House – Episode 20 (Season 2): “Euphoria (part one)”
The first part of a two-episode storyline in House. This one features a strangely giddy cop, and an infected Foreman (so far no sex, but let’s wait and see). There are plenty of spoilers below, so beware!
Joe Luria, a police officer, chases a suspect through an abandoned warehouse and into an alley. Joe has a dry cough, but doesn’t seem particularly short of breath. After he finds the suspect hiding in a trash bin, he starts laughing uncontrollably. He makes bizarre jokes and even continues laughing after he has been shot in the head.
At the hospital, it is noted that Joe has patchy infiltrates on his chest x-ray. A drug screen is negative, and it is decided that the bullet fragments are in the wrong part of his brain to cause his symptoms (and he had the symptoms before he was shot). Chase suspects Joe may have carbon monoxide poisoning and a blood gas test does show elevated levels of carbon monoxide.
Meanwhile, as Joe is being placed in a hyperbaric chamber to treat his carbon monoxide poisoning, Foreman is searching Joe’s apartment, which is a pig sty. He collects several samples and discovers that Joe is growing marijuana in a shed on the patio. Back at the hospital, Joe has developed involuntary muscle contractions of the hand.
After a visit to the police station, House determines that Joe is suffering from Legionnaire’s disease (from a dirty air conditioning unit), and this explains his cough and chest x-ray findings. Whether or not it is supposed to explain his carbon monoxide poisoning is never revealed, as that subject is dropped and never mentioned again.
The team discovers that Joe has “Anton’s Syndrome” — a type of blindness where the eyes are working, but the brain is processing the information wrong. It is caused by damage to the occipital lobe of the brain, and could be related to gunshot trauma, though House suspects a stroke. He wants an MRI, but Foreman reminds him that the bullet fragments are magnetic and are not safe in an MRI. House places Joe on the blood thinner Heparin for treatment of the suspected stroke. An angiogram (where dye is injected into the arteries of brain and then x-rayed) is obtained and it does suggests some clotting around the Circle of Willis (a group of arteries which supply blood to the brain).
Down in the morgue, House shoots a corpse at close range with a bullet similar to the one in Joe. When they MRI the corpse, sure enough, the metallic fragments are drawn out of the head and wreck the MRI machine. Luckily the hospital still has their portable MRI machine.
Events start happening at a rapid pace now. An echocardiogram of Joe’s heart is obtained to look for sources of stroke, but is normal. During the test, Joe develops a sudden tachycardia (a rapid heart rate) and is discovered to have bleeding in the brain. A hole is drilled into his skull (trepanation) to relieve the pressure. Meanwhile, Foreman has become giddy and starts laughing uncontrollably. Both he and Joe are placed in isolation. An MRI of Foreman’s brain shows a lesion in the cingulate cortex (an area in the center of the brain). The differential diagnosis now includes West Nile Virus (a disease spread by mosquito bite), Eastern Equine Encephalitis (another viral disease carried by mosquits), and toxins. The MRI also shows some inflammation around the ventricles which Foreman interprets to mean that he has a Staph infection (an infection from a bacteria of the Staphylococci family). He wants an Ommaya reservoir to feed the antibiotic linezolid (also known as Zyvox — a potent and somewhat controversial antibiotic) directly to the brain.
The tests for West Nile, Eastern Equine, and various toxins all come back negative. Foreman tests himself and notes that he has a negative Kernig’s sign, but a somewhat positive Brudzinski sign (Both are classic tests for acute meningitis). In the same room, Joe is having increased contractions of the hands and forearms. House wants a biopsy of Foreman’’s brain, but Foreman wants his Ommaya reservoir and antibiotics. He shows House the thermometer to prove that he is running a fever. In the operating room, House pretends to place an Ommaya, but takes a biopsy instead.
Up in isolation, Joe develops full blindness and starts complaining of intractable pain that is not helped by the morphine (House refers to this as hyperalgesia).
Foreman’s biopsy shows only non-specific signs of inflammation (in other words, the biopsy shows something is going on, but gives no clue as to what that something is) and the Staph tests are all negative. The differential diagnosis is wide open: any bacteria, fungus or toxin that might cause brain damage.
