S8E13: Man of the House

This is a preserved copy of "Man of the House", originally published at politedissent.com. Wayback capture: 2013-03-26. Original URL: http://politedissent.com/archives/8671.

A slightly above average episode of House, with a medical mystery and medical diagnoses that are (you guessed it) slightly above average.

⚠️ Spoiler warning — plot details for this episode follow.

Joe is a 38 year-old who makes his living running marriage seminars (and selling videos, books, and tapes) across the country. During one seminar, he suddenly spikes a high fever then collapses. He is admitted to House’s service after an initial emergency department work-up was normal. The initial differential diagnosis consists of cerebral AVM (arteriovenous malformation, i.e. bleeding in the brain), cephalic fibromuscular dysplasia (an arterial abnormality that can lead to a stroke), or a pulmonary embolism (a blood clot in the lungs). A d-dimer is obtained to look for the pulmonary embolism, but the test is negative. Diving into the patient’s history, they learn he used to be a motivation business speaker until he got beaten up in a bar three years ago, then he decided to get married, change his diet (gluten free), and switch from motivation speaking to marriage seminars. House asks if he was kicked in the crotch during his bar fight, and he admits he was, so House diagnosis him with low testosterone due to testicular injury. Lab tests show that Joe does indeed have low testosterone, so he is started on testosterone replacement injections.

Just as he is about to be discharge, Joe and the team realize he is unable to control his bladder, so they decide to go for another look. Chase suggests that Joe has a neurological problem, and multiple sclerosis is suggested. A spinal tap and an MRI are checked, but both are normal. Joe now complains of diplopia — double vision. The MRI already showed there was no tumor, so Graves disease and myasthenia gravis are suggested. House favors the later suggestion and starts Joe on IVIG (intravenous immunoglobulins) and plasmapheresis. Joe starts feeling better after treatment has started, but now he has become jaundiced and his liver is failing. Sarcoidosis is suggested, as is celiac disease (an autoimmune disease of the intestines), and Lyme disease. Myasthenia gravis is still on the table as well. House goes with the diagnosis of Lyme disease and starts the patient on antibiotics. There is no improvement, and some of the team want to press ahead with an intestinal biopsy to look for celiac, but Chase points out Joe’s low platelets and is worried about bleeding. House decides to give the antibiotics more time to work, but Adams goes ahead and performs an intestinal biopsy which shows the signs one would expect with celiac disease.

Looking back over old videos of the patient from when he was a motivational speaker, Taub notices that his voice was lower back then. House realizes that Joe’s hoarsness meant that Joe had silent thyroiditis, which is in itself a sign that Joe has Polyglandular Autoimmune Syndrome type III, and his symptoms are related to different glands being attacked and worn away, explaining away his myasthenia gravis and celiac symptoms. It could also explain away the low testosterone, but so could the injury, and the treatment is the same: calm down the autoimmune disease and replace the missing hormones. In the end, though, Joe decides to do without the testosterone replacement because he didn’t like the guy it made him be — the old Joe.

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

There are three subtypes of PAS3: one associated with diabetes, one associated with pernicious anemia, and one associated with vitilgo and alopecia. Joe fits none of the subtypes.

Silent thyroiditis will frequently resolve spontantously, but the autoimmune thryoiditis associated with PAS3 does not resolve so Joe would have low thyroid levels, which would have showed up on the tests they ran for the Grave’s Disease.

For someone with celiac diasease eating wheat gluten, he sure isn’t complaining of any intestinal symptoms.

What explained the liver failure? Sure, celiac can cause some liver function abnormalities, but it’s a long was from that to jaundice.

What’s causing the lung disease?

What caused the incontinence? Was it supposed to be the myasthenia gravis, because incontinence doesn’t fit that — though the double vision certainly does.

How did House know Joe was hoarse, and not just that he had a higher voice today because of his lack of testosterone. (Hoarseness plus frequent clearing of throat, I would think GERD or chronic allergies).

Plasmapheresis and IVIG are not the first line treatment for myasthenia gravis.

Testosterone injections are given every 2-4 weeks, not ever few days.

I found the medical mystery was rather average this week — a patient collapsed, which only happens 2/3 episodes. The interesting part, the fever, they mentioned then quickly dropped. It earns just an average C. The final solution almost fit, and with just a little more work, it could have. It could also explain the lack of testosterone, though House seems determined for that to be related to the fight (likely so the writes can have Joe make his sacrifice at the end). I give it a B-. The medicine has some bright points and actually followed some (not much, but some) logic this week. That earns it a B. The soap opera was was decent if fairly superficial. Two thoughts do spring to mind: 1) we need more Wilson, and 2) All this for $200 dollars a month? I give the soap opera a B-.