Heh, heh. Nice one, Foster. Use his “mallet” indeed.
Oh wait, you were being serious? Damn.

In all her appearances, did Jane Foster perform any actual nursing?

Abby is a seventeen year old high school senior who becomes unresponsive while on a school outing to the planetarium. Foamy red sputum drips from her mouth and her boyfriend reports that she’s not breathing; she is rushed to the hospital and admitted to House’s service.

Abby is found to have pulmonary edema (fluid build-up the lungs). The team understands this to mean that she has either a heart problem or a lung problem. Her drug screen was negative and her blood alcohol level was barely positive. Foreman suggests she may have developed heart disease from binge drinking. A C-13 pyruvate MRI is ordered (a test that looks at blood flow within the heart muscle itself). It doesn’t show the heart disease Foreman was looking for, but there appears to be something wrong with the mitral valve. Fungus is considered as a possibility, but the team decides a fastidious enteric bacteria infection is more likely (enteric bacteria are found in the human intestine, and fastidious means they are difficult to culture). A TEE (transesophageal echo — an echocardiogram performed from the inside of the throat which offers good views of the heart valves) is ordered to get a better look at the mitral valve. Under echocardiography, the valve appears normal, but during the test Abby develops an aortic dissection (a tear in the wall of the aorta), a life threatening emergency. She is rushed to emergency surgery where Taub and Thirteen manage to successfully resuscitate her.

The question now is how did Abby develop the aortic weakness which led to the dissection? A genetic defect is mentioned, but quickly dismissed with the aside that she is not Marfanoid (Marfan’s syndrome is known to cause aortic dissections — of course, there are other genetic defects besides Marfan’s). An allergic reaction is also suggested as a likely cause. Thirteen believes that a severe immune reaction could have led to the aortic weakness. She goes on to suggest that Abby may be allergic to her boyfriend’s semen. A quick test is performed but shows no reaction. However, during the test, Abby develops excruciating abdominal pain and is found to have blood in her urine. “Kidney failure,” screams Chase.

The differential diagnosis now consists of neuropathy (by which they mean syphilis, which can lead to a weakened aorta), a blood clot, insterstitial cystitis, or cancer. A full body scan is suggested, but, for the second week in a row, House mentions how much he hates them (a point on which we agree — of course, House’s opinion would carry more weight if they hadn’t already ordered five or six this season — and he wasn’t a fictional character). Out of other options, House agrees to the full body scan, which is negative. This being House, no test can go smoothly, and Abby starts to hallucinate during the study. This causes the team to reevaluate their differential, which now consists of a vascular disease (probably vasculitis from the way Foreman is talking) or an aneurysm. An MRA (an MRI that looks specifically at blood vessels) is ordered to find the aneurysm, but it also is negative. Foreman suggests a parasite found in the Middle East, but House shoots him down abruptly, saying it was too ridiculous to even consider.

Abby continues to hallucinate, but now has also started to have seizures. House convinces the team to try an experimental technology (conveniently available at that very hospital): cognitive pattern recognition. In a scene more at home on Fringe than House, the team see the image of her boyfriend playing baseball, then the universe, then an older man (“her late father” they surmise) from Abby’s brain. Unfortunately, this isn’t enough to build any sort of diagnosis. Grasping at straws, Thirteen suggests something may be wrong with the liver. Chase suggests she may have polycystic kidney disease (which really would have been seen on that full body scan he wanted). Foreman notices the MRI shows that her pineal gland is calcified (which is normal), but wonders if it may be hiding a tumor. A high powered MRI is ordered to check but is completely normal. House is at a loss until a conversation with Taub triggers his Eureka! moment. It turns out that Abby boyfriend’s father travels extensively, to the Middle East even, where he picked up the parasite that Foreman mentioned earlier, which he passed on to Abby in a drunken sexual encounter. The parasite itself died, but it left enough behind to cause a severe allergic reaction which is causing all of Abby’s problems (Cerebellar schistosomiasis hypersensitivity allergy). A quick brain surgery (to the remove the parasite, presumably) and she is fine physically. Emotionally…is a different story.

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

Schistosomiasis is infection by the liver fluke. It is endemic in much of the world, including the Middle East. So far so good, however:
1. It is the eggs of the fluke that illicit elicit a potent immune response. The fluke can cause an immune response itself, but not the level the eggs do (the level Abby demonstrated)
2. The body walls the offending agent off in a granuloma which absolutely should show up on a scan.
3. Schistosomiasis is not transmitted from person to person; it has a complex life-cycle and needs an intermediate host.

Coincidentally, just this past Thursday, NPR ran a segment on using a computer and pattern recognition to read human minds. Suffice it to say that the scene on House bore little in common with reality.