Foreman stabs Cameron with a needle while she is drawing his blood so that she is exposed too and will have to go back to the Joe’s apartment for more samples. Thoughts at this time include listeriosis, SSPE (Subacture Sclerosing Panencephalitis, a rare late complication of measles infection. Despite what the Chase implies, it has never been reliably shown to be related to vaccination), Aureobacidium fungus (one of the alleged “toxic molds”), toxocara (a parasitic worm common in cats and dogs), trichinella (another parasitic worm, this one from undercooked pork), ergot (a nasty mold that grows on rye wheat, and Cryptococcus neoformans (an infectious fungus). The last seems the most likely and both Joe and Foreman are started on Amphotericin B and Flucytosine (both very strong anti-fungal drugs).
Foreman seems to improve initially, with a lowered fever and a drop in white count. But then Joe develops ventricular tachycardia then ventricular fibrillation, then asystole. Foreman tries to revive him, but can’t, and Joe is pronounced dead. At the same time, Cameron reports that there is no evidence of Crytpococcus in the samples so they’re back to square one. (End episode. Cue “To Be Continued” sign).
So far, it’s an involving mystery. It appears to be an infection of some sort, but I wouldn’t be surprised if many of the symptoms ended up being red herrings. House’s reactions are interesting as well; Wilson points out that for once is acting “cautious” and “common.”
The bad?
- I’m surprised Cameron was caught off guard when House wanted to get an echocardiogram of the heart. That’s standard procedure in a stroke situation, as well as obtaining a Doppler of the carotid arteries.
- The idea of checking a sedimentation rate to look for signs of exposure/infection in the rest of the team is ridiculous — it’s an incredibly nonspecific test and will be elevated with any sort of inflammation anywhere in the body.
- Why did Foreman inject the morphine directly into Joe’s carotid artery? He had a perfectly good IV, so why waste the time and risk the complications in a carotid stick.
- Finally, that code at the end was pitiful. Cameron announces that Joe has “multiple system failure” — with little, if any evidence — and the code is called after barely a minute. That’s ridiculous and embarrassing for all involved.
The ethics shown by Foreman and House in this episode were appalling — more than usual. Shooting a corpse in the head was shocking, but served no real purpose (to prove what would have been easier to test by just placing a bullet fragment in a sealed box in the MRI — it worked for Mythbusters.) Performing a brain biopsy without patient consent? There are simply too many risks involved. Stabbing a colleague, even one as Pollyanna as Cameron, was a little too Machiavellian for Foreman. Sure, he may not have been thinking clearly, but that’s still felonious assault.
No grades yet for the episode, not until I get to see the conclusion tomorrow night.
Still want more great medical reading? This week’s Grand Rounds are being held right here at Polite Dissent! Of course, I think it’s an especially good Grand Rounds this week. Make sure you take a look.
May 3rd, 2006 at 2:15 am
I have always been interested in medicine, although sadly I am not an actual med student. Although I am interested if you have any educated guesses on what this infection can be. Besides being airborne (due to the patchy infiltrates in the lungs) and an infection that attacks the brain, there isn’t much else to think, except that the cause of the infection originated in Joe’s apartment.
Tomorrow’s episode seems more of a “find the needle in the haystack” before Foreman dies scenario. Although his interactions between his father should make for good drama.
May 3rd, 2006 at 6:58 am
Hey Scott, great review. PS: Foreman is already a felon, right? What’s one more? ;-)
I have to be an annoying, picky nerd about this episode because one thing bugged me. Working in ballistics I can tell you bullets will not fragment from hitting kevlar, in fact penetration even with kevlar from a .38 special (even an HP round) is an almost certainty at that range. The bullet would not fragment on impact, hollow points don’t just “fragment,” they mushroom and then fragment, sending pieces all over, hopefully landing in the bloodstream at some point.
Second, civilian ammunition nowadays have a lead core with a copper jacketing. I haven’t seen another material used…well, period. (Rounds aren’t always jacketed, though). ANY bullet will have a ferrous base, not just a “.38 HP” (that’s nothing special). The only rounds that aren’t lead based are Armor Piercing (again, not for civvies), tracers, incediaries, NTs, stunners, and frangibles. Nothing you’d see on the street, or in a civilian’s hand.
Third and finally, even at half grain the bullet House so nonchalantly popped into the dead man’s skull would leave the back of his head looking quite like undercooked chili. Plus the bullet would have full penetration at that range ANNNDDD…it wouldn’t fragment like that at all. It would mushroom and probably be out of the skull by then.
