House – episode 17
A rising black politician has just finished giving a speech when he suddenly collapses. He blames it on being overworked and under the weather for the past few weeks. A physical exam turns up some neurological abnormalities and a lumbar puncture and brain MRI are performed. The MRI shows a suspicious lesion that is ultimately determined (after brain biopsy) to be toxoplasmosis. Dr. House and team suspect that this means the politician has AIDS, because that is by far the most common cause of disseminated toxoplasmosis. The politician swears he does not have AIDS, and while a first HIV test is positive, a second test is negative. Discarding the AIDS diagnosis, the doctors concentrate on cancers that could be causing his symptoms such as hairy cell leukemia. Ultimately, House diagnoses the patient with Combined Variable Immune Deficiency (CVID) based on the combination of a seizure medication and common infection the patient had as a child. Some immunoglobulin shots and the patient is good to go.
AIDS is a logical thought when severe toxoplasmosis is found. The idea of repeating the HIV test doesn;t make much sense as most HIV tests are already a double test – an ELISA followed by a Western Blot if the ELISA is positive (to check for false positives, such as was the case in this episode). The seizure medication phenytoin (brand name Dilantin) has been associated with CVID, as has Epstein-Barr Virus. However, it’s not the double whammy of the two together that can cause CVID as House suggests; instead it appears that that either one alone can cause it (though genetics seems to be a more common cause of CVID). I also find it suspicious that the patient’s CVID had remained quiet for thirty years before suddenly showing up as two serious (and dramatic) fungal infections in a matter of days. A more realsitic scenario would have the politician suffering recurrent common infections for years before developing a more serious infection such as toxoplasmosis or PCP.
The soap opera was good again this week, but not quite as tense as the previous episode. I get the feeling that the writers are setting us up for something big. The writers also seem confused about Vogler’s motivation. He wants to get rid of House becuase he’s costing the hospital money, but also chooses him to speak on his newest drug because he’s a well-known and well-respected physician. Anyone who’s well-respected enough to introduce a new cardiac drug — if they’re not a cardiologist — would be well-known enough to bring a great deal of money into the hospital. The writers are trying to have it both ways: House is famous enough to for Vogler to pull his little stunt, but not famous enough for Vogler to want to keep him around. Puzzling. And don’t get me started on Vogler’s conflicts of interest…
The mystery gets a B+ with the ultimate solution getting a B- (the timing is just a little too coincidental). The medicine earns an A-. The soap opera earns a B.
When Dr. House announces that the patient has AIDS, my wife looks at the clock then looks back at me.
“He can’t have AIDS,” she says. “We’re only fifteen minutes into the episode.”
And she was absolutely correct. The show’s writers really need to make this a little less predictable.
The Good News: House has been renewed for a second season.
The Bad News: Because of this, Hugh Laurie will not be able to play Perry White in the upcoming Superman movie. Instead Frank Langella will. I’m not sure I see that.
Reviews of past House episodes.
April 13th, 2005 at 8:00 am
“The show’s writers really need to make this a little less predictable.”
I should be more annoyed at the formula than I am. House makes a bizarre diagnosis, they run some tests, the patient goes crazy, they do some detective work, House makes another bizarre diagnosis and prescribes a treatment which, if wrong, will kill the patient (or at least not save them from dying anyway), House turns out to be right and patient is saved. (Sometimes, there are two wrong diagnoses instead of one, just for kicks. And often they figure it out just in time to narrowly avert a wrong treatment that would have permanently damaged the patient in some way.) It’d be nice if they mixed it up a bit though — and maybe the whole point of setting up that routine is to throw us a curveball later on.
April 13th, 2005 at 10:05 am
They seem to be using the ‘48 minute reveal’ formula of most current crime dramas.
I thought it interesting that House found out who was the snitch and seems now inclined to make that doctor’s life a bit of a hell. Also a bit surprised about which doctor is leaving, but not surprised by the reason. It’s a bit of a cliche, after all.
I’m not sure Volger wants to get rid of House because he costs the hospital. That’s his stated reason, but I think over the course of the last few episodes we’ve seen that it’s really more a battle of ego. He wants House gone because House isn’t a lap dog.
April 13th, 2005 at 2:57 pm
House ascribes the sudden outbreak of the CVID to the stress of running for public office, making the outbreak a little less sudden. Whether that makes sense or not I will leave up to you.
