Dana was in cooking class when started losing focus and coughing. She looked at her reflection and noticed her lips turned were turning blue. She told her companions that she had cyanosis, pain in her back and chest and a spontaneous pneumothorax. She told them that she was a doctor, and just before she collapsed said she needed a doctor right away. She was taken to Princeton-Plainsboro Teaching Hospital.
Dr. Hadley found Dana in admitting and brought her file to Dr. House. Dr. House was initially uninterested as few tests had been performed and a number of common conditions can cause spontaneous pneumothorax. Dr. Foreman noted that several possibilities had already been ruled out. She doesn't suffer from COPD, she doesn't smoke and she had not been scuba diving. In addition, her blood oxygen level remained low even after they inserted a chest tube. Dr. Taub suggested it might be the result of cystic fibrosis or lung cancer. Dr. Hadley hoped it was just late onset asthma triggered by an allergy. Dr. House agreed and ordered steroids and a CT Scan to look for hyperinflation.
Dana was impressed by how fast they were able to do the CT Scan. When Dr. Taub and Dr. Hadley told her they wanted to get her back to work on her breakthrough treatments, she informed them she had given up medicine. When she was dying, she realized how unhappy she was and that she wanted to do something else. At present, she was learning how to run a kitchen from a chef in New York. She said she never really wanted to be a cancer researcher, but it was expected of her.
Dana's lung volume was normal, ruling out asthma. Dr. Taub told Dr. House about the uterinemyoma and hypothesized that the central line intravenous tube might have accidentlally created a hole in her lungs that expanded. Hoewver, Dr. Kutner noted there was no pleural thickening. However, he did see something on the scan that could be increasted interstitial markings. Dr. Foreman agreed and suggested pulmonary fibrosis. Dr. House ordered a biopsy.
Dana resisted the biopsy because it would be invasive, requiring them to open her chest to get at her lungs. That would keep her in recovery for weeks. She then noted that something on the left side of her abdomen felt wrong. Dr. Taub did a percussion of the area and ran to get a large syringe. Dana thought was ascites, but Dr. Taub thrust the needle into her abdomen and started drawing out blood - she was bleeding internally.
The bleeding turned out to be coming from her liver. Dr. Taub had already performed an MRI and found no tumor, cysts or any clear etiology. Dr. Foreman found a tiny spot on the coldate lobe which might be a granuloma which rose into the hepatic artery. Dr. Hadley thought blastomycosis might explain the granuloma. The infection might have been asymptomatic for months, then spread to her lungs. The steroids they gave her would have suppressed her immune system, allowing it to spread to the liver. Dr. House ordered a biopsy of the lungs again.
The test for blastomycosis was negative. Dr. Foreman went to tell Dana, but when he saw her, he noted she was bleeding from the left side of her skull from where she had been itching. However, on closer inspection, it was clear that she had dug right through her skull and brain matter was leaking out. Dr. Foreman called for assistance.
Dr. Taub surgically repaired the hole and reported that there had been no brain damage. However, she was still complaining about the itch. Dr. House noted that only the top two layers of the skin are capable of feeling itchy, so Dana was merely perceiving an itch, she didn't actually have one. Dr. Kutner thought the symptoms were psychogenic, the result of her changing careers so fast. However, Dr. House noted her symptoms only started recently, not when she quit her own job. Dr. House suggested meningitis or encephalitis. However, Dr. Taub noted the symptoms were too localized for those conditions. Dr. Foreman thought it might be multiple sclerosis, but Dr. Taub pointed out a brain tumor would also explain the symptoms. Dr. House ordered an MRI.
However, the MRI was negative, showing no tumor or lesions. Dr. Taub ruled out Dr. Kutner's suggested that it was psychogenic by pointing out that she kept scratching while she was asleep. Dr. House thought it was a polyneuropathy. He told Dr. Taub and Dr. Kutner to shock the affected area to reboot her nerve function.
However, when they tried to do the procedure, Dana started suffering from the sensation of shocks in her spine - Lhermitte's sign - even though they hadn't started the procedure. Dr. Kutner pointed out that Larmeet's could indicate Bichette's disease or Vitamin B12 deficiency, but Dana had no sores and no anemia. Dr. Kutner had ruled out a spinal tumor because it wouldn't affect the liver or lungs. However, Dr. Taub pointed out an aggressive spinal hemangioma would. Dr. House ordered scans.
