S8E16: Gut Check

This is a preserved copy of "Gut Check", originally published at politedissent.com. Wayback capture: 2012-06-18. Original URL: http://politedissent.com/archives/8885.

Medically, this felt like a return to classic House (with classic errors, of course) — but the mystery and solution were better than most. On the other hand, I did not care for the soap opera storylines this week.

⚠️ Spoiler warning — plot details for this episode follow.

Bobby Hatcher is a 22 year old minor league hockey enforcer who starts coughing up blood (hemoptysis) and collapses on the ice in the middle of the game. He is admitted to House’s service for evaluation. Taub suggests trauma initially, but the ER work-up was negative. Chase and Adams suggests sarcoidosis and psittacosis (patient is a duck hunter), and Taub now suggests dental bleeding or an esophageal tear. House elects to test all the theories — he orders a chest CT, sputum culture, serology, and a stool blood test. The CT is negative for sarcoid but shows splenomegaly (an enlarged spleen). The differential now includes a DVT (blood clot) or leukemia. Once again, House decides to test both diagnoses and orders an ultrasound and a blood count. While drawing the blood, Taub notices that Hatcher has gynecomastia (enlarged breasts in men). With this new information, the differential diagnosis now consists of liver failure, alcoholism, hemochromatosis, leptospirosis, or steroid use. House order antibody titers for the leptospirosis and sends Park and Chase to check out Hatcher’s locker and house for signs of steroid use or alcoholism. The search turns up no evidence of steroids or alcohol, but Park does find that one of Hatcher’s teammates is on Ganciclovir, an antiviral drug, which she takes as a sign he had infectious mononucleosis (i.e. “mono”) — could Hatcher have mono as well?

Returning to check on Hatcher, Taub finds him in the corner, crying, curled in a fetal position. Is this a sign of depression — and is it a symptom or not? Taub suspects it is a sign of traumatic encephalopathy, but the rest of the team demurs. Taub wants a brain MRI, but House just orders a psychiatric evaluation, which is normal. Just when it looks like Hatcher is going to be discharged, he suffers a sudden right ophthalmoplegia (inability to move the right eye). The new differential consists of neurosyphilis and microscopic polyangiitis (an inflammation of small blood vessels). Chase suggests testing for the polyarteritis, but House decides to go ahead and treat with plasmapheresis. As the treatment progresses, Hatcher develops a paralysis of both of his arms. The team now suggests he may have Lyme disease, ALS (amyotrophic lateral sclerosis, i.e. Lou Gherig’s disease), or botulism (from the Botox he had injected to treat a muscle spasm). House decides to start the patient on antitoxin for the botulism, even without a positive test. Despite treatment, Hatcher’s condition worsens and he develops a complete paralysis. House now admits he is now looking for longshot diagnoses (as opposed to their normal common diagnoses, I guess) and the team comes up with polio, MLD (metachromatic leukodystrophy), and prion disease. Despite the risks, House elects to perform a brain biopsy to test for the latter. In a conversation a short time later with House, Taub has his own Eureka! moment this week and realizes that Hatcher has mono after all, complicated with Miller-Fisher syndrome (a rare type of paralysis, seen after viral illnesses). The plasmapheresis did actually improve his symptoms, but the results were delayed.

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

They never tested for mono. As Park explained, it fit almost every symptom, there was a likely history of exposure — but yet was never mentioned again until the very end. They never ran a simple monospot or similar test.

Right after he was found crying in the corner, Adams mentioned that, otherwise, he was responding to treatment. What treatment? All they had done to that point was run tests, no treatment had been rendered.

There were an abundance of tests that were ordered this week, but the results were never given and they were never discussed again (e.g. the ultrasound, serology, sputum culture, stool tests, ultrasound, leptospirosis antibodies). More specifically, the CBC ordered way back in the first 20 minutes should have shown mono.

Ganciclovir is approved for treatment of CMV, not EBV. That being said, there is good evidence it works on EBV and some studies have been run on mono patients. (Still, if I saw someone was on ganciclovir, I wouldn’t immediately conclude it was for mono).

So it’s a bilateral descending paralysis — except that it only affects one eye?

Other than trauma, none of Taub’s initial diagnoses explain hemoptysis. Bleeding from the mouth, yes, but hemoptysis, no.
Stool could be positive for blood with hemoptysis, too, if he had swallowed some of the bloody sputum.

Once again, lack of a good physical exam delayed the patient’s treatment unnecessarily. The gynecomastia should have been found earlier, and dental bleeding could easily have been ruled out.

ANCA is not always positive in microscopic polyangiitis. It’s only 80%.

The team had a much longer differential for splenomegaly last week — yet none of this week’s suggestions were on the list (or any of last week’s causes on this week’s list). A little consistency please (and both were missing one of the most common causes: mono, of course).

The team seems to use plasmapheresis at least a dozen times a season, yet this is the first time they’ve ever mentioned a possible side effect.

It sure is easy to walk right into the OR in Princeton Plainsboro. I’ve never seen ORs so easily accessible — there are usually multiple automatic doors and hallways to maneuver through – partly to prevent people from barging in, just like Taub did.

The medical mystery was was good this week, it seemed like a return to more classic House. I give it an A-. The final solution fit — mostly. I give it a B+. The medicine was way too circuitous, and I can’t believe they never tested for such an obvious answer, and one they themselves admitted was obvious. I give it a C+. The soap opera was painful. The Wilson scenes were either strangely abrupt or a cruel trick, and neither was fun to watch. Chase and Taub’s storylines fared better, but still I can only give the soap opera a C-.