HOWEVER, I realize it’s just a TV show and for entertainment and I further realize I’m taking it WAY too seriously. I get it. I’m sorry for the long rant and you can ban me now, it’s just that I was disappointed to see poor factual accuracy when it came to the ballistics part. I was really looking forward to the day when I’d actually be able to CONTRIBUTE to discussing a House episode and actually know what I was talking about. ;-)
May 3rd, 2006 at 10:30 am
i have no idea why psittacosis was not even considered in the DDX. i think they should have been tested for that.
May 3rd, 2006 at 10:48 am
Official Comment
Vincent,
Thanks for the comment. I figured shooting a pistol like that would do more damage than they showed. Glad you could provide the information.
Doc Vincenzo,
I agree. Whenever I see birds, especially when they make a big issue about the pigeons, I think the same thing. That would explain the atypical pneumonia the cop had as well.
May 3rd, 2006 at 11:28 am
In regards to Vincent’s comment “civilian ammunition nowadays have a lead core with a copper jacketing. I haven’t seen another material used…well, period.”, well I can say that while American made ammo is almost always non-ferromagnetic (being just a copper plated lead projectile with no ferrous base), a good deal of inexpensive imported ammo (such as Wolf and Bear from Russia and Sellier & Bellot from the Czech Republic) uses copper plated magnetic steel jackets; this ammo, while probably not seen much on the street, is widely used among the shooters I hang out with because it’s so much cheaper to shoot, and we tend to expend a lot of rounds.
Also, type IIa body armor (the absolute lowest level worth wearing- most will recommend no less than IIIa) should stop a .38SP HP even at point blank range, that’s what it’s there for. It’s well within the specs of what level IIa will stop, even at that range.
Type IIa
“This armor protects against 9 mm Full Metal Jacketed Round Nose (FMJ RN) bullets, with nominal masses of 8.0 g (124 gr) impacting at a maximum velocity of 332 m/s (1090 ft/s) or less, and .40 S&W caliber Full Metal Jacketed (FMJ) bullets, with nominal masses of 11.7 g (180 gr) impacting at a maximum velocity of 312 m/s (1025 ft/s) or less. It also provides protection against the threats mentioned in [Type I].”
Notice the spec deals with impacting velocity, not muzzle velocity directed at a target of a given distance. Even if we assume a +P loading in .38 special, you can expect the velocity to be below 1000f/s at the muzzle.
I could be wrong about the body armor, as I only know this from from what I have read from various sources, and have no actual experience related to shooting at targets protected by body armor
May 3rd, 2006 at 11:34 am
So, they can’t use the MRI because of bullet fragments. Is there something wrong with doing a CT scan? Did the hospital just throw the CT machine in a dumpster when they picked up the MRI machine?
May 3rd, 2006 at 11:43 am
Official Comment
Thanks, Karl.
Dan, they did a CT scan before the team took over the case. It was one of the films House put on the screen along with the chest x-ray in the very beginning.
May 3rd, 2006 at 12:15 pm
Karl – “Protection” in that context means nonlethal penetration.
Wolf and Bear don’t make 38 special. 38SP S&B ammo has a lead core with a CuZn 30 jacket.
May 3rd, 2006 at 12:38 pm
My guess? Avian flu. The reasons I suspect this are here and here.
May 3rd, 2006 at 1:16 pm
Vincent,
US standards for “protection” do allow for upto 44mm of “bullet impact depression”, which could actually be potentially lethal.
My point about Bear and Wolf was mainly in respone to your statement “I haven’t seen another material used…well, period” not specifically about .38Special. I think .357Mag is about the only load from S&B that still use a steel jacket.
May 3rd, 2006 at 1:40 pm
Im not a medstudent or doctor, but would toxoplasmosis be a possiblity?
I was however thinking that the disease is something airborne (this would also account for the “patchy infiltrate in the chest xray” , such as some kind of fungal spores or what not, because Foreman didnt ingest or inject any pathogen at his time at the appartment right. Isnt there some broad range anti fungal that House could have given them both?
Was testing for cryptococcus even a smart idea, because if the patient isnt immunocompromised, then their body should be able to deal with cryptococcus right?
May 3rd, 2006 at 1:42 pm
Granted, we’ll find out in a few hours, but what do you think of a prion infection? We haven’t seen one of those yet in the show (or have we? No, I don’t think so, since almost every House patient recovers.) and prion diseases are scary enough to warrant a two-part sweeps episode. Then again, it’s pretty easy to test for prion diseases… ugh. Have they checked back up on the lesions in Foreman’s and Joe’s brains? Kuru, in particular, is a prion disease that causes uncontrollable laughter. I have *no idea* how either of them could’ve contracted it, since it’s localized to indigenous cannibalistic populations in the South Pacific… oh, but this show is big on medical stretches. (Not to mention the fact that the incubation period of the disease would be much longer than a few hours.)