The scans found the hemangioma, and it looked repairable. However, they started to find more hemangiomas on her lungs, spine and pericardium. Dr. Kutner realized they were everywhere. Dr. Taub reported it appeared that Dana had mesothelioma that had metastasized, the very cancer that she was working on before she quit. However, Dr. Taub noted it appeared to be spreading too fast. Dr. House directed them to get a consulot from Dr. Wilson, who could do a biopsy to confirm.
Dr. Wilson performed the biopsy, but there was bleeding from the biopsy site, which doesn't happen with mesothylioma. Dr. Wilson though it might be AVN secondary to shistosomiasis, but Dr. Taub pointed out that they would have seen the parasites. Dr. Taub suggested Gorham's disease and Kasabach-Merritt as they both cause aggressive vasular tumors. Dr. Taub was then called away as Dana had a cardiac arrest.
Dr. Taub found Dr. Kutner who reported the patient had a cardiac tamponade from bleeding in her pericardium. Dr. Kutner inserted a needle into the pericardium and withdrew blood, which resulted in a rise in Dana's blood pressure. Dr. Kutner thought it was working, but Dr. Taub instead noticed that Dana was bleeding from her ears, eyes and nose.
The team started transfusing platelets and FFP to try to stem the blood loss, but they were barely keeping up. Dr. Kutner wanted to resect the vascular tumors to stop the bleeding, but Dr. House noted that no surgeon would operate in this condition. Instead, Dr. House suggested deliberately creating embolisms to block blood flow to the tumors. However, Dr. Taub pointed out they couldn't kill the tumors that way without also killing healthy tissue - she could lose up to 75% of her lungs. Dr. House wanted to proceed as although this might prevent her from engaging in intense physical activity, she would at least be alive.
Dr. House ran into Dr. Cuddy. Dr. Cuddy had been particularly hard on him the past few days but was now apologetic. He figured it was because she had stoped menstruating the previous day. All of a sudden, he remembered Dana's uterinemyoma. He went to her room and found an empty box of feminine pads. Given that her bleeding started with her menstrual cycle, Dr. House thought it was likely she had ectopic endometriosis. Given her uterine surgery eight months ago, it was likely that uterine cells had gotten into her bloodstream, found their way to her spine, lungs and liver, and started multiplying. Once they reached a critical mass, they started swelling and bleeding just like the endometrial cells in the uterus when her menstrual cycle came about. They just needed to cut out the endometrial masses once the bleeding stopped.
The surgery was successful and Dana started to recover.
A reflection of House
Miller is a brilliant physician without much regard for her profession. She turns out to be as good a cook as she is a physician.
Reaching the diagnosis
The team rules out the causes of spontaneous pneumothorax before moving on to chronic conditions. Determining that asthma is the most likely, they start the patient on steroids and plan a CT Scan to look for hyperinflation.
However, the scan rules out asthma, but shows increased interstitial markings that could be pulmonary fibrosis. House orders a biopsy. However, before they can perform it, the patient starts bleeding from the liver. An MRI of the liver showed only a small spot on the caudate lobe that could be a granuloma from blastomycosis. Another biopsy is ordered.
The biopsy is negative for blastomycosis, but the patient's itching became so bad she scratched through her skull. As the itching is recent, localized, and the cause seems not to be related to her skin because she itched right through it, the most common cause would be a brain tumor. House orders an MRI.
However, when the MRI is negative for a tumor, House figures it must be a problem with her nervous system. He orders electro-convulsive therapy.
Before the shocks can begin, the patient starts suffering spinal shocks. After ruling out some autoimmune conditions, they determine it could be a hemangioma. They do radiology, and find numerous hemangiomas, indicating mesothelioma. However, when they do the biopsy to confirm, it causes bleeding. On top of that, the patient suffers a cardiac tamponade, then starts bleeding from her eyes and nose. House orders his team to operate to cut off blood supply to the tumors, which may have the effect of reducing her lung function.
However, House finally realizes that as the patient is on her period, the bleeding started the same time, indicating endometriosis, most likely from uterine cells leaking into the rest of her body during her uterine cancer surgery.
Explaining the medicine
- The endometriosis explains most of the symptoms, such as the pneumothorax (caused by blood leaking into the pericardial sac), and blood filling her abdomen.
- Endometriosis can cause itching when the uterine cells are found just below the skin.
|October 2020||November 2020||December 2020|
|Transplant (episode)||Dana Miller||Murphy (neighbor)|
This article was the featured article for November, 2020
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