House – Episode 19 (Season Three): “Act Your Age”
Frankly not a good episode tonight — in fact, I gave it a failing grade. There were too many missteps and some appallingly misunderstood medicine. See if you agree — or can show what I’m missing…
Jasper, a very rambunctious eight year-old boy, has just been a fight and received a bloody nose and his father has been called to day care. While his father is stopping the nosebleed, his six year-old sister Lucy collapses and is struggling for breath. She is admitted to the hospital and found to have a restrictive pericarditis (the sac around the heart becomes too tight to allow the heart to correctly fill with blood) and elevated blood pressure. She undergoes surgery to remove the pericardial sac. Differential diagnosis includes bacterial infection, viral infection, amyloidosis, sarcoidosis, hemochromatosis, and tuberculosis. Blood tests are negative, but the perciardial sac shows granulomas which are thought to represent a fungal infection. House wants a lymph node biopsy to determine which fungus (but why not just test the granulomas themselves?), but the test is negative suggesting that there is no fungal infection. As the biopsy is being performed, Lucy develops double vision which is ultimately diagnosed as uveitis.
The differential now includes autoimmune disease such as Lupus, Kawasaki’s Disease, and JRA (Juvenile Rheumatoid Arthritis). Lucy is started on steroids to treat the presumptive JRA. While Foreman is talking to the father, she develops a left-sided facial droop and is diagnosed with a middle cerebral artery stroke. She is started on tPA (a “clot busting” drug used to break up the clot that caused an acute stroke or heart attack. Not approved for use in children, but I’m not sure what else one could try). She is noted to be polycythemic (her blood is too thick because there are too many red blood cells), and is started on hydroxyurea (a drug used to treat polycythemia vera — one particular type of polycythemia that the team doesn’t even know whether Lucy has) as well as therapeutic phlebotomy (blood letting).
When Cameron and Chase are searching the house looking for carbon monoxide (a cause of polycythemia), they come across a bloody t-shirt hidden in a vent in Lucy’s room. They are concerned Lucy might be the victim of child abuse. A vaginal exam reveals shallow cuts around the vagina, but no evidence of penetration. Ultimately the team discovers that the blood is menstrual blood, and Lucy had started her menstrual cycle…at age six (the shallow cuts are from her attempt to shave her pubic hair off with Dad’s razor). The team now considers a tumor a likely cause, especially a pituitary adenoma (a type of hormone secreting brain tumor) or an ovarian tumor. Cameron suspects that Lucy has been exposed to excess estrogen from the environment.
An MRI shows no tumors in the brain, but it does show what appears to be a tumor on her ovary — however it ends up just being a cyst. While the cyst is being biopsied, Lucy slips into ventricular tachycardia, but is successfully revived (just once on House, I’d like to see an episode where a patient does not have v-tach during surgery. I promise you, codes during surgery are very very rare. At least Foreman used correct pediatric setting for the defibrillators.)
Meanwhile, her eight-year old brother Jasper had been hitting on Cameron. When he goes so far as to attack Chase in jealousy, House realizes that Jasper is also going through precocious puberty. His testosterone is measured and is sky high.
Lucy now complains of abdominal pain. Scanning shows new cysts in her pancreas, kidneys, and lungs. Cameron is now convinced that the others were right and that it is a pituitary tumor (just one that won’t show up on an MRI). She wants to remove Lucy’s pituitary and even talks the dad into agreeing to the procedure. House is not convinced about the tumor; he now agrees with Cameron’s original assertion that there has been an environmental hormone exposure. He goes to the daycare center the kids attends and talks to their teacher. He discovers that she has been having a relationship with their father. She has also had a recent lip wax to remove excess facial hair. House puts all the clues together and deduces that the father has been using a non-prescription testosterone cream. Even though he has been careful about applying it only at the gym, the excess hormone has seeped through his pores, exposing his children to high levels of testosterone (and the day care teacher too), causing their symptoms.
Medically, this episode was very scatter shot, with symptoms not matching up with the diagnoses. I’ll agree that excess testosterone can cause polycythemia, which can lead to a stroke. However, I can find no connection between testosterone and restrictive pericarditis, or testosterone and uveitis. Nor do I understand why high testosterone would cause randomly appearing cysts. More importantly, I cannot understand why testosterone, a hormone that leads to male sexual characteristics (e.g. the teacher’s hairy lips) would cause early menstruation. If anything, high levels of exogenous sex hormones would shut down Lucy’s pituitary/ovary axis by feedback inhibition. Frankly, I’m also skeptical of the excreted-though-the-pores scenario, but I can’t find any good studies. Testosterone is a complex chemical and not excreted in any meaningful amounts through pores (my sources indicate excretion is 90% urine, 10% feces).
The medical mystery was fair — and I liked the red herring of the mother’s brain cancer — so I’ll give it a B. The ultimate solution, while clever, simply did not fit the majority of Lucy’s symptoms. I’ll give it partial credit, but only a D+. The medicine had too may unexplained symptoms and the confusion over male/female hormones dropped the score to a F (if anyone can show why I’m wrong, I’ll certainly re-evaluate). The soap opera aspect was better than last week’s (thanks to the Cuddy/Wilson play angle) and earns a B+.
The previous House review
A list of all prior House reviews
April 18th, 2007 at 12:04 am
Yeah, I know very little about medicine (besides an amateur’s interest), and was still confused about every single thing mentioned — I saw little logic between symptoms and explanations. On that front, I thought it was pretty bad. But the soap made up for it in some ways, and that little girl (though showing signs of confusing and elusive conditions) was a pretty good actress. Great review, as always.
April 18th, 2007 at 12:24 am
question, wouldn’t the testosterone levels have shown up in the initial blood work? Also, if they suspected an environmental cause, wouldn’t they have checked the blood of the father & brother too, just to be safe?