5cc of Adrenalin is a high dose. Even in emergencies, it is generally given in 1cc doses (though it will likely take more than a single dose). Plus, in the medical profession in the United States we call it “epinephrine,” half the OR staff wouldn’t know what you wanted if you asked for “adrenalin.”

Taub is suddenly a cardiac surgeon now? There’s a great deal of difference between a plastic surgeon and a cardiac surgeon. They only share one year of residency — the rest is completely different.

We’ve discussed this before, many times, and in great detail last week, but once more: blood in the urine is not a sign of kidney failure.

If the offending parasite’s body was so small it didn’t show up on a scan, how did they know where to operate to remove it?

Only in the hospital for a few minutes, Taub breaks HIPAA (Health Information Portablilty and Accountability Act, a Federal law which deals with, among other things, patient privacy) by telling Abby’s boyfriend about her medical condition. That’s a big fine for the hospital. $$$$ Nice going, Taub.

I know I often complain about the unrealistic time course of tests on the show, but this week’s deserves a special mention: fungal cultures are very slow growing — weeks, not days — so there’s no way they’d be negative so soon.
To my knowledge, there are no blood cultures for parasites. They are generally detected by O&P (ova and parasite) studies of the stool and blood smears.

She seized for just about a minute, yet in that time they managed to hook up a multi-lead EEG and record the waveforms. That’s damn impressive.
And can we stop the “OMG! If she has another seizure she’ll stroke out!” That’s unrealistic and insulting to people who actually have a seizure disorder.

The medical mystery was average — nothing we haven’t seen before: C. The final solution really didn’t make much sense. If they wanted her to have schistosomiasis, they should have given it to her in a way which could actually happen. If they wanted the edginess of sex with her boyfriend’s father, they should have just made her allergic to his semen, as was discussed earlier. Combining the two was a bad decision: D. The medicine had holes this week, though no more than usual, other than House giving up so fast. I give it a B. The soap opera was good, though not as strong as the last couple of weeks: B+.

The review of the previous episode of House
A list of all prior House reviews

Sorry Doc, but you don’t treat a black eye by putting some sort of cream on it. Think of it this way: a black eye is essentially a bruise around the eye — and when do you put anything on a bruise? The real treatment of a black eye is easy: ice, and time. That’s it. Nothing fancy needed.

(Now in his defense, I guess the skin around the eye could have been broken open by the punch, and Blake might be putting some sort of antibacterial ointment on it, but that’s still a stretch).

Frankie is a 28 year old vegetarian (well, mostly vegetarian) who presents with a sudden case of severe coagulopathy (blood that won’t clot correctly — in Frankie’s case, her symptoms included facial bruising and bleeding gums). The initial thoughts include a congential thrombocytopenia (an inherited condition of low platelets), a toxic exposure, or a deficiency in clotting factors. House thinks the toxin exposure is the best option, and has the team search her apartment. Nothing is found in the search, but a conversation with a neighbor indicates that she has been exposed to rat poison (this is important because a common kind of rat poison is an anticoagulant and would explain her bleeding problem). Soon, Frankie complains of “muddy” urine, which the team takes to be a sign of kidney failure, meaning that rat poison was not the cause.

Looking at conditions which cause both a coagulopathy and kidney disease, the differential now includes hemolytic-uremic syndrome, Gaucher’s disease, Sjogrens syndrome (an autoimmune disease), and Haff disease (sudden development of rhabdomyolysis shortly after eating fish, thought to be related to some form of toxin). The latter seems the most likely and she is started on saline and mannitol (the suggested treatment for Haff disease is fluid and diuretics so these are reasonable choices). Chase still believes his suggestion of Sjogrens was the best, and reads over Frankie’s blog looking for clues. He sees one post mentioning decreased sexual arousal and he suspects this is due to vaginal dryness, a sign of Sjogrens. He wheels her into the x-ray suite to perform a sialogram (an x-ray of the salivary glands, because decreased saliva production is another sign of Sjogrens). He is unable to get the x-ray because she complains that it is uncomfortable to lie down. Chase recognizes this as a sign of valvular heart disease, and sure enough, an echocardiogram reveals severe problems with an unspecified mitral valve disorder (probably mitral valve regurgitation, as this has been associated with Sjogrens). Her condition is so bad that she will need an artificial mitral valve.

As she is being readied for surgery, Frankie develops severe right lower abdominal pain and vomiting. Emergency abdominal surgery reveals a burst appendix. Even worse, studies suggest that the appendix burst because it was full of cancerous cells — lymphoma — that has now spread throughout the body. The team tells her that it is too late for regular chemotherapy, but that she is a candidate for an experimental anti-lymphoma vaccine. Without it, she has maybe a year to live. She agrees and is started on the vaccinations. Everything goes well at first, but after the third dose she suffers a high fever. The suspicion is that the vaccine has triggered a severe immune response of some sort.

