The team in this week’s episode of House followed a more logical approach to the patient, but they were still hampered by bad medicine. But hey, an opossum!
Daryl is a 22 year-old college football player hoping to be spotted by pro scouts. In the middle of practice, he suddenly becomes uncontrollably violent. He grabs his opponent and drags him around by his helmet until it finally comes loose, and then he bashes himself in the face repeatedly with the helmet until he starts bleeding.
He is admitted to the hospital for evaluation, but has no memory of the incident. A head CT scan and a psychiatric evaluation — both obtained in the Emergency Room — were negative. House suspects Daryl’s symptoms are due to steroids, even though he tested clean in the Emergency Room. He believes he is on the “good stuff,” i.e. steroids that don’t show up on tests. The rest of the team suspects a pituitary adenoma (a tumor in the pituitary gland) caused by repeated head trauma. Tests for GnRH (gonadotropin releasing hormone, which controls the gonadotropins, which control the production of testosterone in men) are high, but a pituitary MRI is negative, which lends credence to House’s theory of steroid abuse. He tells the team to start Daryl on a somatostatin-analog (a medication which inhibits the pituitary gland) to block the effects of the elevated GnRH.
Daryl denies any use of steroids and begins to suffer a racing heart rate and chest pain. He has an episode of paroxysmal tachycardia (sudden onset of an abnormally fast heart rate) that requires cardioversion to return it to a normal rhythm (by definition “cardioversion” means returning the patient to a normal heart rhythm. This can be done chemically, such as with adenosine, or electrically). Taub reports that the cardiac symptoms do not fit the diagnosis of steroid abuse, so the team gives Daryl’s heart a further work-up including EKG and sestamibi scan (a test that looks at perfusion of the heart itself), but they are completely normal. The differential diagnosis now consists of a PFO (patent foramen ovale, a hole between the two sides of the heart) or hypertrophic cardiomyopathy (muscular thickening of the heart). House favors the latter and has the team put Daryl on a treadmill to stress him until he develops cardiac symptoms. Unfortunately (or fortunately, really), Daryl is in good enough shape that his heart rate never rises high enough to cause a problem. Going for “plan B”, House decides to chemically induce heart stress by injecting Daryl with a vasodilator (such as adenosine or dipyridamole — they mimic the effects of exercise on the heart). Before he injects the medication, however, he notices that the palms of Daryl’s hands are unusually white.
This new symptom causes the team to reassess their diagnosis. Taub thinks Daryl’s pale hands are due to Raynaud’s phenomenom (spasm of the smooth muscles around the small arteries of the fingers), which he thinks is caused by rheumatoid arthritis. Thirteen suspects that Daryl has plaques in his arteries, and these are breaking off and sending tiny clots blocking the arteries in his hands. Chase believes Daryl has Takayasu arteritis (inflammation of the aorta and other large arteries), and Foreman, ever the optimist, blames lymphoma. House likes the last two ideas the best, and tells Foreman to put Daryl on an ethanol drip. If he develops itchiness, it’s a sign of lymphoma, and if he loses his radial pulses, it’s a sign of Takayasu. Daryl develops itchiness while on the drip, so Foreman’s suspicion of lymphoma appears to be correct. Daryl is taken to surgery for a splenectomy, but during surgery Chase notices that his spleen is fine but his liver is inflamed.
Biopsies reveal no lymphoma and a non-specific liver inflammation. The new differential diagnosis includes polymyositis (a chronic inflammation of the muscles), Felty syndrome (rheumatoid arthritis + splenomegaly, which doesn’t fit at all), and viral hepatitis. Blood is drawn for further testing, but Foreman reports that the blood clotted almost immediately after being drawn. This suggests that Daryl has cryoglobulinemia (abnormal proteins in the blood that thicken with cold temperatures), brought on by football practice on cold days, and needs to be started on anticoagulants (blood thinners). This isn’t good enough for Daryl; he doesn’t want to miss his shot at the pros, so he leaves the hospital, promising to come back the next day. At the exhortation of Daryl’s mother, Foreman tags along to look after him — it was a good thing he did, too, as Daryl starts to experience shortness of breath and blurry vision. He is admitted back to the hospital. As the team begins to evaluate the new symptoms, Foreman admits that their really aren’t any new symptoms. He had dosed Daryl with nitrates (a class of blood pressure medication) to drop his blood pressure so he’d feel bad enough to want to come back to the hospital.
Looking over the chart, House notices that Daryl has only lost one pound during his stay in the hospital and he should have lost more. This lack-of-weight-loss could be due to steroid abuse, or paraneoplastic syndrome — only there’s been no evidence of cancer. The team performs blood test after blood test, and scan after scan, but can find no cancer. House then realizes that the cancer they are looking for is not inside the body, but outside. It turns out that Daryl has melanoma, a skin cancer hard to spot on African-Americans, and this cancer (or course) is causing paraneoplastic syndrome, which explains his symptoms.
