S8E19: The C-Word

This is a preserved copy of "The C-Word", originally published at politedissent.com. Wayback capture: 2013-03-26. Original URL: http://politedissent.com/archives/8964.

As usual, in a soap opera heavy House episode, the medicine suffers — though the writers tries to distract us by adding an unlikable character into the mix.

⚠️ Spoiler warning — plot details for this episode follow.

Emily is a six year girl with a variant form of AT (ataxia telangiectasia, an inherited neurodegenerative disease) who is admitted to House’s team after she develops a nosebleed and breathing difficulties while riding on a merry-go-round. Her mother Elizabeth, a geneticist and expert on AT, also joins the team, whether they like it or not. The initial diagnostic possibilities include a worsening of the AT or head trauma, but her mother rules them both out. Park suggests Wegener’s granulomatosis and Elizabeth agrees that is a possibility, so an MRI is arranged (AT patients have a decreased ability to repair broken DNA strands, so ionizing radiation such as x-rays are avoided whenever possible as they run the risk of damaging DNA). The study shows no signs of Wegener’s, but while undergoing the MRI, Emily develops cold and blue hands and feet. Emily’s circulation is restored and the new differential diagnosis includes primary Raynaud’s disease or Raynaud’s secondary to lupus. Emily’s mother doesn’t like any of these and instead blames heavy metal poisoning from her estranged husband’s new apartment. While she goes to search his apartment, Chase and Adams decide to search hers. They find evidence that Elizabeth has been giving Emily Lex-2, an experimental antibiotic thought to help patients with AT. Unfortunately, the antibiotic has also been tied to renal failure, and now there’s concern that may be what is ailing Emily.

Luckily, an ultrasound of the kidneys is fine, but then Emily develops chest pain and starts to cough up blood. Pneumonia is discussed, as is a pulmonary embolus (a blood clot that blocks part of the lungs(. An MRI of the lungs shows no evidence of any clot. However, Chase notices scleral icterus – yellow eyes – a sign of jaundice and deduces that Emily is now in liver failure. Further studies show she has a blocked hepatic vein (large veins in the liver). Diagnostic possibilities include polycythemia vera (the blood is thickened with too many red blood cells), a connective tissue disease (another name for an autoimmune disease), or advanced Lyme disease. The team decides that the Lyme is the most likely cause — it had been held in check by the experimental antibiotic Elizabeth was giving her, but flared up when the antibiotic was stopped. A lumbar puncture is obtained to confirm the diagnosis, but Emily suffers a stroke after the procedure. The differential diagnosis now includes a fungal infection or a hematological malignancy (cancer of the blood forming cells, like leukemia or lyphoma). Then Chase realizes Emily has an atrial myxoma, a tumor of the heart. Little pieces of this tumor are breaking off and have been causing all her symptoms (Raynauds, obstructed hepatic vein, stroke, pulmonary blockage). Surgery removes the tumor, and Emily is back to normal (her normal, that is).

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

The chest MRI may not have shown a clot, but it should still have shown a blockage, or at least evidence of a recent blockage, especially given the severe symptoms Emily was having.

A normal renal ultrasound does not rule out renal failure. Blood tests and urine tests tell you a lot more about what’s going on in the kidneys.

I can see a shedding right atrial tumor causing blockages in the pulmonary circulation, but how is it going to get all its little clotty pieces into the systemic circulation when they have to travel through the lungs capillary beds first, which act as a filter. An ASD or VSD wouldn’t explain it, because that would cause a left-to-right shunt.

Emily doesn’t seem to be showing many signs of AT – which of course they explained away as “Atypical AT” but she wasn’t showing any signs of the condition at all.

I know it was a pathos thing, but I would be leery of an oncologist with as poor a grasp of statistics as Wilson. Trade a 25% chance of death for a 33% chance of death? Sure! Sign me up!

I like how Wilson’s blood counts miraculously improved overnight. (And how House doesn’t seem to believe in isolation or neutropenic precautions).

Foreman should never have allowed Emily’s mother onto the case. Her objectivity was compromised — demonstrably so with the discovery she was dosing her daughter with Lex-2 — and her alleged expertise added nothing; seriously, she said “no” a lot and never contributed anything constructive.

The medical mystery was fairly interesting, though the AT aspect only contributed slightly to the medical aspect of the show (the “no x-ray” part; the AT did contribute majorly to the pathos aspect of the show). I give it a B+. The final solution was modestly succesful; it explained most of her symptoms — though a murmur probably should have been found on a good physical exam. I give it a C+. The medicine overall was average and earns a C (which still makes it better than most soap opera heavy episodes). The soap opera was good and heartbreaking. Both the Wilson/House aspect and the knows-she’s-dying-before-her-time little girl aspect. I give it an A.