April 18th, 2007 at 12:43 am
The soap-opera parts of the show were the best tonights, I just loved the look on House’s face during those scenes. There has to be something going on ‘tween him and Cuddy.
April 18th, 2007 at 1:02 am
There have been cases of puberty induced in young children whose parents used testosterone creams. Here’s a link to an article on the topic published in the journal of the American Academy of Pediatrics.
http://pediatrics.aappublications.org/cgi/content/full/114/1/282
April 18th, 2007 at 1:54 am
Once again I can’t comment on the medicine, but I have to say I was at least curious to the point of being skeptical about the cream-pores connection. My roommate went so far as to exclaim that it was impossible, but I figured it was yet another quite unlikely but interesting effects.
The episode also contained several good laughs, from the flowers House sent to the Wilson and Cuddy part, and House’s repeated instances of gullibility about it. They really seem to be fronting him and Cuddy more than before. Best line of the night I’d say was his frank question to the little girl: “Do you have hair in your special place?” Heheh.
April 18th, 2007 at 3:03 am
I was so hoping someone was schtupping the little girl. My bets were on the brother.
April 18th, 2007 at 3:13 am
I found it surprising that they didn’t think of menstruation before child abuse. I didn’t buy the self-inflicted cuts while shaving, either.
I liked Chase’s “relaxed idiots” line.
April 18th, 2007 at 4:14 am
While I have to agree with most of what you said, I think you were wrong about the testosterone not causing the little girl to menstruate. The body’s natural defense when there is an imbalance is to correct it. So since she her body had too much testosterone, the body began to make more estrogen, which is why she began to menstruate.
April 18th, 2007 at 4:44 am
That article seems to refer strictly to virilization, though – and there’s no suggestion (that I noticed) that it was excretion of testosterone through the skin that caused the problem, but rather exposure to treated skin or to the product directly (through excess testosterone spray having ended up on sheets and so forth); it’s mentioned specifically that one father failed to wash his hands after application.
April 18th, 2007 at 4:45 am
i’m guessing the uveitis was actually an incorrect diagnosis, one they made because they thought it most likely, and on retrospect her visual symptoms were probably a result of a stroke.
April 18th, 2007 at 5:14 am
This was one episode where I was actually ahead of the game, I started suspecting that there might be hormone troubles with the brother when I remembered that he got into fights in school and had body odor (if you remember in the beginning, some kid said he smelled like a monkey).
I agree the skin pore solution is a bit outlandish (maybe the dad was sweating gallons everytime he hugged his kids). But assuming the dad didnt wash his hands after applying the cream, then based on the case studies T-bird presented, skin to skin contact may not be so outlandish.
April 18th, 2007 at 5:28 am
Also, the son was tested with 100 TIMES the normal amount of testosterone for children?? How much cream was the dad using? That must have been one crazy kindergarten teacher. Lol
April 18th, 2007 at 6:34 am
One other problem I just thought of…
Both the kids were described as having “thick blood” due to excess red blodd cells. I assume this is what they were attempting to illustrate in the initial segments bloody nose that wouldn’t stop. But…wouldn’t thicker blood be less likly to continue bleeding? I mean, that’s how it works in physics, thicker liquids are less likely to leak than thinner liquids.
April 18th, 2007 at 7:24 am
Official Comment
T-bird,
Ledasmom is right. The article, while intriguing, discusses virilization (that is, enhanced male sex traits) due to the estrogen. The “precocious puberty” in that case was from concerns about pubic hair growth (and likely in a male pattern, not a female pattern), not menstruation. (And I worry about what Google searches these phrases will bring to my site).
Jenna,
The human body has some ingenious feedback/inhibition loops in the hormone production system, and the high testosterone will trigger a high level inhibition and shut down almost all sex hormone production via the pituitary gland (which tells the ovaries what hormones to make).
April 18th, 2007 at 9:24 am
I liked the Wilson-House interactions the most from last night’s ep: “Really?” “no.”
Also, I was horrified by the sight of a 6 year old girl suffering a stroke! Harrowing!
As for the medicine, it seemed all over the place. I think that the medicine has become too much of a freak show…every patient is seizing, having unnecessary surgery, and requiring de-fibrillation. They could tone all that down and make the show better.
Cameron’s and Chase’s love connection? Meh. 8 year old boy grabbing Cameron’s shapely rump: Suh-weet!
April 18th, 2007 at 10:03 am
The only possible explanation for her menstrual symptoms is that Testosterone is the immediate precursor of estradiol which is the useful form of estrogen. Estradiol is the sex hormone responsible for the development of secondary sex characteristics (i.e. menstruation and body hair). I agree completely that the medicine is far fetched and obviously not a case from JAMA or NEJM (Journal of the American Medical Association and New England Journal of Medicine). The problem with house is that the “medical” writer on the show is not an MD, but a former professor of 1st year medical curriculum. It really needs an MD on the show to look at this stuff. I suggest webMD for any varification of this, and not something like Wikipedia.
April 18th, 2007 at 10:15 am
I knew it was a hormone thing from pretty early on. I assumed though, that the father was taking Viagra (c) and the kids were swiping his pills, or the stuffed rabbit was a carrier of some rare, one-in-a-million disease.
I can’t comment about the medicine but, the soap-opera I found amusing. It was good to see House torturing Wilson throughout the episode. Also, Cameron playing with Chase’s emotions was funny to.
April 18th, 2007 at 10:32 am
I liked the House-Wilson interaction a great deal, and it was nice to see the rare (in recent episodes) demonstration of their friendship. Thus, even after Wilson expresses his frustration at House’s having sent the flowers to Cuddy, he ends up with a good-natured and exasperated “good night, House” and House responds with “good night, Wilson.” Just cool to remember that these two actually *do* like each other.