And the preview for the next episode makes it appear that the person who quits at the end will not be the one leaving the show.
April 13th, 2005 at 3:59 pm
I have to disagree re Perry White. I’m a big fan of Hugh Laurie (especially on “Jeeves and Wooster,” but I think he was a terrible choice for Perry. Langella has the right gravitas and gruffness.
But, then, I’m very dubious about this whole Superman movie, anyway.
April 13th, 2005 at 9:18 pm
Is it so illogical that House is both well-respected and not making money for the hospital? He has no patient base. Nobody comes to the hospital to see him, and if they did, he’d probably refuse. He only works on a case if he feels like it. Sure, there are the clinic cases, but they only get to him by luck of the draw, right?
Still, thank you, thank you, THANK YOU, for providing informed but not anti-House medical background. I mean, it’s fiction, so I don’t expect total accuracy, but it’s fun to second-guess the writers. I’m definitely bookmarking you.
April 14th, 2005 at 12:31 pm
Love your House discussion. I too am very fustrated by the Volger character – he needs to get sick enough to warrant a brain biopsy. Since CVID is dx by the immune levels – why in the heck did they not run that panel when they were “re-running” the HIV. CVID has nothing to do with stress and everything to do with infections. Trust me, I have it. Can’t wait to see what they throw at House next.
April 20th, 2005 at 2:11 pm
Glad my husband and I are not the only ones who looked at the clock when the AIDS diagnosis came in. The medical stuff is fascinating but needs a bit of shaking up. Volger was added I assume to make the show more interesting but it has taken out the great House v Cuddy stuff I enjoyed and I am not sure where its going. Kind of scary to think someone can buy a hospital just because they can afford too isn’t it??
May 20th, 2005 at 9:18 am
Late commenting here, but I just found your site! Thanks! I love this!!
What do you think of the “Toxoplasmosis” in this episode being called a fungus? I’m pretty sure it’s a protozoa, not a fungus, but they said “fungus” multiple times in this episode. My friends and I were all bug-eyed at those references. That seems a pretty big lapse to me–but it may be because I’m a vet. med student and Toxoplasma is so important to us. Is it considered/treated as a fungus in human medicine?
December 27th, 2006 at 6:24 pm
I wouldn’t dare to scare the hell out of a patient by telling him he has AIDS without the proper lab work to back me up.
December 30th, 2006 at 1:59 pm
Is it just me, or did the black senator bear an uncanny resemblance to Barack Obama?
January 22nd, 2007 at 7:40 pm
In this episode, the politician is sitting on the edge of a table with his lower legs hanging. One of the three duckings uses a hammer to test his patellar reflex. When they cannot elicit this, House says the problem is in his brain. I thought the patellar reflex does not reach the brain. Am I correct?
March 23rd, 2007 at 2:17 pm
About the toxoplasma reference, it made me sad when I saw it, too. I think the misudnerstanding came from the fact that the protozoan has a sporozoite stage. Someone probably saw “spore” and connected it with fungi. It would make sense for them to do research about the things they mention in the show, but then what would we bio nerds have to do? :-)
April 20th, 2007 at 3:35 am
Technically, toxoplasma gondii, like malaria, is a plant; certain drugs were found to work against them that shouldn’t have (they didn’t inhibit the cellular nor mitochondrial ribosomes and the experimenters knew that these were ribosomal inhibitors) and then they realised that a third circlet of DNA (the golgi adjunct) was the bit with the affected ribosome; this turned out to be the DNA of a chloroplast.
July 18th, 2007 at 4:28 pm
Toxoplasma is neither a plant nor a fungus, and protozoan is a dirty word in the brave new world of molecular phylogeny. Toxoplasma is an apicomplexan. It is closely related to the organism that causes malaria (Plasmodium), and very distantly related to brown algae (kelp/kombu, etc.), but these aren’t really plants either – in the sense of organisms with primary plastids. Toxoplasma cells do contain the evolutionary debris of a secondary plastid (the apicoplast), hence the potential usefulness of certain herbicides in treating aplicomplexan parasites. Since we’re arguing about kingdom Plantae and kingdom Fungi, the nearest thing to a kingdom to which Toxoplasma belongs is termed the Chromalveolata (well, this week at least). I’m guessing ‘the chromalveolate is invading your brain’ was a bit technical.
