House finally returns to television with new shows, with a sadly mediocre outing, though it started out promising.
An episode recap, medical discussion, and spoilers follow!
Maggie, a 34 year-old single mother develops sudden and complete paralysis of her hands. A series of workups by orthopedists, neurologists, and immunologists is negative so she is admitted to House’s team. At this time her symptoms consist of flaccid paralysis (paralysis with loss of muscle tone) of both hands and intermittent numbness of her arms. There is a known family history of breast cancer and Maggie is positive for the BRCA1 gene (one of the breast cancer genes), so she had a double mastectomy (both of her breasts surgically removed) several years before because she felt her risk for cancer was too high. It also turns out that Maggie, and her daughter, never lie to each other. Never, ever. This becomes a source of fascination and aggravation for House.
Taub suggests paraneoplastic syndrome from some remaining breast tissue that may have become cancerous, but an MRI of the chest is negative. Later, he and Foreman talk to her most recent sexual partner and trick him into admitting that he slipped her some Ecstasy. In light of this, Maggie is started on dialysis, but she shows no sign of improvement — in fact, she gets dramatically worse and goes completely blind. The differential now includes problems with the dialysis solution, Kearns-Sayers Syndrome (a rare genetic disorder that includes abnormal heart conduction, paralysis of the eye muscles, and degeneration of the retinas), Multiple Sclerosis, or a vascular (blood vessel) problem. A variety of tests are run including an MRI and a fluoroscein angiogram of the eyes but both are normal. There is no evidence of any pathology including macular degeneration or optic neuritis. Her house is also searched and her computers brought in for House to examine. To him, her e-mails suggest increasing joint pain and fatigue, but nothing ever comes of this.
The differential diagnosis is now conversion disorder — a psychiatric condition where mental concerns are “converted” into physical problems — so the team lies to her and tells her that she has “infectious parapheresis” (a fictitious condition) and they have a medicine that will cure it right away. They believe they can trick her out of the conversion disorder. Unsurprisingly, it doesn’t work (because she doesn’t have conversion disorder, and even if she did, you can’t cure it that way), and once again, she gets worse with swollen lymph nodes closing off her throat. She is intubated initially but Taub is able to reduce the size of the lymph nodes so she can once again breathe on her own. A fungal cause is now suggested, as is sarcoidosis. It doesn’t really fit, but House orders a bronchoalveolar lavage (washing the lungs with sterile saline and then testing the fluid) just to be sure. As before, the test is negative, but as is usual for House’s patients, her symptoms dramatically worsen during the test. She is now bleeding into and out of her eyes. It turn out that her platelet count is extremely low so her blood cannot clot right. The differential diagnosis now consists of splenic sequestration (the spleen is trapping all the platelets), tuberculosis, gaucher disease (an inherited disease), TTP (thrombotic thrombocytopenic purpura, a blood disorder that leads to increased blood clots and then to low platelets), hemolytic uremic syndrome and lupus. House cuts off Kutner before he can finish suggesting more causes and orders a bone marrow aspiration (note the pictures at the bottom of the link — no drill is used). Chase attempts to perform the aspiration but runs into trouble when it turns out that her bones are as hard as rock — it seems that Maggie has osteopetrosis, a condition where the bones are harder than normal.
The team initially hopes the she has Carbonic Anhydrase Type II deficiency (CA2), because it is the only cause of osteopetrosis that is not fatal (not true, patient with adult osteopetrosis — also known as benign osteopetrosis — can have lives of normal length). The start to arrange a bone marrow transplant, but then tests reveal that Maggie does not have CA2, therefore they assume that she must have one of the fatal causes of osteopetrosis. (Along the way, House also determines that Maggie’s daughter is adopted, a fact Maggie never told her, meaning that she does lie to her daughter.) A causal conversation with Wilson convinces House that he missed something, so he injects Maggie with Risperidone. This antidepressant antispychotic drug can cause breast tissue enlargement, and House figures that Maggie has abnormal breast tissue somewhere in her body that has become cancerous and is using the Risperidone to find it. Sure enough, an area behind her knee swells up and House is even able to get breast milk from it. Maggie has osteopetrosis related to Breast Cancer and paraneoplastic syndrome. He tells her and her daughter that after surgical removal of the cancer and chemotherapy, she should recover.
The medicine, particularly in the second half, was pretty shaky tonight.
First, there is a difference between osteopetrosis and osteosclerosis. Osteopetrosis is a type of osteosclerosis, but the terms are not interchangeable. All the causes of osteopetrosis are genetic, and if Maggie had one of these diseases, it would have shown up with other symptoms long before now.
Osteosclerotic (and osteosclerotic) bone is harder than normal, but so hard that it is actually brittle and fractures are common. Chase would have shattered the bone, not scorched it — plus I find it harder to believe that any bone, even hardened bone, would be stronger than surgical steel. And a drill for a bone marrow aspiration? No way, a special needle is used.
Breast cancer can cause osteosclerosis…in metastatic lesions (breast cancer that has spread to the bone). This means that individual spots on the bone will be sclerotic, not the entire skeleton. It is also only in metastatic disease, which has poor survival even with surgery and chemotherapy…so not quite the rosy recovery House suggests.
Risperidone may cause breast tissue enlargement and galactorrhea (milk production), but that doesn’t mean it will. It’s a very rare side effect. It certainly doesn’t occur that fast and after a single dose.
Conversion disorders are extremely difficult to treat and you can’t cure the patient with a placebo. If that were the case, then every cure would work because the patient believed it would.
You don’t use dialysis to treat an ectasy overdose, but then ecstasy is often cut with even worse drugs so who knows what was actually in the pills, and dialysis can be used for an unknown overdose (and that’s why they tested the pill itself).
I give the medical mystery a B because it was genuinely interesting. The final solution, though clever, falls apart on close examination so scores a mere C-. The medicine started out good, but ended up bad, and that averages out to a C. The soap opera was good, both with the team and Secret Santa, and the “I never lie” family. I give the soap opera a solid A.
For the record, Contagious Ecthyma is a viral infection of ruminants — usually sheep and goats — that can be passed to humans. The lesions heal on their own, no treatment is necessary. Contagious Ecthyma is also known as Orf — a disease I’ve been predicting would show up on House for several years (though I neglected to put it on my challenge list). As far as I can tell, it does not affect donkeys or mules.
The previous House review
A list of all prior House reviews
Challenge scores can be found at the post immediately beneath this one (or click here)
Tags: television medicine house paralysis blindness osteopetrosis breast cancer
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