April 18th, 2007 at 10:40 am
You think House was serious about taking Cuddy out to a play?
I’m torn. I just hope the writers actually ACKNOWLEDGE this event in future episodes. This show has a highly irritating history of not carrying forward actions/outcomes/developments of previous episodes.
April 18th, 2007 at 11:09 am
Wertrew: Actually, House sent the flowers to Wilson, making him think they were from Cuddy. (The idea of one man sending flowers to another was perfectly in keeping with the House-Wilson “you think is a date?” banter from earlier in the episode.)
April 18th, 2007 at 11:44 am
I’m definitely surprised that House and crew didn’t catch the testosterone levels sooner – like Nick F. says, the they should have drawn blood from all the family members and figured it out immediately. This was definitely one of the more ridiculous episodes as far as medicine goes – but I don’t think it deserves an F, just because there have been documented cases of this sort of thing happening (although the cases talk about Tanner stage III pubic hair, and not exactly full-blown menstruation).
The only thing glaringly wrong with this scenario is House’s theory about the kids getting it from sweat, but they could have gotten it from contact. (or the dad could have been lying when he said he only applied it at the gym…)
I love the House/Cuddy storyline! I’m betting they get together in some fashion to leave us hooked for the season finale:)
April 18th, 2007 at 12:22 pm
MrBuddwing: Of course you’re right. I just got distracted while writing it. Is there anyone out there that didn’t *immediately* know it was House who sent them? Good stuff. As for the stuff with Cuddy and House, it seems absolutely obvious that they’re setting us up for some story line between the two of them — those posters who “hope” it’s going to happen needn’t worry. That was the point of his interrupting her dates, of his anxiety about Wilson asking her to the play, and about HIS asking her to the play at the end of this episode. Personally, I only hope they don’t rush the story, and make it some quickie one-or-two episode story arc (like Cameron and Chase), but let it be a little more adult, serious, and extended.
April 18th, 2007 at 1:04 pm
Official Comment
Ryan,
Those case studies merely show that young women exposed to exogenous testosterone will develop virilization, which although it looks like puberty, is not. They do not show actual female precocious puberty, which is what Lucy was experiencing. Testosterone exposure does not cause that in young women.
April 18th, 2007 at 2:23 pm
There’s also no way anyone would ever give tPA to a child, and no way IN HELL that anyone just after getting open heart surgery would get a sniff of it! This checklists for this thing are like filling out a tax return form, only more dangerous!
April 18th, 2007 at 2:44 pm
Scott, I know it’s been a long time since med. school, so I’ll give you a break on this one: precocious puberty would be caused by the same mechanism that causes gynecomastia in anabolic steroid users – aromatase enzymes. High levels of circulating testosterone result in increased conversion of testosterone to estrogen. However, I agree that the excretion through the pores bit was ill-conceived. I can’t connect testosterone to the other conditions either. What really confused me though, on a non-medical note, was that the six-year-old girl shaved her pubic hair. Kindergarteners are awfully innocent when it comes to that sort of thing – it seems to me like a big leap by the writers to cover up a telling symptom.
April 18th, 2007 at 3:29 pm
1. Those saying nay seem to forget (or have never paid attention) that the writers get all of their cases from -international- medical journals. So somewhere on the planet someone’s kid suffered from this.
2. That 8 year old had a serious case of roid rage, huh?
3. Ryan: The father said that he also applied the cream in the shower (His own home? Or hers?). If it was his home, there could’ve been residue in the shower. Or if he was applying it to his wing wang, it’s also possible that he doesn’t wash his hands after pizzlin’, so if his hands touched his wang and then he touched his kids (ew, but it happens), then it can rub off onto them.
4. There is a reason why doctors warn patients AND the partners of patients who’re going to go on Androgel (topical testosterone gel). Like what happened to the chick the father was dating, there are very real side effects for partners as well.
5. I know all of this crap because I was on Androgel and was given the warnings!
April 18th, 2007 at 3:32 pm
6. A P.S.: Everyone’s body reacts differently to hormones. Hell, everyones’ bodies react differently to everything, period. So it’s possible that though not typical, the girl’s symptoms were probably very real in the case they yanked this from.
April 18th, 2007 at 4:01 pm
What im wondering is how they managed to make that little girl smile crooked, I believe a previous episode of House introduced the FAST acronym for stroke and one of the symptoms is a crooked smile. Ive been trying curl my upper lip like she did but no success.
April 18th, 2007 at 4:21 pm
My question is how is her period blood on the t-shirt?
April 18th, 2007 at 4:32 pm
Trina: It was explained that a friend of hers recommended stuffing a t-shirt in her underwear.
Not sure how believable that is as something a 6-year-old would recommend.
April 18th, 2007 at 4:36 pm
Just a note- in case anyone is interested- about House’s clinic patient. Houses reference’s to “Eggs benedict” was an allusion to an old Woody Allen standup routine. Fairly appropriate too.
April 18th, 2007 at 11:19 pm
Hah, this site really make’s me enjoy not knowing jack about medicine. I suppose when a show comes along about processing medicare claims, I’ll be the one in a hizzy over the technical details.
April 19th, 2007 at 12:54 am
Wouldn’t the little girl have breasts? Most girls going through puberty get breasts before they menstruate.
I didn’t get it that House really sent the flowers. So, the the last scene between House and Wilson, I thought House was upset that Wilson was going to kiss Cuddy. I think Wilson knew House sent the flowers before he came into his office at the end. Either that, or he figured it out after he left House’s office to kiss Cuddy. Which is it?
I love the House/Cuddy thing. What is happening with Cameron and Chase is exactly why House is not interested in Cameron. He doesn’t want someone who is immature and plays relationship games. It means House is interested in a realtionship.