During a discussion of the case with Cuddy, the fact that Frankie is a night owl comes up in conversation because this is new for her. Until six months ago, she was up during the day instead of at night. According to the team, day-night reversal can be a sign of liver disease (true, to a point). A liver biopsy confirms that she has liver failure. What was initially thought to be lymphoma is now recognized as a granulomatous build up (inflammatory cells) related to the liver failure. Instead of a year to live, she is now given a few days.

Looking over her symptoms of fever, cell atypia, coagulopathy, liver disease, kidney disease, and heart disease, the team suspects some form of infection but can’t narrow it down any more than that (I don’t buy it: something inflammatory like an autoimmune disease could explain all the symptoms just as well). House orders her started on broad spectrum antibiotics. A later conversation with Wilson leads to his Eureka! moment. He realizes that in all her blogging, even the intensely personal stuff, she never mentioned her bowel movements. Direct questioning reveals that she had a change in bowel habits consistent with a malabsorption syndrome — in this case Whipple’s disease. A course of antibiotics and she’ll be fine (though she’ll still need the new mitral valve).

As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

The writers don’t seem to understand kidney failure. It is – just as the name suggests – a failure of kidneys – that is: they don’t work any more. Instead of normal urine production there is a decreased or absent urine production. Dark urine is not a sign of kidney failure.
Dark urine is a common sign of a bleeding disorder, just like Frankie has. It would be more proof of rat poison exposure, not less.
Her kidney labs are normal, at least the creatinine is (arguably the most significant one), so she has no actual signs of kidney failure.

How did they miss severe liver failure on this patient? Liver labs should be drawn for every patient with an undiagnosed clotting problem,and it should have shown up on her other tests as well.

I don’t buy the whole “the lymphoma is too advanced for chemotherapy” argument. What tests have they done to show how widespread the cancer is? What treatments have they tried and failed?
The vaccine only works for follicular lymphoma, a rare type, and it doesn’t cure it, it just extends the time until the inevitable relapse this type of lymphoma always has.

Frankie has severe enough mitral valve disease to require a new valve sooner rather than later, yet no one heard a murmur on exam?

Other than a possible Vitamin K deficiency, what other signs of severe malabsorption does she show? None. Where’s the long history of weight loss (no way she wouldn’t have mentioned that on her blog), joint pain, fatigue, and fever?

Day night reversal is a sign of severe hepatic encephalopathy, which is seen is severe liver failure.

Her bleeding and bruising came on incredibly fast. I wouldn’t call it impossible, just very very very unlikely.

I find it sloppy work that no one asked about her bowel movements until House finally did. (It’s one of my “big four” questions I ask every patient). Especially in a patient they were considered hemolytic-uremic syndrome in.

If the team ever did a thorough admission exam and history, these shows would be lucky to last a half hour. How many diagnoses have they missed because of sloppy exam or poor history?

Another interesting medical mystery — better than most this season. It earns a B+. The final solution was a stretch. If her Whipple’s (and liver and kidney) had really been that bad, there would have been many signs along the way. I give it a C. The medicine had lots of holes this week, and the parts didn’t add up. It deserves no more than a C-. The soap opera was good. It was nice to a non-melancholy Chase again, and the House/Wilson scenes were well down. The speed dating was terrifically over the top. The soap opera earns a swofting A.

The review of the previous episode of House
A list of all prior House reviews

Elizabeth and raininthehills both had the week’s high score with 12 points.

Overall, TRad and Noether continue their dominance, with 82 and 80 points, respectively. Theta Sigma is third with 57 points, Corien retains fourth with 54 points, and The Erskine holds on to fifth with 52 points.

Click here to see the full scoreboard.

Only it turns out, this isn’t the first comic with this scene. Sgt. Fury #6 (March 1964) features a similar scene.

Of course, the stories couldn’t be more different:
Sgt. Fury #6, by Stan Lee and Jack Kirby, features Lee’s typical bombastic storytelling. Fury and his squad take on Rommel’s entire North African Division, and were actually winning when they were stopped by the British Army — because the British had found out Rommel had to a part to play in a plot to assassinate Hitler and wanted him to follow through with it.

“What’s the Color of Your Blood” is more down to earth, featuring two former boxing champions meeting on the battlefield to decide once and for all who is the champ. (If you’ve never read it, the entire story can be found here, and is well worth your time).

The Atom is called to Arkham Asylum to treat a neurological problem the Joker is having. He has to shrink down to microscopic size, enter the brain, and release an “experimental chemical” at a specific location to cure the Joker.