July 24th, 2007 at 3:07 am
I just watched this episode tonight, and I thought the whole speech scene was a bit odd. Vogler goes on and on about House’s integrity, and then was shocked and dismayed that House displayed his integrity? Vogler’s trying to have it both ways too.
October 12th, 2007 at 8:28 pm
I am also confused about the knee reflex thing. Basically this monosynaptic reflex circuit should be a circuit consisting of a sensory afferent relaying a signal from the periphery to a motorneuron which in turn should innervate the neuromuscular junction. Only higher motor functions should be connected to the brain over the Cortical Spinal Tract. So how can House say that its a problem with the brain when the Senators knee doesn’t react?
October 31st, 2007 at 5:01 pm
Re: The patellar reflex – reflexes are indeed affected by events in the brain – it’s the modifying effect of the descending fibres. For instance, in strokes you get increased reflexes on the side (or opposite side as it is) affected. However, I’m not sure about how toxoplasma patients present.
x
December 11th, 2007 at 10:32 am
Yeah, it was a great episode until they said that Toxoplasmosis is a Fungal disease….. Whoops, ruined it for me… as it is a protozoan parasite, not fungus… Sorry House, your wrong buddy…
December 21st, 2007 at 6:53 am
I’m enjoying your reviews very much– my wife and I just started watching House season 1 on DVD (we’d missed out on the fun until now) and I’m reading your blog entries after we watch each episode. Great job!
I did want to comment on something– “The idea of repeating the HIV test doesn’t make much sense as most HIV tests are already a double test – an ELISA followed by a Western Blot if the ELISA is positive (to check for false positives, such as was the case in this episode).” If the false positive rate was what House stated it was in the episode– 1 in 5000– then this would not be so unusual, as a Bayesian look reveals that the chance that a positive is false would then be 3.2% (assuming a prevalence rate of .60% in the population)– pretty low, but within the realm of possibility. Unfortunately, a quick search reveals that the false positive rate on an ELISA and Western Blot is more like 1 in 250,000, which would make the Bayesian chance that a positive is false more like .067%. The writers probably confused indeterminate results on the Western Blot with false positives.
December 26th, 2007 at 8:07 pm
As an immunologist, this episode made no sense!
CVID does not usually present as a T-cell/AID”S like disease. Toxoplasmosis is not that common. Even if he got toxo from having CVID, why would IVIG work better than anti-toxo drugs? IVIG is good for B-cell deficient patients with bacterial respiratory infections, not for protozoal infections.
For the record, CVID can show up in mid-life, but usually presents as recurrent pneumonias/severe pansinusitis and bronchitis that occur multiple times per year. I had one patient with early onset CVID that had had twenty pneumonia episodes before the age of 16.
May 3rd, 2008 at 5:47 pm
“False negative on the P.C.R aids test?”
“Ran it twice.”
When did a ELISA start having anything to do with a Polymerase chain reaction?
Assuming he is talking about the ELISA, which he did run twice.
A PCR on a retro virus as HIV seems highly unlikely to find proper Primers.
Or am I missing something here?
July 10th, 2008 at 2:54 pm
Another one confused on the reflex point. My understanding was that upper motor neuron lesions show up as brisk, rather than absent, reflexes…. is this a mistake, or am I missing something?
July 22nd, 2008 at 12:17 pm
The “toxo is a fungus” mistake from Foreman AND House was really disappointing… as well as the dumb announcement “you have AIDS [even though we haven't tested you]“. As pointed out above, toxo is a “protozoan” i.e. a protist, quite closely related to malaria parasites, with not dissimilar aetiology of disease caused by the relevant bits of the lifecycle. Surely in the House world of cool mildly unbelievable experimental treatments they could’ve brought something in about the plastids in apicomplexans?
re the AIDS thing, it would’ve been possible to squeeze all the required poignancy out of the situation by having the politician bloke refuse his HIV test, without that “you have AIDS” announcement being so stupidly unbelievable (even for House)… and without the incredibly unlikely false positive….
What I don’t get is that they clearly have some good medical advice, and yet they so frequently have really basic mistakes. Are they reading a medical dictionary? Or do the scriptwriters decide not to follow medical advice?
When will a medical drama exist that is as good as House AND gets its medicine right? So many of the mistakes are spectacularly unnecessary…
August 25th, 2008 at 10:01 am
Each alone EBV and phenytoin can cause fluctuant immunodefficiency.
