Alex (Born: Alexandria Robinson) was the supermodel patient in Skin Deep.
Medical History[edit | edit source]
Although the patient had well developed secondary sexual characteristics, she had not yet started menstruating. Alex also had an addiction to heroin.
Case History[edit | edit source]
Alex's dad had just given her Valium during a fashion show because she was nervous and nauseous. However, she soon became dizzy on the catwalk, deliberately (although not consciously) struck another model twice and then collapsed.
Dr. Cuddy presented the case to Dr. House. She presented with double vision, sudden aggressive behavior and cataplexy. He became interested in the case of the "teenage supermodel". He went to visit her and asked her what set off the brawl. Alex informed him that she didn't even know the model that she hit. Alex told him that when she collapsed, she knew what was going on around her, but could not walk or move. Dr. House informed her the medical term was catoplexy. He asked how much she had been drinking, and her father said she only had a sip of champagne. However, he also admitted he gave her Valium. However, Dr. House assured him that that couldn't be what caused the symptoms. When asked about her sweating, Alex said that she'd been nauseous for a couple days. House told her that his team would be by shortly to draw some blood and collect urine.
Dr. House instructs Dr. Cameron to do the blood work, get a tox screen, and take a more complete medical history. The tox screen showed Valium and Heroin in her urine. Dr. Chase pointed out that she had never menstruated. Dr. Foreman started eliminating symptoms that could be caused by drug withdrawal, and lack of a menstrual cycle was also consistent with withdrawal, However, Dr. Cameron argued that that could just mean bulimia or that she was just late starting - many 15 year olds haven't started menstruating yet. However, Dr. House noted her secondary sexual characteristics. Cameron thought that it could be neurological, such as juvenile multiple sclerosis or Parkinson's disease. Dr. Foreman suggested detox using methadone, but Dr. House noted that would take four weeks. If there were an underlying condition, the patient could die in the meantime. He suggested using a rapid detox procedure - put her in a coma and pump her full of naltrexone to detox her in one night.
Dr. Foreman told the father about the heroin. He was unaware of it. Foreman told him about the rapid detox procedure. The father asked how dangerous it was, Foreman told him that there are certain risks, such as a likely overdose if she relapses. He reluctantly consented on the condition they not tell the patient how dangerous it was. They induced a coma just as she was starting to feel withdrawal pains. While in the coma, Alex had a heart attack. She was clinically dead for under a minute,. but they managed to stabilize her
The father wanted her out of the coma worried that she would have another heart attack. But House told him what kind of pain Alex would be in due to the opiate blockers if they woke her up. It convinced the father to keep her in the coma. The father was worried when it took Alex a while to wake up, but she woke up about thirty minutes after they withdrew the anesthetic. She was not in any pain. She apologized to her dad for getting addicted to Heroin. Dr. Chase started a banana bag. Then she started saying exactly what she had said before, indicating anretrograde amnesia and short term memory loss. Dr. Foreman thought it was from hypoxia during the heart attack which was caused by the rapid detox. However, Dr. House pointed out that it takes more than thirty seconds of lack of heart activity to cause brain damage. Dr. House thought that she had Post-Traumatic Stress Disorder due to the fact that her father may have sexually abused her. He noted that the father was always with her. Dr. Foreman noted that this theory was completely unprovable and exculpated any action Dr. House took to treat her. Dr. House ordered an MRI and lumbar puncture to confirm she had no brain damage, which would only leave PTSD as the cause. Dr. Foreman accused Dr. House of letting his personal pain influence his judgment.
During the MRI, Alex could not keep still as her muscles were twitching.
House asked her father if he was sexually abusing Alex. He assured the father he was covered by doctor-patient confidentiality. Dr. House told him that there is treatment for PTSD but that is only if there is a definitive diagnosis. If he didn't confess to it then Alex would die. The father finally admitted that it was just once and he was really drunk.