April 19th, 2007 at 1:07 am
Nuts, I was so sure it was an altered-for-TV-drama version of Werners syndrome up until the period and the brother hitting on Cameron. It’s rare and weird enough for House. But as my dad pointed out House wouldn’t be able to cure it so no can do.
April 19th, 2007 at 2:11 am
Even I caught the estrogen/testosterone mix up. I also wonder why Cameron/Chase didn’t clue in when an 8 year old boy started acting like that and make the connection. House had his “revelation” and for once, I had already made it. That’s never happened before since I dont know anything about medicine/physiology.
Other than that though, I liked this ep for the character interactions and the intriguing mystery.
April 19th, 2007 at 8:14 am
to minitiger: house doesn’t *always* cure his patients. offhand, there was the college student with radiation poisoning, and the bag lady with rabies.
April 19th, 2007 at 10:27 am
sue: Yes, Wilson knew that House had sent the flowers before he left the office — he was trying to find out how far House was prepared to let him go in his apparent crush on Cuddy.
As for House and Cameron, I suppose you can call it “immature” and playing “relationship games”, but Cameron would say she’s being very mature and not playing any games at all! After all, she never lied to Chase about her intentions, was extremely candid about what she wanted and what she didn’t want, and at no point tricked or deceived him in any way. I guess you can call wanting a purely sexual relationship with no emotional attachment “immature” — but I don’t really see how it’s a “relationship game.”
But at the same time, House is significantly older than Cameron, so, yes, I think is more attracted to someone with Cuddy’s perspective, experience, and personality. Seems reasonable to me!
April 19th, 2007 at 12:11 pm
I knew something was wrong (I went as far as to imagine something hormonal) the moment the kid pay a compliment on Cameron’s necklace. He was obviously staring at her funbags.
I thought the writers pulled a clever old one on us when it turned out that the kid sister was the one falling sick. And they double-pulled us with the eventual inclusion of the brother as well. Cool.
April 19th, 2007 at 1:57 pm
I did figure out that what ever it was, the boy had it too. If House is interested in anyone, it would be Cuddy, simply because she is more complex and interesting. Cameron interests House in the same way a disease does. I think Wilson is going to tell Cuddy about how interested House is about her,behind the scenes. Has anyone noticed that House doesn’t seem to be hoovering the pain meds lately? Can anyone spell out the acronym FAST for me for the stroke mnemonic please? I like wikipedia better than web md, it’s more in depth, and has better links.
April 19th, 2007 at 5:27 pm
your right, it could cause a stroke, but thats about it.
April 19th, 2007 at 6:28 pm
Two non-medical questions:
- what does it mean “Panty hamster get a spin on its wheel” line?
- what does it mean “may october” talk at the end of the episode?
Yeah, watching House whan you don’t understand full cultural context is sometimes difficult.
April 19th, 2007 at 7:09 pm
TRad:
Where are you writing from? Or rather, where are *you* from?
Anyway, in response to your question, the “Panty hamster” line was pretty confusing to me too. It clearly was asking whether Cuddy had taken her panties off — in other words, whether she and Wilson had had sex (House asked loudly to embarrass Cuddy). But I’ve never heard the phrase before, and the idiom is not intuitively clear. Once you know that hamsters run on wheels in their cages it makes a little more sense, but after all, the hamsters don’t actually move on that wheel, so the saying actually appears, on further review, to mean the opposite of what I assume House meant by it. (Okay, I know I’m over-thinking it, but I think the writers got a little too clever here).
The “May-October” reference is more familiar, and is not the creation of the show’s writers. A “May-October” relationship is one between a much older person (usually a man) — the “October” — and a younger one — the “May”.
Hope this helps.
April 19th, 2007 at 7:35 pm
- what does it mean “Panty hamster get a spin on its wheel” line?
Lol…panty hamster is slang for vagina. The wheel is the action. House was basically asking if she had sex.
- what does it mean “may october” talk at the end of the episode?
Cuddy says she doesn’t get the May to December thing. House says it’s May to October at worst. It’s a reference to a movie called May to December about a guy who falls in love with a girl half his age.
April 19th, 2007 at 7:49 pm
Here’s my attempt to explain ‘panty hamster’ to the folks who didn’t grow up speaking American: A juvenile and certainly disrespectful way to refer to a woman’s genital area is ‘beaver’. I have also heard it referred to as a ’squirrel’. House picked another furry creature. He is asking her if she let hers out for some exercise (the spin on the wheel).
April 19th, 2007 at 7:55 pm
Wertraw
From Poland. I’m translating House episodes (as a hobby – and an exercise) – and the biggest difficulties aren’t medical terms – but language games and cultural context.
April 19th, 2007 at 8:59 pm
My wife, as soon as they found the t-shirt in the vent, said that she had her period. It was obvious because of the stroke, and she made the connection in that this child obviously had something wrong with her biological clock. When you think about it, it is pretty obvious.
April 19th, 2007 at 9:37 pm
Here’s another one: why didn’t Cameron RECOGNIZE the bad shave job by the six year old? Six year olds have NO pubic hair, it would have at least shown up a little. More evidence that you shouldn’t send an immunologist to do… well, anybody else’s job.
April 20th, 2007 at 1:56 am
So with regards to the hormones, would the excess testosterone cause negative feedback limiting the production of GnRH thus limiting FSH and LH and then oestrogen and progesteron, thus the reason why menstruation wouldn’t occur? And wouldnt excessive testosterone in the girl cause other physical symptoms apart from pubic hair growth? Thanks for the reviews by the way Scott, love reading them and have directed everyone from Monash Uni’s physiotherapy society here :).
April 20th, 2007 at 5:55 am
I can forgive the bad medicine in this episode for one very important reason: I believe this is the first network show in the US history to use the phrase “squish mitten.”
April 20th, 2007 at 9:16 am
The article at the weblink in the 4th post above indicates that little girls exposed to testosterone start growing a penis (clitoral enlargement). You’d think Cameron would have noticed that too.
