This medical review of House contains lots of words (probably too many) and several spoilers, so don’t say I didn’t warn you…

Fletcher Stone, a famous journalist, is at an office function when he falls and hits his head on a desk. There is some confusion whether he tripped or fell. He was knocked unconscious briefly, and when he came to he was unable to speak normally. He had developed aphasia and he only spoke in random words. He could understand what was being said, but was unable to talk intelligibly. When he was later examined in the hospital, he was also noted to have agraphia, the inability to write. Both aphasia and agraphia are signs that something very bad is going on in the brain.
Stone had apparently been the stereotypical “wild journalist” for most of his life. He had volunteered for risky assignments, drank copious amounts of alcohol, and indulged in frequent recreational drug use. He gave up all his vices when he got married a few years before the episode occurs.
House is away in Baltimore and Cuddy wants to transfer Fletch to another hospital. Foreman convinces her to let the rest of the team handle the case, though they keep in touch with House by phone for most of the episode. They initially suspect that Fletch may have had a stroke, suffered a seizure, or may be having a medication reaction. A carotid Doppler was normal as was an EEG. Fletch suddenly develops a coughing spell and has trouble getting oxygen. He is emergently intubated and placed on a ventilator. A chest x-ray shows pulmonary edema (fluid build-up in the lungs). He is given a diuretic (a “water pill”), which apparently worked very well because he is never shown intubated or having breathing problems again.
Meanwhile, his drug screen has come back positive for amphetamines. His editor confesses that Fletch had found difficulty sleeping in his new married life, so he started taking sleeping pills. Those made him too tired during the day, so he started taking amphetamines. Of course his wife knows nothing about this.
Fletch starts running a fever of 101. The team is now concerned about infection (encephalitis or meningitis) or an autoimmune disease. The treatment for these two conditions is very different, and treating both would be counterproductive, so they have to choose one treatment and go with it. House suggests treating the suspected infection with antibiotics and antivirals. He also insists the team obtain an MRI. The MRI shows brain swelling; it also shows scarring in the brain — as if from an old injury — but not in the areas of the brain that would cause aphasia.
Feeling they’ve reached a dead end, the team falls back on an old House standard: breaking and entering. Foreman and Chase search Fletch’s office and home. They find the sleeping pills and amphetamines, as well as a bottle of Topamax (officially a seizure medication, though it has many unofficial uses). At the hospital, Fletch starts complaining of a metallic taste and Cameron realizes that he is going into kidney failure (a metallic taste in the mouth is a symptom of kidney failure).
A lumbar puncture is performed. This can be a dangerous procedure on a patient with elevated intracranial pressure or brain swelling. When the puncture is performed, a sudden drop in intracranial pressure can occur. In patients with swelling, this can be enough to smash the brainstem against the spinal column, causing death. Luckily, Fletch’s test is performed safely and shows some non-specific signs of infection.
Belatedly, the team realizes that Fletch is hiding some of his past from his wife. They lure her out of the room and are able to discover that Fletch has bipolar disorder, which is why he had been taking the Topamax (one of its unofficial uses is as a mood stabilizer). To “cure” his bipolar disease before getting married, he had crossed the border into Mexico or the Caribbean and had an experimental brain surgery designed to cure bipolar. It didn’t work, but it did cause the scarring that the MRI revealed. Also, while he was “south of the border” he contracted malaria, and that is the underlying disease that had been causing all his problems. Fletch is soon cured of malaria, but sadly, his wife had left him because he kept too many secrets from her.
The writers played very loose with the diagnosis of aphasia. The symptoms shown by Fletch (sentences seemingly composed of random words – yet retaining understandable syntax) are not common in any type of aphasia, particularly the “expressive aphasia” Cameron mentioned. In addition, the idea that one can “decode” aphasia is simply ludicrous.
The final solution of malaria was a bit of a letdown as well. Malaria can certainly cause kidney failure and pulmonary edema, but it’s very rare and only in very severe cases. I’m not certain how the malaria caused the aphasia — a stroke maybe? — as that part was conveniently left unexplained. I find it hard to believe that malaria severe enough to cause renal, pulmonary and neurological disease would not have been easier to diagnose; there are many more common early symptoms including the classical cyclical fever (a high fever recurring like clockwork every 24-36 hours). According to the timeline of the episode, Fletch would have to have had malaria for several years without knowing it — something unheard of. While a mechanically tested blood sample would not show malaria specifically, it would show other abnormalities that could be picked up on. Finally, intravenous quinidine is not routinely available in the United States and must be shipped directly from the CDC so the hospital would not just have some on hand.
The soap opera aspect consisted of House and Stacey flying to Baltimore to defend House’s Medicare billing. A snowstorm leaves them stranded in Baltimore and in a single hotel room. There is some mutual smooching going on, but then the case intervenes. Things are left up in the air between House and Stacey, but with a definite “this is never going to work” undertone. I’m not sure why they had to fly to Baltimore (except to get them together and out of the hospital). The billing inquiry could have been handled over the phone or by mail.
I give this episode a B+ for the mystery, bot only a C- for the solution. The medical content also earns a below-average C- (mostly for the “decode the aphasia” scenes). The soap opera earns a B.
Tags: television medicine house aphasia malaria.