Dr. House informed the team about the abuse and ordered a psych referral. However, his team informed him that the lumbar puncture showed that she had elevated proteins in her CSF, which ruled out both PTSD and the rapid detox as a cause of her neurological symptoms.
Dr. Cameron wanted to report the father - suspected abuse has to be reported by law. But House told her that he wanted him here in case there was something else that they had been lying about that he needed to know to diagnose her. They started a differential for the elevated proteins and came up with viral encephalitis and Creutzfeldt-Jakob disease. He told them to do a brain biopsy. Dr. Foreman wondered if they should, but Dr. House reminded him that if they didn't figure out what was killing her, she would die.
Dr. Foreman explained the procedure to Alex and she consented to the brain biopsy. Alex was prepped and the procedure went well. Dr. Cameron reported the abuse to Dr. Cuddy, who confronted Dr. House about the failure to report and told him that she had already called child services and that he had better cooperate with the investigation.
The biopsy came back normal - there was nothing wrong with the white matter of the brain. They started a new differential on grey-matter brain diseases and came up with neuronal ceroid lipofuscinosis, Heller's syndrome and mitochondrial encephalomyopathies. However, there are no definitive tests for gray matter diseases. Dr. House thought that she may have had a cancerous tumor causing a paraneoplastic syndrome that would explain all her symptoms. However, paraneoplastic is rare in 15 year olds. However, there was a way to confirm it. Dr. House stopped the twitching by giving her intravenous interferon which sweeps up all the antibodies that cause the twitching. However, all that did was prove that she had cancer - it didn't tell them where the cancer was.
However, they did several scans and biopsies, including an MRI and mammogram which showed no sign of cancer. However, the patient was still rapidly improving on the interferon. The pancreas and bones were clear. Ovarian cancer had been ruled out and Dr. Wilson told Dr. House that the scans merely showed her ovaries were undersized. The patient just couldn't have cancer. However, even Dr. Foreman thought it had to be cancer, but Dr. House told him to rule it out. Dr. Chase suggested that perhaps the proteins in her spinal fluid were an anomaly or a strange presentation of PTSD. However, if it were PTSD, the twitching wouldn't have disappeared with the interferon. However, Dr. House thought that she may have been subconsciously faking the twitching and subconsciously stopping the twitching when he gave her interferon - the patient watched him do it. Dr. House ordered the interferon discontinued to see if the twitching came back.
The social worker spoke to Alex, who denied sleeping with her dad. Her father denied it too and the social worker dropped it. Dr. Cameron confronted the patient, but Alex told her that she deliberately got him drunk so that she could seduce him and afterwards he would let her do whatever she wanted to. She told Dr. Cameron she also slept with her financial manager, photographer and tutor before she slept with her father. Otherwise, she would be getting C's on her report card and would still be working local advertising campaigns. She asked Dr. Cameron if she ever tried to sleep with her boss or a professor. The twitching returned, showing that the effect of the interferon was real and not psychological.
However, after Dr. House treated a male patient who was having a sympathetic pregnancy, he asked Cameron if Alex had developed pubic hair. Cameron said she only had a little. House also noted that the patient had a total lack of aggressive behavior, and again raised the fact she had never menstruated. Dr. House and Dr. Cameron did another MRI. He pointed at the tumor, which was in her groin next to structures that looked like testicles.
Dr. House told them about the tumor being on her left testicle. He explained to Alex that she had male pseudohermaphroditism. All fetuses start out as girls, but with an XY chromosome pair, the structures that are ovaries in a girl develop into testicles and drop through the abdomen. However, in about 1 out of 150,000 births of an XY child, there is a genetic condition that does not allow the body to process testosterone. As a result, she can only process estrogen which is why she had heightened female characteristics. Dr. House schedules the patient for surgery. However, the patient is deeply upset and disrobes in front of Dr. House shouting that she is a girl. He tells her anger is solely due to the cancer and she will be fine after surgery.
The surgery goes well and Dr. House set her up for a psychiatric visit. He guessed that her father would never sleep with Alex again.