April 20th, 2007 at 11:55 am
Cud the testosterone cause her estrogen level to rise… (eg it was picked up by the brain tht testosterone is high so it tells the ovaries to produce more estrogen or like that… a sorto negative feedback… cuz i guess feamle also have testosterone but very very very low… so increaseing tht wud cause production of enough estrogen to counter the effect and balance the estrogen/testosterone ratio)…
Is this possible?
April 20th, 2007 at 12:00 pm
Also the day care lady already had a larger amount of estrogen(comparatively) so she did not show severe symptoms.. just the facial hairs…
April 20th, 2007 at 5:35 pm
This is the FAST mnemonic:
F – FACE…Ask the person to smile. Does one side of face droop?
A – ARMS…Ask the person to raise both arms. Does one arm drift downward?
S – SPEECH..Ask the person to repeat a simple sentence. Are the words slurred? Can he/she repeat the sentence correctly?
T – TIME…If the person shows any of these symptoms, time is important. Call 911 or get to the hospital fast. Brain cells are dying.
And about Wikipedia? I love it, too. BUT…it is user-edited; not checked for facts by any “authority.” So, caveat emptor (buyer beware)…
:))
April 20th, 2007 at 7:57 pm
I, like a few people who have mentioned it themselves, am not familiar with the medicine. Around the time they start bouncing diagnosis ((what’s the plural for that word? :s I’m getting spell-checked for diagnoseses…is it diagnosi? I have no idea)) off of each other, I start to lose them and lose focus.
However, my friends and I were talking about the episode on Wednesday, and we all agreed that it wasn’t as good as previous ones have been…even the soap opera, in my mind, wasn’t that great. ((However, I loved the House/Cuddy/Wilson “dramedy” going on there…that was great XD))
As I’ve mentioned before in a previous reply I left here, I love this site, and the reviews are very well done! :)
April 21st, 2007 at 1:06 am
Love this site. Thanks for writing it!
What are Cameron, Chase and Foreman anyways? I assume they are not interns, but are they residents? Fellows? Attendings? What is House? Maybe I missed something but I haven’t been able to figure that out!
April 21st, 2007 at 6:37 pm
Not in love with the medicine on this episode. I called the shaving the pubic hair thing early then was gunning for Progeria (very rare genetic abnormality causing early aging) as an end diagnosis, then a pituitary tumor, but did not like the topical testosterone explaination.
From a Peds background- you can see some early pubic hair darkening, but not usually menarche (menstruation) first. Usually there is some form of thelarche (breast development) and other signs of adrenarche (body hair, body odor, skeletal growth, etc.) then menarche. If there is an underlying uterine disorder- maybe bleeding can occur- but I would think that the breast development would be higher on a physical exam finding than the bloody t-shirt in a vent under the bed. Would think that PCOD symptoms would be front and center (Polycystic Ovarian disease)
V-tach or seizure is a must in any epidose apparently for the shock value… ugh- just never happens.
Really like the House/Wilson action though. Nice dialog and quips.
Scarlett- think the “Young Guns” are either fellows in “diagnostic medicine”- not a board certified speciality- one made up for the show, or junior staff MD’s to House (senior MD in the dept.)- all are actually residency and some- fellowship trained- Foreman in Neurology (a residency) and I think Cameron is Infectious Disease board certified as is House. Residency is 2-6 years beyond Med school and Fellowship usually 2-4 year beyond residency. Forget what Chase is trained in- but some FMGs (foriegn medical graduates) do a speciality as part of their medical school/residency.
April 21st, 2007 at 10:51 pm
It’s very simple, the thick blood caused the stroke, and an autoimmune response which led to the pericarditis, uveitis, and the granulomas.
The high testosterone caused early menstruation when the body, not wanting to be unnaturally transformed into the opposing gender, overcompensated with enough estrogen to kill a horse. Ironically, it was her body’s victory against the hormones, that caused her symptoms.
“hydroxyurea” – Is indicated for use against thrombocytosis(that caused her stroke). It also has an ironic side effect in that it reduces the number of blood cells(hemodilution). one man’s trash is another man’s treasure eh?
“I promise you, codes during surgery are very very rare” – please note that these are very rare cases, that these doctors are not surgeons trained to deal with complications, A biopsy is not surgery, and your tie is ugly.
April 22nd, 2007 at 3:53 am
The soap-opera was worth gold this episode. Especially when Wilson tried to lure House out by planning on kissing Cuddy.
The medicine, however, was so far off. After the first 15 or so minutes, no diagnosis fit anymore. The end result was not even close to satisfying, and the “testosterone through the pores” theory is ridiculous.
Another episode that makes me hope the next season improves dramatically in the medicine department.
April 22nd, 2007 at 7:00 am
House: Infectious Diseases, Nephrology, Pathology (we see him doing autopsies in Maternity and Detox)
Foreman: Neurology
Chase: Intensive Care, Homeopathy (Clueless), Literature (Kids)
Cameron: Allergies, Immunology, Infectious Diseases (?)
Cuddy: Endocrinology
Wilson: Oncology
April 22nd, 2007 at 11:49 am
House describes himself as double boarded in nephro/ID. The autopsies are just another one of those things that he shouldn’t be doing but does anyway. Like when Chase works in the NICU, Foreman does neurosurgery, and … pretty much every procedure they do in every episode. Other than that, the above list is right on based on what’s been said in the show.