(Here’s my take on what’s going on: you may have noticed during the episode that the team gave two different definitions of paraneoplastic syndrome. First, they described a situation where a cancer produces a hormone which can cause systemic effects: in this case, the melanoma is apparently producing GnRH which increased Daryl’s testosterone and gave the appearance and symptoms of steroid abuse including “roid rage,” weight gain, and probably the heart symptoms. Second, House describes paraneoplastic syndrome as a situation where the body is making antibodies against the cancer, and this produces the systemic effects. This would explain the kidney failure and liver inflammation. The apparent cryoglobulinemia may be an effect of the extra paraneoplastic antibodies, or cryoglobulinemia can occur with certain cancers. Both definitions of paraneoplastic syndrome are correct, but I’m not certain if a patient would ever experience both situations.)
I admit that I’m somewhat confused by House’s take on steroids. If Daryl was taking steroids, his GnRH should be suppressed — lower — not higher. Or is House suggesting that Daryl was receiving GnRH itself, or a synthetic substitute — and if that’s the case, the body generally downregulates GnRH receptors when GnRH levels are unusually high, actually leading to hypogonadism and less testosterone.
As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:
The clotting in cryoglobulinemia resolves at normal temperatures, so why would Daryl be clotting in the presumably warm hospital room. Did Princeton-Plainsboro not pay the electric bill?
Why didn’t he show abnormal clotting during surgery as most operating rooms are kept PDC (pretty damn cold).
Surely they drew blood before surgery, at least a blood type/transfusion panel, and should have notoiced the clotting then.
Blood thinners are not the recommended treatment for cryoglobulinemia.
Giving a patient enough of a nitrate to intentionally cause hypotension (low blood pressure) is dangerous. How did Foreman know he didn’t give too much? I’d also expect Daryl to develop a severe headache — the most common nitrate side effect – before any other symptoms.
I guess he learned it from House, who was trying to induce a cardiac event in a patient without even having him hooked up to any cardiac monitors.
Stress tests aren’t used to test for hypertophic cardiomyopathy, at least not as a first-, second-, or even third-line test. An EKG has already been obtained. A structural test, such as an echocardiogram or MRI is the next logical step. If needed, cardiac catheterization may also be performed.
Sorry Taub, steroid abuse can cause heart problems, including tachycardia.
Is there really a link between repeated trauma and pituitary adenoma, a type of cancer? I haven’t been able to find one, but then again, I’m not a neurologist or sports medicine specialist.
GnRH is released into the pituitary, not from it, so why would a pituitary cancer lead to “leaking” GnRH?
There is a condition known as the “lymphoma itch” that is a severe itching, primarily of the lower extremities. It is most commonly seen in Hodgkin’s lymphoma, but even then it only occurs in 10-25% of patients.
It is not associated with alcohol. A separate condition (severe aches and pains) can be worsened by alcohol intake in certain patients with lymphoma.
I don’t know it alcohol will really shut off blood flow in the radial arteries in patients with Takayasu’s arteritis, but who in the hell would thank that is a good idea. Personally, I like my hands to have full blood flow, thank you.
Return to full contact football a day after abdominal surgery, even a laparoscopic one? Nonsense.
Blood in the urine is really not a sign of kidney failure. It suggests that there is a problem with something farther along in the urinary system. This is especially true in patients on blood thinners, were urinary bleeding is more common – maybe from inserting the catheter in the first place.
Why would a melanoma secrete GnRH?
It is certainly possible to have rheumatoid disease with a negative rheumatoid factor.
Wasn’t Chase the one who shot down Taub’s suggestion of rheumatoid arthritis? So why would he later suggest Felty’s, which requires rheumatoid arthritis?
Paraneoplastic syndrome has become the lupus of this season.
I found the medical mystery interesting this week. Not great, but better than recent episodes. I give it a B+. The final solution clever (hidden melanoma in a black male), but too much of “Been there, got the T-Shirt” feeling (paraneoplastic, again, and a nearly impossible one at that). I give the solution a C-. Overall, the medicine was more driven this week, and followed a logical progression, but too much of it was questionable or downright wrong. Another C-. The soap opera was decent. I liked the Foreman and Foreman scenes, and the Wilson/House scenes were good, but I figures Lucas was the culprit fairly early on as Mark Michael Weston was listed as a guest star, but nowhere to be seen. I give the soap opera a B.
The House Challenge scores have been posted here.
The review of the previous episode of House
A list of all prior House reviews
Jirel is the ruler of a small medieval kingdom and her lands always seem to be under threat from natural, and supernatural, enemies. Her stories tend towards the darker aspect of fantasy.
This week’s Fringe cipher was: REVEAL.
Volume Four of Apothecarius Argentum moves the action from Beazol to the neighboring kingdom of Navara, a poor and starving country with a widespread wasting disease brought on by overuse of a toxic pesticide. Princess Primula and her companions, including friend/love-interest/Royal apothecary Argent and his rival, Lorca, third Prince of Navara. 
Belladonna is a plant that has a long history of use in traditional medicine and continues to be used, to some extent, in modern medicine as well. The plant is very potent and must be used sparingly because of the high potential of adverse events, especially death. This is especially true for children (especially sickly malnourished ones like the prince). Let me put it this way: the more common name for belladonna is 
The 
Subscribe to Polite Dissent