There are many, many problems with this comic. I’m all for Fantastic Voyage homages, but it is obvious that Straczynski has no understanding of how the brain or nervous system actually functions. A twelve year old with access to Wikipedia and five minutes to spare could write a more accurate — and no less engaging — story.

The main stumbling block is Straczynski’s misunderstanding of synapses — the junctions between nerve cells*, where one cell passes a signal to the second cell. These synapses can be either chemical (a message molecule known as a neurotransmitter carries the impulse from the first cell to the second cell), or electrical (the two cells are connected by channels which allow an electrical signal — ions, really — to be passed from the first cell to the second cell).

I’ll just touch on a few of the bigger errors here:

What the doctor here is describing is not particularly rare at all. When too many synapses fire off, you have a seizure. If it involves part of the brain, it’s a partial seizure; if it involves most of the brain, it’s a generalized seizure. If the seizures happen repeatedly, then it’s considered epilepsy. If it is a seizure that cannot be stopped, then it is called status epilepticus, and yes, it can lead to brain damage and death (but it’s not rare: 42,000 deaths a year). • If the Joker really were in status, he’s be dead long before the Atom ever got there.

This is some horrible, horrible technobabble. I know everyone uses “the brain = a computer” metaphor, but it’s just that: a metaphor; a figure of speech. The brain is not really a computer — it is orders of magnitude more complex and you can’t “reboot” it. For one thing, I’d want my brainstem to keep working no matter what, since it controls such things as the heartbeat and breathing. • “Synaptic array at the microscopic level” is redundant. All human synapses are microscopic.

Straczynski seems to think that all synapses are electrical in nature, but that is not true — in fact, chemical synapses are much more numerous; electrical synapses only show up in certain pathways where speed is important — reflexes, for instance. He spends most of the issue confusing the two types of synapses. “Synaptic gaps” occur in chemical synapses; electrical synapses are tied together by ion channels. Chemical synapses are involved in the higher processes, like memory. Electrical synapses transmit ions from one nerve cell to another through channels in the cell membrane — there is no “electrical pulse” or lightning bolts (as drawn in the comic) between the nerves. The rest is just more technobabble.

For a better “The Atom in somebody’s brain” story, I recommend The Brave and the Bold (original series) #115, where the Atom controls a brain-dead Batman to solve his murder.

*There are also synapses between nerve cells and other cells, such as between a nerve cell and a muscle cell.

In the story, Pepper Potts granddaughter mentions:

“Five years ago I was one of the millions who caught G7N1. A Stark ubi-vaccine – something you were playing around with years ago – well, it saved my life.”

To me, G7N1 sounds like an influenza virus, so let’s run with that.

A little background:
Influenza A is the most pathogenic flu virus in humans. All known flu epidemics have been caused by it. Influenza A mutates rapidly, so new strains are developing all the time. The subtypes of Influenza A are named for two proteins coded by the virus: hemagglutinin and neuraminidase. Different strains of Influenza A have different versions of these proteins. So the H1N1 virus codes for hemagglutinin #1 and neuraminidase #1, H3N2 virus has hemagglutinin #3 and neuraminidase #2, and so on. So far, nine different Hs and 16 different Ns have been identified. Luckily, most strains are not pathogenic in humans — the main ones that are now are the H1N1 (swine flu), H3N2 (Hong Kong flu), and H5N1 (bird flu).

Influenza B is not as common as Influenza A. It does not mutate as quickly either, so it is not divided into subtypes. Because of the slower mutation rate, and the fact that it is can only infect a few distinct species of animals (humans, ferrets, and seals), Influenza B has never caused large epidemics.

Influenza C is even less common than Influenza B. Like Influenza B, it does not occur in more than one subtype. Generally, it causes mild disease in children, but occasionally Influenza C can cause a local outbreak, but never large epidemics.

Back to the speculation:
G7N1 — the name doesn’t fit an Influenza A virus (no “H”), but it is similar. Given the fact that the virus causes epidemics, it’s unlikely to be Influenza B or C. So it is most likely a new genus of influenza. As I mentioned, the naming pattern sounds similar to Influenza A, so maybe it started as a major mutation of A, or is suspected to have been derived from A at some point.

Also note that it is “G7” so there have been at least 7 subtypes of this heretofore unknown virus identified in about sixty years — a high mutation rate.

Here’s Magneto working hard, oblivious to the rest of the world, trying to save the life of a certain X-Men. I suspect his nose is bleeding from the effort of breaking the laws of physics –more than usual, that is. Magneto is using his power to affect an object so distant in space that his power his is traveling faster than the speed of light — which considering that his power involves generating electromagnetic waves is pretty damn impressive.

All previous Psychic and Superpowered Nosebleed Zen posts

Tags: comics medicine nosebleed magneto x-men