August 27th, 2008 at 4:16 am
Are toxoplasma and pneumocystis really funguses? I thought they were protozoa.
September 19th, 2008 at 4:56 pm
Kristin–I totally thought the same thing. Pretty much everything he did reminded me of Obama.
October 23rd, 2008 at 12:36 pm
re Toxoplasma: Wouldn’t have been a bit more adequate, accurate and simple too to say “unicellular parasite” instead of fungi (or “chromalveolate” :) ) ?
November 4th, 2008 at 7:23 pm
Did anyone else notice that Foreman told the politician toxoplasmosis was caused byt a FUNGUS? Toxoplasma gondii is a PROTOZOAN – not even in the same kingdom. What whack doctor is House’s technical advisor?
November 4th, 2008 at 8:09 pm
It appears that Barack Obama’s…..I mean Senator Wright’s chances of winning weren’t so bad after all.
December 8th, 2008 at 7:28 pm
I agree with Brandi and Kristen. Looking back now (I didnt see the episode when it originally aired) I see a clear Obama representation as well! And its funny how House matter of factly states “there will never be a black president in our lifetime” or something to that effect. I dont know the if the resemblance was accidental in this episode, or if the writers were trying to make a statement. It would be cool if they were, but Im inclined to believe the former. Its kind of hard to see 2-3 years into the future so, maybe its all just irony in hindsight.
December 8th, 2008 at 7:34 pm
Markin, after gaffe after crazy gaffe, I really believe they dont even use tech advisors, med consultants anymore. I mean, it just keeps getting sillier and sillier. I think if they had a med advisor, they cut him from the budget long ago. now its all just the writers writing just what “sounds good” and throwing fancy terms together that they assume laypeople will just assume are true (or not care to find out otherwise, be too interested in the drama.) Eh, I love the drama, but they screw that up too sometimes, so maybe if they could just consistently get one out of two right, I’d be happy. :P
March 8th, 2009 at 3:18 am
A little late but,
Perhaps the reason why Vogler wants to get rid of House is that he is ultimately more of a liability to the hospital than an asset?
March 12th, 2009 at 12:32 am
Volger simply does not like House. House is a rebel. And Volger likes to control everything. House refuses to conform. So really its a power struggle. When Volger first got there, House told him he cant do anything about him because he has tenure and it requires a unanimous board approval to fire him. House told him he wont be able to get that because he has Wilson and Cuddys vote.
June 18th, 2009 at 11:37 am
CZllyvilly5, House didn’t say there would never be a black president – he was pressing Senator Wright about his sexual history (following the positive HIV test, which later turned out to be a false positive), and said he believed there could one day be a black president, a gay president, even a gay black president, but the one combination he couldn’t see happening was “gay, black and dead”.
October 4th, 2009 at 6:45 pm
No one mentioned the sexsomnia case? That was the most interesting bit of all! :D
December 17th, 2009 at 6:17 pm
writer ruins fairly good episode again by making stupid mistake……i dont have to repeat its already been said in above comments but i am compelled to say it “TOXOPLASMA IS NOT FUNGUS ITS PROTOZOON”….they could have even call it parasite no body will bite them! except our friend mr. steve cook the molecular phylogeny guy!….sorry man just kidding….
they’ve really ruined great episode
December 17th, 2009 at 6:28 pm
Pneumocystis carini is misnomer real name is Pneumocystis jirovecii……….its was initially thought to be parasite but later in re-classified as fungus [yeast like fungus] thats why it sounds more like parasite!
December 23rd, 2009 at 12:48 am
Not sure what everyone’s talking about here. Firstly, HIV is not synonymous with AIDS. A lay person might make that mistake but Foreman and the great Dr House!? Absurd. Secondly, you don’t test for AIDS. You test for HIV (the virus which causes AIDS). AIDS is a syndrome which means multiple signs and symptoms are present some of which are AIDS defining. Not one sign i.e toxoplasmosis. And again by definition, such signs and symptoms can’t just disappear with repeated lab test! They remain but the cause (i.e not HIV) IS what alters.
December 23rd, 2009 at 1:02 am
and Nick. You’re absolutely correct. If they wanted a fungi associated with the immunosuppressed go for Candida. Totally innocuous member of the normal flora and a common opportunistic pathogen with clearly visible hyphae on microscopy.
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