They all claim to be board certified, meaning they have completed training and testing in their fields rendering them capable of acting as independent attendings. For unclear reasons Foreman, Chase, and Cameron are subjecting themselves to a seemingly endless fictional fellowship in “Diagnostic Medicine” (a certification that doesn’t exist). They are all super-geniuses, too, because based off of their ages and the actual time required to complete the training they supposedly have, they must have started or finished early (ages in season 1 in parentheses):
Cameron (26) for immunology: 4yrs undergrad, 4yrs med school, 3yrs IM residency, 2-3 yrs immunology fellowship, meaning she graduated from high school at about age 14
Foreman (30): 4 yrs undergrad, 4yrs med school, 4 yrs Neuro residency, he would have had enough time to go straight through
Chase (26), assuming he trained in the US: 4 yrs undergrad, 4 yrs med school, and either 4 yrs Anesthesia residency then 1 yr Critical Care Fellowship for Anethesiologists OR 3 yrs Internal Medicine residency then 1-2 years Critical Care Fellowship for Internists (either way, about 5 years) So he would have graduated from high school about age 13. And don’t forget, he spent an unspecified time in seminary training, too…
And, in case you’re interested:
Wilson’s training: 4 yrs undergrad, 4 yrs med school (NOT easy for an American to get into McGill Univ, either), 3 yrs IM residency, 3 yrs Heme/Onc or 2 yrs just Onc fellowship
Cuddy’s training: 4 yrs undergrand, 4 yrs med school, 3 yrs IM residency, 2 yrs endocrine fellowship
House’s training: 4 yrs undergrad, 4 yrs med school, 3 yrs IM residency, 2 yrs Nephro fellowship, 2 yrs ID fellowship
April 22nd, 2007 at 4:00 pm
Didn’t the East German athletes who took testoron develop large breasts? So at least under some circumstances testeron can cause a compensating overproduction of female sex hormones?
April 22nd, 2007 at 4:10 pm
When I saw heart problems, stroke and then premature menstruation, I thought she had that premature aging disease. Shows how little I know about medicine, LOL
April 22nd, 2007 at 6:49 pm
From what I understand Australians do not need to attain the four year undergrad degree as they do in the states. From what I have been told they go straight to Medical school from high school. So if Chase was educated in Australia its possible that he could be around thirty. (however I have to say thtat Jesse Spencer does not look anything near thirty but that’s part of TV fiction)
And House and Cuddy are the only ’ship’ on this show that makes sense to me. Chase and Cameron I can take or leave but I just don’t get House and Cameron.
April 22nd, 2007 at 10:33 pm
there are some (by some, i mean at least one) med schools that are 6 years total, that start right out of high school – culminating in a BS and MD (i.e. UMKC). that would cut at least two years off of the schooling times. and not all med schools require an undergrad degree for matriculation into med school. it just helps during the application process.
April 23rd, 2007 at 3:20 am
Here in Pakistan you do 5yrs med school get a MBBS degree and then give your USMLE 1 2 3 CS CK … and get a residency… in the USA… obviously the competition is tough so you have to score high like in the higher 80s or 90s…
April 23rd, 2007 at 3:59 am
The testosterone/early puberty link apparently has a valid medical basis.
“At the annual Pediatric Academic Society meeting in May in San Francisco, they presented a report that described how a preschool-age girl, and then her kindergarten-age brother, mysteriously began growing pubic hair… It turned out that the testosterone level of Dedekian’s first patient was almost 100 times normal – in the range of an adult man. The same problem affected her brother. The doctors realized that the girl’s father was using a concentrated testosterone skin cream bought from an Internet compounding pharmacy for cosmetic and sexual performance purposes. From normal skin contact with their father, the children absorbed the testosterone, which caused pubic hair growth and genital enlargement.”
http://medicalweeknews.com/news/Factors-linked-to-a-risk-of-early-puberty/
April 23rd, 2007 at 8:17 pm
wouldnt this be based on an actual event? i read somewhere that the medical mysteries they use are real life events, they just manipulate them so that they can fit it into a one hour episode.
But i do agree this episode wasnt very good or convincing. House has gone a little down hill this season, better make up for it at the end of the season
April 25th, 2007 at 3:46 am
I enjoyed the episode – I like knowing which part of the medicine is right and which part is wrong (thanks to this site) but I still think it’s more accurate than every other medical show.
I think sometimes it takes some stretching because this show relies almost entirely on medicine to drive the plot. For example, on ER when they need something exciting to happen, one of the doctors has a personal crisis… or a man walks into the hospital with a gun and starts taking hostages. On House, the excitement comes from the medicine… and it’s hard to squeeze the right amount of excitement out at the right times without stretching the facts.
I thought the soap opera aspects were great. The rapport between House and Wilson was perfect and made them really seem like good friends for once. My favorite part was at the end when House tells Cuddy he has tickets to a play, an obvious euphemism since he explained in detail to Wilson earlier in the show that he would only go to a play with a woman for one reason…
April 25th, 2007 at 3:48 am
Oh… I also have to give them props for having two very good child actors. They seemed completely believable in difficult roles, and the director never spent much time trying to demonstrate how terribly cute they were like so many children on TV.
April 25th, 2007 at 2:48 pm
They never said what was in the cream: only that it was a “male enhancement” obtained on the gray market. Is it possible for such a cream to explain all the symptoms? I’m not a doctor, but I thought I’d throw that out there..
I liked that the show drew attention to poisoning through the skin. Most people aren’t aware it’s possible.
Geoff
April 27th, 2007 at 12:29 pm
I have hardly any medical knonwledge, but I recently did a paper on steroids *which are essentially testosterone* and one condition, known as gynecomastia occasionally occurs in steroid users. This condition causes a male user to develop female breast/breast tissue. The excess of testosterone in the bloodstream either causes the body to increase estrogen production or the testosterone itself is somehow chemically altered to work as estrogen. Either way, estrogen levels in the body rise, which would stimulate possible premature puberty in a girl I guess.
