Case HistoryEditWhile having sex with his wife, Bob suddenly had trouble breathing. After she called 911, his wife noticed that his lips were turning blue.
- "Yes, we need an ambulance at 10600 Xavier, here in 4B, my husband can’t breathe! Oh my God, he’s turning blue, you have to send someone now, please! Hurry!"
- ―Maria calls 911
- "The last one had no idea, just referred us to Dr. House."
- ―Bob explains his referral
Dr. Cameron reported back to Dr. House. Dr. Foreman thought it might be vocal cord paroxysms from rough sex - it can cause choking. However, there was no sign of neck trauma. Dr. Chase thought they should reexamine the possibility of food allergies. Dr. Foreman thought it was a neurological issue like progressive bulbar paralysis. However, Dr. Cameron pointed out that ALS would affect the muscles in his face first. Dr. House thought that the patient may have mistaken suffocation for choking and the problem might be in his lungs instead. He ordered further blood tests, a CT Scan of his chest and a plethysmograph.Bob was instructed to pant for the plasismograph. It revealed decreased lung capacity indicating interstitial pulmonary fibrosis. However, the cause was unclear. Arthritis, sarcoidosis and prescription drugs had been ruled out, and he had no exposure to coal dust or asbestos. Dr. Cameron thought it was ideopathic, but Dr. House corrected her - the cause was currently unknown, but there was no evidence that it couldn't be traced to a cause. However, for the time being, Bob was stable. Dr. House wanted to wait for a new symptom to appear. At that moment, the team was paged - Bob was complaining of a severe itch and had red marks all over his chest.
- Bob: "Do something!"
- Cameron: "Okay, stop scratching, we’ve gotta look at it"
- Bob: "I can’t. It’s just driving me crazy!"
- — Bob explains his intractable itching
- House: "No. Lungs, skin. Skin, lungs. Sklungs? Lungs, skin. Throat. Heavy metal toxicity. It explains the lungs, the itching, the swelling in the tongue and throat."
- Foreman: "I thought you didn’t believe there was anything wrong in his throat."
- House: "I never said I didn’t believe it. I just said I had good reason to doubt it."
- — House has his epiphany
However, when Dr. House consulted Dr. Wilson, they came to the conclusion that to get lead poisoning this severe, Bob would have to have eaten off of lead-glazed pottery for months.
Dr. Foreman and the wife did an environmental scan of their home. The only thing out of place were some ants, which were soon ruled out as possibly being poisonous. The resort in Mexico was a 5-star establishment that didn't cook with pottery. The tests for heavy metal were also negative. Dr. House wanted all the tests repeated because the symptoms fit so well with heavy metal poisoning. He also ordered that Bob be started on treatment for lead poisoning, although he did let Dr. Chase test for milk, wheat and legume allergies.During the allergy scratch test, Bob started complainign that he felt his feet were on fire and he said he may have stepped in something. However, he socks were clean. When Dr. Chase tried to remove them, Bob cried out in pain. Dr. Chase ordered Gabapentin.
- "The symptoms all point to heavy metal poisoning. Yeah, we all get it. Unless you’ve got proof and can tell me which heavy metal it is, I’m starting treatment for lupus"
- ―Foreman defies House
The extreme pain in the extremities ruled out allergies. Dr. Foreman thought it was a clear neurological problem, but Dr. House once again pointed out it is a classic symptom of heavy metal poisoning. However, all the tests were negative. Dr. Foreman suggested lupus again, but Dr. House pointed out this disease was progressing too fast and there was no joint pain. Dr. Foreman wanted to do an ANA, but Dr. House overruled him.
Once again, Bob's tongue swelled up, cutting off the airflow to his lungs. Dr. Chase prepared to intubate. Bob started to aspirate and Dr. Chase called for suction. However, there was too much vomit so the only alternative was a tracheotomy. It was successful and they managed to restore air flow.Bob's urine test showed elevated protein levels and red blood cells. Dr. Foreman argued this was a classic case of lupus induced kidney failure. Dr. House pointed out heavy metal poisoning could explain the vomiting, but Dr. Foreman said it was more likely that it was the kidney failure. Dr. Foreman had started Bob on steroids and insisted on doing an ANA and serum complement test. However, Dr. House had noted that Bob had not improved on steroids, but Dr. Foreman pointed out that there were other treatments that might, such as cyclophosphamide or immunosuppressants. However, Dr. House pointed out that due to the danger of those treatments, the ANA and serum complement weren't enough - to conform they would also need an anti-DNA IV pyelogram and kidney biopsy. However, House had to admit that he had no idea which heavy metal was poisoning Bob. Dr. Foreman went to the wife to break the news and seek consent for treatment. She agreed.
- Cameron: "You think she’s poisoning him?"
- House: "His symptoms should be getting better the longer he’s here, instead they’re getting worse."
- — House reaches another epiphany
Then, while dealing with another couple who had developed herpes, Dr. House started suspecting the wife. He asked Dr. Cameron to search her belongings, but she was incredulous. Dr. House pointed out that the disease was getting worse, while even heavy metal poisoning would get better once a patient reached the hospital, even if they didn't treat him - it would cut off the source. He figured she was deliberately poisoning him. Dr. Cameron pointed out all the tests had been negative. Dr. House countered that the standard tests only test for toxins that are regularly found in air or food. There were dozens of other possibilities they didn't test for because deliberate poisioning is the only way to be exposed to them. Dr. Cameron thought it still might be lupus, but Dr. House noted he still wasn't improving on lupus treatment. They had ruled out every other possibility except deliberate poisoning. Dr. House insisted Dr. Cameron search the wife, but she refused.