Anyway, it’s just an idea. It’s probably wrong — no, it is wrong — but after having written multiple things and done far too much research on prions, the second I see a disease with laughing, I think prions. If Foreman does indeed have a prion disease, he’s pretty much doomed, and from spoilers I’ve read he’s going to appear in future episodes.
The second thing I thought was some kind of pesticide used on the marijuana. They already explored that angle with the pidgeon poo, but maybe didn’t get into it enough? “Everybody lies,” after all, and it’s possible that Foreman stole a bit of Joe’s pot and smoked it, thus getting the pathogen into his system.
In any case, I’m extremely excited to see what the results are, mostly because I’m totally stumped. If they’ve really given EVERY TOXIN TEST, I don’t know what it could be! (N.B. I’m pissed that they ruled out ergot poisoning, that would’ve been a trip. Hardy-har.) I love it the infectious diseases with bizarre psychological symptoms. Those are my favorite.
May 3rd, 2006 at 2:27 pm
I think toxoplasmosis was already tested for (in passing House mentioned it).
Very unlikely to be prion disease (takes a long time to develop and you need to actually ingest something rather than just inhaling).
Psittacosis would be on the top of my list, except that chest x-rays typically take much longer to resolve. It should be in the differential for encephalitis. Treatment is doxycycline.
I wonder why a lumbar puncture has not even been considered (that’s somewhat routine for encephalitis)?
BTW, I think when in doubt after an EXTENSIVE workup (and they haven’t done that, at least not the right tests), throwing the antibiotic book at the patient should be considered–e.g. antifungals, doxycycline, gram positive and negative coverage.
May 3rd, 2006 at 2:36 pm
I forgot to mention Q fever (caused by C. burnetti) which can also cause encephalitis and multisystem failure. It’s spread by aerosol and tick bites, but typically seen on farms. And the treatment is…yes, doxycycline.
(This week’s New England Journal of Medicine has a case of Q fever too)
May 3rd, 2006 at 5:15 pm
I think that the bird is very significant to this case. I firmly believe that this is bird flu. It accounts for the fever, conjunctivitus (which could explain the blindness), respiratory problems (explains the coughing)…the giddiness is the only thing not explained, but maybe House knows something we don’t. Regardless, i firmly believe that it is birdf flu…treat him with Tamiflu and send him home, House!…
May 3rd, 2006 at 5:32 pm
I’m wondering if there is something to the marijuana seeds or hydroponic chemicals that might explain things. If he ordered the seeds where did they come from?
Also, the fact that the cops apartment was EXTREMELY messy raises an eyebrow to me, in the opening scene he didn’t look like a slob, but that apartment was uninhabitable. Not sure how it would tie in, but are we sure he actually lived/stayed there?
….all speculation…..we shall see tonight I guess.
May 3rd, 2006 at 5:58 pm
One other question; The cop had all those pot plants, he even told Eric “Being a cop is stressfull”, like he was explaining his drug use. But the tox-screen came back negative?
Weird…
May 3rd, 2006 at 10:13 pm
It would have been so appropriate if Foreman were suffering from C. formans. Wilson should have come down with Wilson’s Disease. And the other three … well, I can’t think of any conditions that would fit their names.
May 3rd, 2006 at 10:14 pm
Not other three … four. House, Cameron, Chase and Cuddy.
May 3rd, 2006 at 10:43 pm
What was the diagnosis and the parasite?
May 4th, 2006 at 12:28 am
*Spoiler*
It was Naegleria fowleri. It is an amoeba borne from water. It seemed both the cop and Foreman contracted this amoeba from his irrigation system in his marajuana operation. It seemed that the cop gathered his water from elsewhere, on the roof of the shed, instead of through the water system that Cameron originally tested, thus that it wasn’t found at first. I have some questions regarding how exactly this disease infected the cop and Foreman and the symptoms. Although I’ll wait for Scott’s review on tonight’s episode before I ask my question.
May 4th, 2006 at 10:58 am
Let me first say I really enjoyed this episode so far, but is anyone else bothered by the complete lack of clinic dutie scenes and the almost complete exclusion of Cuddy from the storyline as of late? I hope they bring those things back, because they’re part of what made the show truly unique.
