The patient is a non-smoker.
Brian started coughing up blood during home room. He was taken to the emergency room of Princeton-Plainsboro Teaching Hospital where in addition to hemoptysis, he presented with chills, headaches and chest pain. The emergency room ruled out pneumonia, bronchitis and lung cancer and the case was referred to Dr. House. Dr. Chase thought it was obviously epistaxis: blood from the nose backed up into the lungs and was coughed back up. The fluids explained the other symptoms. However, Ms. Masters suggested it was toxic exposure to ammonia or sulphites would cause trauma to the lungs which would result in neuralgia and fever. It also fit the chest pain. Dr. House agreed and ordered an environmental scan and blood cultures for bacteria and fungi.
The patient admitted to having occasional nosebleeds, but the last time was a few months previously after he was hit in the face by a volleyball. Dr. Chase asked him about the cleanliness of the showers he used, and the patient admitted they were not cleaned properly. Dr. Chase thought the red fluid may have been serratia, a red colored bacteria. He went to start the patient on levoquin. However, the patient coughed again and it was clearly blood on his hands.
When Dr. Foreman and Dr. Taub arrived at the patient’s home, they found books and boxes piled everywhere. The room was cold because there was no electricity, natural gas or even running water. They realized the patient was a hoarder and Dr. Taub suggested it might be an additional symptom of a brain injury or early onset Alzheimer's disease. However, Dr. Foreman didn’t think that it would explain his coughing up blood. They did find a refrigerator that was plugged in to a neighbour’s line, but it contained a frozen dead cat and what appeared to be spoiled food. Dr. Foreman realized that aspergillis would explain the coughing up blood and aspergillomus would explain the headaches and chest pain.
The patient was upset that the doctors broke into his home, but accepted the diagnosis of aspergilosis. They went to start him on anti-fungals. The patient explained he used bottled water and flashlights to get around his home and got by just fine - like camping. Dr. Foreman insisted on a psych consult but the patient said he wasn’t a hoarder, just a slob. Dr. Taub pointed out he saved ear wax.
However, the psychiatrist confirmed the patient showed no sign of being a hoarder. In addition, the treatment for aspergilosis was ineffective. Brian’s pain got worse and he had to be put on oxygen. Dr. Chase thought it was some other toxin, but Dr. Taub pointed out that if it was environmental, he should have gotten better in the hospital. Dr. Foreman theorized that there was something in his house that was keeping him from getting sick. The team realized he might be using a portable gas heater for heat and that carbon monoxide in small quantities would act as a vasodilator and actually increase his lung capacity. Dr. Chase and Ms. Masters agreed to go back to the house.
Ms. Masters thought there would be some clue within the hoard, but Dr. Chase thought it was just a pile of junk. They tested for carbon monoxide, but found no significant amounts. However, Dr. Chase found some raccoon feces. Raccoons carry Q fever, which fit all the symptoms. However, as they continued to search, Ms. Masters came across the patient’s wife Nina, who was cowering under a tarpaulin.
Both Brian and his wife were started on doxycycline. Brian explained that telling people about Nina usually complicated their lives and that’s why he didn’t tell them. He told them he was fine with her hoarding. He told them it started as collecting, then art projects, then the hoarding started. He told them he stayed because his wife saw beauty in everything.