ridiculous diagnosis: scurvy. Really? Easy bleeding, sure, but no other symptoms match.

Like most of this season’s episode, this week’s medical mystery was mildy interesting, but little more. I give it a C+. The final solutions to both medical mysteries fit, at least better than usual. They earn a B+. The A-storyline had sloppy medicine, and that was before they added in the multiple personality aspect. The B-storyline was better, but not enough to save the episode. I give it a D+ (the plus is from the B-storyline). The soap opera wasn’t compelling this week. How many times can we see Foreman stew over where to draw the line with House, and how many times can Wilson ineffectually hem and haw. It was particularly hard to accept the hard ass Foreman this week after we say him sharing a beer with House at an out-of-town boxing match last week. The soap opera earns a C-.