May 4th, 2006 at 11:01 am
Er, duty* O:)
May 4th, 2006 at 11:08 am
Sorry for the third post in a row, but I just followed your post about Legionnaire’s Disease, interested because there was an outbreak in a local mall recently, and I found this paragraph that led me to a little nit-picky point:
“The Legionella bacteria are found naturally in the environment, usually in water. The bacteria grow best in warm water, like the kind found in hot tubs, cooling towers, hot water tanks, large plumbing systems, or parts of the air-conditioning systems of large buildings. They do not seem to grow in car or window air-conditioners.”
The air-conditioner in the precinct was a window air-conditioner. Oops. Can’t blame them too much for that, I guess; even Dr. Scott missed it. ;)
May 4th, 2006 at 2:47 pm
This doesn’t seem right to me. I looked up naegleria f. on several websites (here’s one) and there is no euphoria or blindness or hyperalgesia or contractures. I feel duped.
May 4th, 2006 at 3:56 pm
In the beginning I was thinking Jacob-Creutzfeld or mad cow; I’m amazed by House and his crew – They are pathologists, microbiologists, radiology techs, cardiologists, respiratory therapists, lab techs, urologists, neurosurgeons and every other specialist all in one team of four docs!
May 4th, 2006 at 5:42 pm
Re: The bullet not shattering on kevlar
This is a moot point by now, but it looked to me like the bullet struck the cop’s badge, not his vest. What metal are those badges made of?
May 5th, 2006 at 6:10 am
Just out of curiosity, why wouldn’t the sed rate be a good way of determining if any members of the team might be exposed? If you don’t know what you’re looking for, it makes sense to me that you’d want to look for some non-specific test.
May 7th, 2006 at 1:18 pm
Greg – I not a doctor, but I would think the sed rate is so nonspecific – it tells you there is inflammation going on somewhere in the body – that’s it! It could be any number of things from rheumatoid arthritis to an abscessed tooth! I could be wrong about this, however!
June 12th, 2006 at 5:47 pm
I think the sed rate makes sense, if they found something on that test, then they would look closer, but the general inflammation test seems fine as a way for dismissing exposure, not confirming it.
I also think House shot the corpse just to see if any of the team was infected. He could have tested the MRI any number of ways, but he was testing the team to see if they were horrified by what he did.
June 13th, 2007 at 2:26 am
Good idea to check if anyone from the team found shooting a corpse funny.
Also a cute way to give the TV version of Mr. Holmes hitting corpses with a stick.
July 8th, 2007 at 11:04 pm
A late contribution to the discussion, but still.
The notion that an MRI-machine’s magnetic field is turned off between scans is a wrong one. So the bullet, if at all, won’t be dislodged a the push of the startbutton.
The coils of most MRI-machines are made of superconducting materials. The coils therefore have to be cooled with liquid helium. Keeping the coils at a stable low temperature is essential for proper functioning and is a lot more cost-effective than varying the temperature, which would have to be done in order to switch off the main magnetic field. The consequence of this is that the magnetic field is always there, because of the effects related to superconductivity.
If the magnetic field has to be switched off quickly during an emergency for instance (this is called quenching), a lot of energy would be released, resulting in a rise in temperature of the coolant medium. Because of this a large part of the very expensive helium coolant medium will turn from liquid to gassious state and will be lost. The helium is vented via specially designed ducts to protect the patient (the helium would force the oxygen out of the scanroom when no ducts are present, suffocating everyone in the scanroom (and you wouldn’t be taken serious crying for help in a silly high pitched voice ;), would you?)). After quenching it takes several days to get the machine back to proper operating temperature, which lays just above 0 Kelvin, absolute zero.
Pushing the startbutton to initiate the scan only activates some initialising signals, the gradients and the pulse-sequences. The latter two are used to determine where all the signals are coming from, slice thickness and to specify the region of interest (the gradients) and for creating the image information in such a way to optimally show the suspected pathology. These are for instance, to name a few: T1, T2, protondensity, FLIR, STIR, inversionrecovery and are produced by generating different pulse sequences.
Gradients and pulse sequences also produce magnetic fields, but they are very small compared to the main magnetic field and will play no part in an eventual accident with ferrometals unlike shown in this episode.
So if the bullet from the dead man’s would have come out of his skull, it would have been while positioning him prior to the scan and not at the start of it.
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