Instead, Dr. House asked the wife if he could search her purse. He told her he thought she was poisonign her husband. She handed over her handbag, but he found nothing suspicious. However, she refused a body search. Dr. House went to Dr. Cuddy for permission, but she refused as well. Dr. House and Dr. Cameron started arguing about it, but Dr. Cuddy told him in no uncertain terms that neither he nor a member of his team could do the body search.
Once again, Bob started to crash. Dr. Foreman called for the defibrilator and adrenaline. They managed to restore his pulse and his pupils were responsive. His heart had not been stopped long enough for hypoxia, but it might have been a stroke. Bob finally started responding to questions.
Foreman pointed out the heart failure showed a systemic disease and lupus was most likely. However, the immunosuppressant drugs weren't working. Dr. Chase wanted to start cyclophosphamide. Dr. House wanted to give Bob interferon just in case it was a viral infection. Dr. Cameron pointed out the patient had no fever. Dr. House hypothesized that Bob had come in with a post viral autoimmune reaction and the immunosuppressants had allowed a dormant virus to spread. Dr. Foreman pointed out that if he was right about lupus, the interferon would make it worse.
Dr. Foreman went to see the wife to tell her they were starting interferon for a viral infection because the progression of the disease seemed to rule out lupus. The wife wanted to know the risks, but Dr. Foreman told them that given his condition, it was the only thing they could suggest. The patient consented to treatment.However, Bob's lungs and kidneys continued to get worse. The dose of interferon had already been increased, and the team had run titers to test for viruses, but they were all negative. Dr. House wanted the dose of interferon increased again.
- " I didn’t have a problem with you going to the bathroom. I just didn’t want you to wash your hands. I never actually did find a mummy, but I did learn a fair amount about the ancient Egyptians. For example, they discovered that stannous chloride is not only great for toughening ruby glass, but if it’s mixed with gold, it turns bright purple. [He turns over Maria’s hand, which is turning purple.] Now, either your fingers are actually worth their weight in gold, or you’ve been sprinkling your husband’s cereal with gold sodium thiomalate. It’s an arthritis remedy it’s rarely used here in the US, but it’s still popular in Mexico. I’ve gotta give you props. I’ve never heard of anyone using gold before. It’s almost… poetic."
- ―House puts all the pieces together
A reflection of House Edit
Bob is betrayed by the woman who loves him and, as a result, is left with a permanent medical condition.
Reaching the diagnosis Edit
Previous doctors had ruled out allergies and an anxiety attack being the most likely diagnosis for a blocking of the airway without other organic explanation. There was no sign of trauma to the neck which could have resulted in swelling. Foreman's suggestion of progressive bulbar paralysis is rare, but it does start with difficulties swallowing. In addition, Cameron is correct that it would also affect his facial muscles. Given the lack of a clear pathology related to the throat, House decides to focus on the patient's lungs in the event the patient mistook suffocation for choking. He orders blood tests, a CT Scan of the chest, and a plethysmograph.
The plethysomgraph shows decreased lung capacity, and the cause was confirmed by the CT as scarring. However, interstitial lung disease has several underlying causes. However, arthritis, sarcoidosis, prescription medication, coal dust and asbestos are quickly ruled out. As the team considers their next move, the patient develops serious hives.
Lupus would explain the lung scarring and the hives, but allergies would only explain the hives. However, House realizes heavy metal poisoning would explain the lungs, hives and the swelling of the throat as well. However, there doesn't appear to be any exposure to heavy metal toxins. House orders an environmental scan and tests for lead, arsenic and mercury.
However, the environmental scan and the heavy metal screening both come up negative. House decides to treat for lead poisoning, but also agrees to an allergy scratch test for the most common food allergies.
When the patient develops severe pain in the lower extremities, it seems to further confirm heavy metal poisoning. House insists that it can't be lupus because it doesn't progress this quickly.
The next symptoms - nausea, and urine with elevated protein levels and red blood cells in the urine is confusing - it points both to lupus and to heavy metal poisoning. Foreman believes it would take too long to confirm lupus and, despite the fact the patient hasn't improved on steroids, he wants to move on to cyclophosphamide.
But none of the lupus treatments have any effect and the patient keeps getting worse. When he develops cardiac symptoms, House wants to switch to treating for a viral infection, but Foreman points out that there is no fever and blaming this on the steroids is a stretch. However, House insists and the patient is given interferon.
However, the interferon has no effect, despite increasing the dose. In addition, the tests for autoimmune diseases are also turning up negative. However, House realizes that the patient and his wife have been to Mexico and that the wife has a family history of arthritis. There is an arthritis medicine, only available in Mexico, that contains gold compounds. Tests find very high gold levels and House finds gold residue on the wife's hands, confirming his suspicion that she had been poisoning him.
Explaining the medicine Edit
- Anxiety attacks don't actually cause the tongue to swell, but they often do result in the tongue going numb and the perception that the tongue is swelling. .
- The plethysmograph looks at changes in volume of an organ. It is a good indicator of lung function.
- Although each heavy metal causes different toxic symptoms, they do have symptoms in common, such as neurological damage.
- Sodium aurothiomalate, or gold sodium thiomalate, is a legitimate arthritis medication. An overdose will result in heavy metal toxicity symptoms.
Character relationships Edit
- Married to Maria Palko
|October 2019||November 2019||December 2019|
|Occam's Razor||Bob Palko||John Larroquette|
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