S8E4: Risky Business

This is a preserved copy of "Risky Business", originally published at politedissent.com. Wayback capture: 2012-07-22. Original URL: http://politedissent.com/archives/8146.

House acted like a real bastard in tonight’s episode. If you like that, then you’ll probably enjoy it. If you enjoy coherent medicine or decent mysteries, then you’d better just skip it

⚠️ Spoiler warning — plot details for this episode follow.

Local businessman Thad Barton is cleaning up his yard when he suddenly develops micropsia (a condition where everything appears small or far away). He is admitted to House’s service. The initial differential diagnosis includes JBE (Japanese B encephalitis, a vaccine-preventable disease), central serous retinopathy, atropine poisoning, or thyrotoxicosis (high levels of thyroid hormones in the blood causing hyperthyroid symptoms). House decides the latter is the most likely, and is just about to start the patient on PTU (propylthiouracil, a drug used to treat hyperthyroidism) when Barton reports he is no longer seeing things appear small, but now things are appearing larger than they should. To House, this suggests that Barton has Alice in Wonderland Syndrome, which House explains as a type of atypical migraine.

A short time later, Barton develops severe respiratory distress and hemoptysis. Angiography reveals a hemorrhagic site in his left lower lobe. The differential diagnosis now consists of hyperviscosity syndrome (blood that is thicker than normal), Factor V Leiden deficiency (a genetic condition that causes blood to clot more easily), or myelodysplasia. House tells the team to give Barton activated protein C. According to the team, it will cause a life threatening reaction if he has either Leiden or myelodysplasia (but a different life threatening reaction in each case); House realizes this and wants to give it so they can figure out which diagnosis Barton has. However, instead of the expected life threatening complications, he develops a brief episode of itching. Adams now proposes that Barton has cancer caused by HTLV-1 infection, which his late wife also had and it caused her lymphoma. House agrees with her theory and starts the patient on radiation therapy. Unfortunately, during his first radiation treatment, he develops chest tightness and a rising heart rate. Adams thinks he’s having a heart attack, but the troponin (a blood test for heart attacks) and EKG are equivocal (meaning “maybe yes, maybe no”). House wants an echocardiogram on the patient (to look for areas of abnormal heart wall motion, a sign of a past heart attack), but the patient’s heart is beating too rapidly for the test. Adams is able to get a cardiac catheterization which is normal. The team next proceeds to look at an EP study (electrophysiology study, a test of the electrical “wiring” of the heart), but Barton’s blood oxygenation suddenly drops in the middle of the test for no reason.

House consults a neurologist who suggests the patient has normal pressure hydrocephalus. Park disagrees and thinks the symptoms suggest autonomic dysregulation. She wants to do a tilt table test to prove her diagnosis, but the other neurologist tells her that the patient will slip into a coma if he has normal pressure hydrocephalus. Park proceeds with the test anyway, and Barton falls into a coma. House considers this a fluke and never thought the patient had normal pressure hydrocephalus. He now wonders if the patient might have hepatic encephalopathy, but a liver biopsy is normal. His team suggests Eastern equine encephalitis or loa loa disease, but a glance at an orthopedic x-ray gives House his Eureka! moment of the week. He diagnoses the patient with hyperviscosity syndrome caused by the increased number of antibodies in his blood because of his rheumatoid arthritis. A quick plasmapheresis treatment and the patient miraculously wakes up.

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

Another episode where the team goes straight to treating cancer with radiation therapy, without ever confirming the patient has cancer, let alone what type of cancer it is. The situation is even worse in this episode as no HTLV-1 related condition is treated with radiotherapy.

Similarly, House plans on treating the patient with PTU, despite having no proof the patient actually is hyperthyroid – an easy test to check. PTU is not a benign drug.

So, the patients tachycardia makes getting an echocardiogram impossible (reasonable, if the heart is beating too fast, then it’s damn near impossible to get a good reading on the echo), but yet they are still able to perform a cardiac catheterization, where the same issue would apply – even more so because it is an invasive test with definitive risks, unlike echocardiography.
Apparently no one thought to give a medicine to correct the tachycardia.

Lots of handwaving* with this episode:
What caused the oxygen desaturization? (frantic handwaving – thick blood!)
What caused the heart attack> (more handwaving – thick blood!)
What caused the coma? What did it have to do with the tilt table. And why did it miraculously correct with plasmapheresis?
*My term for when the writers try to distract you so you never notice the patient’s symptoms don’t match the diagnosis.

A migraine is just one possible cause of Alice in Wonderland syndrome; there are others.

House is right to belittle Andrews suggestion of normal pressure hydrocephalus – it doesn’t fit the case at all. But then again, Park’s suggestion is no better.

Ironically, between the time this episode was filmed and broadcast, Xigris (Activated Protein C) has been withdrawn from the market.

This week’s medical mystery was modestly interesting, at least compared to last episode. I give it a B. The final solution fit, but was blindingly obvious — at least it would have been, had the writers been playing fair. Holding out the fact that the patient had rheumatoid arthritis — much different than your standard degenerative arthritis — was clearly intentional. The fact that they had to hide this fact that should have been provided from the very beginning shows that they knew how weak the mystery was. I give it a B for realism, but knock it down to a D for cheating. The medicine this week bad. Missing repeated clots and bleeds. Dropping inconvenient symptoms. Radiating the patient. I give it a D+. Without more Wilson, the soap opera never rose above average: C.