S8E17: We Need the Eggs

This is a preserved copy of "We Need the Eggs", originally published at politedissent.com. Wayback capture: 2012-11-08. Original URL: http://politedissent.com/archives/8911.

After last week’s improvement — medically, at least — House takes a turn for the worse this week.

⚠️ Spoiler warning — plot details for this episode follow.

Henry is a 35 year old who is admitted to House’s service after he is discovered crying blood. The team’s initial thoughts are lymphocytosis (a high white blood cell count — which is more of a symptom than a diagnosis) or a cavernous sinus thrombosis. Further blood work up is done and is normal, and a CT shows no evidence of a sinus thrombosis.

Henry is very guarded about his girlfriend Amy, and Adams suspects he has no girlfriend, but is instead secretly a junkie. A search of his apartment reveals no evidence of drug abuse, but they do find a very lifelike sex doll – “Amy.” When Henry starts running a fever, the team rethinks their diagnoses. Adams thinks there are neurological issues (which, if they exist, seem more psychological than neurological to me), but Chase thinks there are no neurological concerns; Henry is just weird. House suspects a bacterial infection caught from using (and reusing) Amy, but she is clean. The team does notice a strange swelling in her side and obtain a CT, which shows an irregular air-filled area. Chase suspects this may be Clostridium (Clostridium perfringens, a bacteria which causes gas gangrene, and food poisoning), but once again, the test is normal. A short time later, Henry collapses, wheezing. From the description, it sounds like he has pulmonary edema (fluid in the lungs). The team now considers heart failure due to anemia, DIC (disseminated intravascular coagulation), or lung disease caused by inhaling silicone particles. House agrees with the last option and has the patient started on plasmapheresis.

That night, Henry starts hallucinating. On exam, the team notices some right upper quadrant abdominal distention and also deduces he has liver failure. The differential diagnosis now consists of vasculitis (blood vessel inflammation) or hepatic fibrosis (with secondary pulmonary A/V shunts). House starts the patient on steroids.

Henry starts to get worse. He has light sensitivity, vomiting, and a stiff neck. Adams tells him she thinks he has meningitis. The team debates the possible cause of the meningitis. Cancer is discussed but discarded. An amebic cause is brought up and almost discarded until Chase mentions finding a Neti pot in the patient’s apartment. Instead of using the recommended distilled water for the pot, the patient had been using tap water — infected tap water — and given himself an amebic meningitis by pouring infected water up his nose (likely Naegleria, since that is the amoeba recently in the news associated with Neti pots — it’s also been used as a diagnosis before, in the two-parter where Foreman ended up in isolation).

I don’t have much commentary this week, as the medicine was more superficial and slapdash than usual. As always, major complaints are in red (red caduceus), modest complaints are in blue (blue Vicodin), and nit-picking ones in green (green pencils):

How is plasmapheresis going to improved the deposition of inhaled silicone particles in the lungs?

So…why was he crying blood again? Was it from the poor clotting due to the liver failure — which somehow was bad enough to cause bleeding, but not bad enough to be detected until halfway through the episode?

Bleeding from the eyes is not a symptom of cavernous sinus thrombosis. You know what is? A dozen different things Henry didn’t have.

Still, this diagnosis was miles ahead of the diabetes suggestion. Even if the retina are friable, the eye is a sealed system and you’re not going to cry blood. You don’t cry vitreous humor, do you?

No isolation for a patient with meningitis?

So a needle biopsy was out of the question?

The team is so advanced in medicine that they can find any zebra, but don’t recognize a Neti pot? They wouldn’t last one day in a primary care clinic. Neti pots are not some rare only-used-by-alternative-weirdos device. They are sold at Walgreens, for heaven’s sake. I’d say at least a third of my patients use Neti pots or similar nasal rinsing devices.

The medical mystery started out strong, but was all but abandoned by the end. I give it a A- for at least trying something new. The final solution wasn’t great. The symptoms and timecourse didn’t fit. It was also a retread — and the first time was so much better. I give it a D+. The overall medicine lacked any coherent strategy or logic. I give it a C-. The soap opera was unimpressive. House and Dominika had some good scenes, but for everyone else it was “been there, got the t-shirt“. (Seriously, enough with House fixating on everyone’s relationships.) I give it a B-.