April 30th, 2007 at 1:35 am
Heres some info guys:
HIGH levels of testosterone in females, regardless of age really, will be converted into Estrogen by aromatase and could thus cause precocious Puberty in the young (i.e. pubic hair and menstruation due to stimulation of the endometrium) or bleeding in the post-menopausal. Two caveats, however. 1) WEAK testosterones (like Danzol) are actually used to treat conditions like endometriosis (when there are bits of endometrial tissue outside the uterus that grow and bleed once a month) because WEAK androgens exert a negative feedback on the Hypothalmus-Pituitary-Ovarian Axis which would thus decrease the amount of estrogen released and of course lead to a decrease in endometrial growth. 2) One would expect the little girl to also show virilizing signs as well, like facial hair and even acne due to the absurdly high levels of Testosterone in her blood.
Still, this episode was cool….but the pericarditis and the cysts on other organs are a bit of a mystery.
May 3rd, 2007 at 3:01 pm
Dr. Who, what’s your source of information for menarche in response (indirectly) to testosterone? Although there are plenty of examples of development of secondary sexual characteristics – and it’s hardly surprising – I hadn’t seen any examples of actual menarche in response to estrogen.
May 12th, 2007 at 4:17 pm
In response to
“More importantly, I cannot understand why testosterone, a hormone that leads to male sexual characteristics (e.g. the teacher’s hairy lips) would cause early menstruation. If anything, high levels of exogenous sex hormones would shut down Lucy’s pituitary/ovary axis by feedback inhibition”
well my knowledge of medicen is limited and clearly what ur saying makes sense but anabolic steroids cause hypogonagism i think thats the word right? and they are created to mimic the male sex hormone testosterone which causes a growth…..in that place..so maybey its just the same concept? i dunno..
May 17th, 2007 at 11:51 am
Gary-
If you think about it, all people have aromatase in their fat cells (boys and girls) and girls usually have a high level of aromatase in their ovaries(as well as other places). Aromatase has one main function: coverting Testosterone to Estrogen. It is the enzyme responisible for gynecomastia (breast growth) in male athletes on high levels of anabolic steroids. This enzyme is used in females to generate estrogen. Synthesis of estrogens starts in ovary by the theca interna cells when they convert cholesterol to androstenedione (”ANDRO” is the substance Mark Mcguire admitted taking….when it was still legal in baseball). Androstenedione then crosses the into the surrounding granulosa cells of the ovary, where it is converted to testosterone. This testosterone is then quickyly converted to Estrogen (usually the form called “estradiol”). This final conversion, from T–>E, iss regulated by Aromatase. Therefore, THEORETICALLY, if a little girl is al jacked up on Testosterone, a certain level of Estrogen will be made, it has to be b/c the enzymes are in place in her fat and ovaries. The crux of this episode was 1) how much Testosterone could really get into this little girl from the traces on the fathers hands/sweat/whatever, 2) If the testosterone was high enough to generate enough estrogens to trigger menses, it SHOULD have also casued her to get facial hair…like the teacher….which she DID NOT HAVE.
May 17th, 2007 at 4:00 pm
dr who, I should have been more clear. I’m familiar with the conversion of testosterone to estrogen, what I was asking about is the onset of menses – menarche, in response to estrogen. From what I’ve read on this subject – which isn’t all that much – it’s not at all clear that swamping the girl in estrogen would cause menarche. It most certainly would lead to development of the other secondary characteristics which, as you say, she did not have (other than pubic hair). However, I didn’t think it was actually known, yet, precisely what triggered menarche. It’s undoubtedly multifactorial, and perhaps estrogen plays a central role (though almost certainly taking > 2 years even so), but I didn’t think the evidence was yet clear that this sort of contamination could cause menarche itself. I thought you might have some new information, which is why I asked.
Otherwise I’m sure we’re in total agreement. It was pretty shaky medicine, no question.
May 17th, 2007 at 11:07 pm
Oh, I see what your asking, sorry I thought you were inquiring about the mechanism. Well, to get to your real question, I can’t give you a confirmed case of Testosterone cream actually causing menarche in a prepubescent girl. However, there is the aforementioned article about virulization: http://pediatrics.aappublications.org/cgi/content/full/114/1/282. And, in my opinion, if virulization can occur, menses can too if you understand the mechanisms.
Something else of note: Anyone who has worked in a New born nursey (or maybe some new moms out there) knows that sometimes a baby girls can have vaginal bleeding. While this might be b/c of a congenital defect, it may also be due to one of two reasons: 1) Excess estrogen the crossed the placenta in utero and into the baby’s blood or 2)Excess Estrogen in the breast milk. Both of these conditions aren’t common, but they aren’t rare either. Hope that sheds a little light
-dr who
October 25th, 2007 at 3:45 am
[...] Purtroppo ho visto solo la seconda puntata. Ieri sera avevo un’intervista, poi mi sono fermata a cenare al cinese, quindi sono rientrata a casa alle 22.00. Se tutto va bene, dovrei riuscire a recuperare la 18, ma non è sicuro. Per cui, oggi vi parlo solo della 19. Divertente, piacevole. Una bella ora della mia vita. Certo, vedere House e Cuddy che tubano e Cameron e Chase che hanno problemi di coppia mi fa male al fegato, ma occorre arrendersi all’evidenza: per fattori anagrafici, di plot e pure di presenza scenica, se House dovesse accoppiarsi starebbe meglio con Cuddy. Spando la mia lacrimuccia e vado avanti. I duetti tra House e Wilson a questo giro sono stati fantastici, soprattutto il tormentone “ci sei andato a letto?” “sì” “davvero??!” “no”. Invece Cameron continua ad essere sospesa nel limbo del “non so esattamente cosa sto facendo, non so manco chi sono, attendo che gli autori si chiariscano le idee”. Gli piace Chase? Sì, no, forse. Ci vuole solo trombare? Sì, no, forse. Resto sempre più perplessa. Per quel che riguarda il caso, intrigante, ma, a quanto sembra, un po’ poco plausibile. Peccato, perchè tutta questa storia dei bimbi che crescono forzatamente era molto bella. Peccato che poi stamane, mentre passavo l’aspirapolvere, mi è venuto in mente che la puntata è vagamente moralistica. Riflettiamo. L’omino è vedovo da un anno, con due figli piccoli. I valzer li apre Cameron, accusandolo di violentare la figlia, e un giro lo fa anche Foreman, dicendogli che non sa badare ai pargoli. Poi, scopriamo che è stato lui a far ammalare i figli. Come? Osando trombare con un’altra donna. Eh sì. Il vedovo tradisce la sacra memoria della moglie andando a letto con un’altra, dico di più, con una donna più giovane di lui. Sommo sfregio, osa usare una cremina per aiutarsi nelle sue prestazioni sessuali. La punizione per il suo peccato è repentina e terribile: i figli rischiano di morire. Attenzione: lui non ha messo la crema in bella vista a casa vicino al tubetto della maionese, non l’ha lasciata accanto ai pastelli della figlia. È stato attento. L’ha tenuta fuori da casa. No, il suo peccato è solo ed esclusivamente l’adulterio verituale ai danni di una morta. Direte che esagero. Non so. La Cuddy stessa rimarca la cosa chiacchierando con House mentre il padre di famiglia varca la porta dell’ospedale. Complessivamente ne ho tratto un’idea di fastidioso bigottismo. Quel povero cristo non aveva colpe, diciamocila verità. Stava facendo una cosa sacrosanta. Evidentemente gli autori non erano d’accordo. Resto dispiaciuta per la puntata sull’aeroplano: si prospettava gustosa… [...]
March 31st, 2008 at 12:36 pm
Just watched the episode again and found another thing that appears odd (I’m an amateur, by the way, even though I’m quite interested in medicine): If Jasper’s testosterone levels were (quote Chase) “A hundred times higher than in a normal 8-year-old”, wouldn’t there have been other symptoms, like, I don’t know, typical male changes during puberty like the voice change, facial hair, etc. ? Weird enough that excess testosterone in a girl would cause menstraution, but that it wouldn’t cause what it’s supposed to do?
April 11th, 2008 at 11:10 pm
What I don’t understand is how much of this creme would this dad have to be using for it to be excreted through sweat in quanities high enough to do this to his children?
September 2nd, 2008 at 9:04 pm
I was very intrigued once Jasper hit Cameron – I immediately thought, “Testosterone!”, and was wondering how two kids in the same environment received two different sex hormones from the same source.
(I also suspected the kid of molesting his sister, causing the bleeding and cuts, but in retrospect they identified it as menstrual blood, didn’t they?)
November 26th, 2008 at 4:49 pm
I’m surprised nobody has picked up on this yet, but pericarditis does not manifest in the way it did in this episode. You don’t suddenly collapse; the chest pain and breathing difficulties build up over a period of several hours – if not days, in the case of constrictive pericarditis. I simply can’t imagine Lucy going that long without noticing or complaining about the pain.
March 3rd, 2009 at 9:57 am
It’s not that I dispute that this episode deserves an ‘F’ in Medicine, it’s that scoring it thus seems inconsistent. As bad as it is, it isn’t worse than several other episodes. For example: House failing to comprehend the rudiments of science and statistics in Distractions (the self-induced migraine mess), believing that regular household appliances generate gamma radiation – and possibly focused right on the tumors too, suggesting potassium iodide as an antidote to x-ray exposure, etc. etc.). It’s just run of the mill bad medicine for the show, especially Season 3.
June 1st, 2009 at 2:06 am
Is temper issues and liking girls really that odd for an 8 year old boy?
I had severe problems with controling anger and had a definite sex drive before 10. I had no disease.
June 21st, 2009 at 12:35 am
I think that little girl acted pretty well.
When I found out House was the one who actually sent the flowers to Wilson, I was like, “Wow, House, you did a good job.”
March 31st, 2010 at 10:27 pm
Don’t the granulosa cells in the ovaries convert testosterone to estrogen? I seem to remember that from anatomy (admittedly, I’m a nonruminant nutrition student and anatomy was last semester) Excess estrogen could’ve caused the problem….but then again, testosterone excretion via skin seems quite unlikely. *shrugs*
July 8th, 2010 at 10:38 pm
I thought excess androgen could cause ovarian cysts?
November 3rd, 2010 at 2:09 pm
I have done countless hours of research on this very topic. My now 7 year old daughter began showing signs of precocious puberty at 5, although at 5 I didn’t know that’s what was going on. We went to the pediatrician and she blamed her acne on her overly sensitive skin (she has had this since birth). 8 months later I noticed the beginings of breast buds. 3 months after that, the beginings of pubic hair. FINALLY we were referred to a pediatric endocrinologist. We have had bone scans, MRIs, ultrasounds, countless blood tests- all of them came back normal, with the exception of her bone scan. Her bone scan tracked her at the age of 10 1/2 years old, at the time she was 6 1/2years old. After seeing this (rerun) episode of House, it made me question her father (we are divorced) about his medications and such. It turns out that he too has been on a prescription hormone cream. When I told this to the pedi endocrinologist he immediately tested her testosterone levels. They were also through the roof. I admit I am not a doctor, nor am I in the medical field in any way. I am just a mom who wanted answers as to why my little girl has these premature signs. Although we have a few more tests that she needs to go through, right now all test results are pointing to my ex husband’s cream usage. So, I do not know how it all works in the body to have these results but, I do know it can happen. My daughter is living proof.
April 17th, 2011 at 8:49 am
this is a feedback to t bird < thanks to the article but still its verlization due to parental use but this is cannot apply to the episode as Juscy is complaining of early menopause ???
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