Medical History Edit
Jack had seen 17 doctors who could not diagnose his conditions. Jack has been treated with antibiotics, but his fever and abdominal pain got worse. Clostridium difficile had been ruled out, as had kidney failure from diabetes mellitus. The fever and pain had been increasing in intensity, and Jack also suffered from dehydration, diarrhea and weight loss. He had not been camping and his only trip outside of the United States was to Canada.
Case History Edit
- Jack: "Am I going to die?"
- Roy: "No, of course not."
- ―Roy tries to reassure his son
- Roy: "Is House in jail?"
- Cuddy: "No. Foreman is currently working with two of House's most veteran associates."
- Roy: "Rehab?"
- — Roy Randall nearly gets it right on the second guess.
- Roy: "Where's Doctor House?"
- Cameron: "In his office. He's really more of a decider than a do-er."
- — Cameron, being truthful
However, when Dr. Cameron re-examined Jack's abdomen, she noted it felt normal but looked bigger. Suddenly, Jack became unresponsive. Dr. Foreman noted that his right eye was fixed, indicating lateral rectus palsy. He realized Jack was having a seizure and ordered 5 mg of diazepam. Dr. Foreman ordered the lights turned off so he could get a look at Jack's optic disc. Dr. Cameron noted that his heart rate was rising. Dr. Foreman noted that the optic disc was swollen indicating intracranial hypertension. He ordered 20 mg of intravenous furosemide and 500 mg of intravenous phenytoin. Dr. Cameron objected but Dr. Foreman noted that given his hypertension, if they did not relieve it, his brain could herniate. Dr. Cameron administered 50 mg. Dr. Foreman told the nursing staff to page Dr. Chase to meet them in the operating room and they rushed Jack there to drill burr holes. As the phenitonen didn't seem to be working, Dr. Foreman ordered 3 mg of pancuronium to paralyze the patient then intubation and hyperventilation. The father consented to the surgery. Once the burr hole was drilled, the seizure stopped and the intracranial pressure dropped. Dr. Foreman admitted he had no idea why Jack had the seizure.
The new symptom pointed to Hirschsprung’s disease. They planned a barium enema and biopsy to confirm. After treatment, the next x-ray showed a clear colon, the patient's pain subsided and his appetite returned. They were just waiting for the biopsy results to confirm.
- Roy: "Wait! Where... where's House?"
- Cameron: "OK, Mr. Randall, we need you to step back."
- — Cameron gets assertive
Dr. Cameron assured the father that brain cancer would be treatable. However, the biopsy came back negative. The CT Scan was also clear. However, Dr. House still thought it was cancer, but of the stomach - adenocarcinoma. It would cause pain, constipation and nutritional deficiencies that could cause seizures. It also wouldn't show up on the CT Scan. Dr. Foreman ordered an endoscopy and more biopsies and the father was informed.
Jack didn't have another seizure and a cytological examination of his sub-dural matter showed no abnormalities. However, fluid was also building up in his abdominal cavity, which enlarged it. It clearly wasn't a side effect of the enema or biopsy because he had no headaches or change in mental status. A shunt had been inserted to drain the fluid. Dr. Chase thought it must be a systemic infection. However, Dr. House noted the patient had been on intravenous antibiotics for a week. However, Dr. Foreman saw that the fluid buildup in the brain was unusual. Normally, it builds up in a tapered layer. The fact that it didn't indicated the dural layer had separated from the brain before the fluid buildup. This indicated brain cancer and Dr. House ordered a biopsy of the dura.
- "I inherited a $10 million pipeline business when I was 24. By the time I was 30, it was worth over a billion. Since then, I have been involved in over 50 deals that make that first one look like a loser. Everything I do, everything I touch turns to gold... Except my family. First, my wife. And now... my son. This is my fault. It's karma."
During the biopsy, Jack had another seizure. Dr. Chase terminated the procedure and administered diazepam. However, Jack's intracranial pressure remained normal and the shunt was functioning.
They managed to stop the seizures, but Jack din't regain consciousness. There were no signs of masses in his stomach or the lining of his esophagus. He was still accumulating fluid in his brain and abdomen. Dr. House noted that every time they looked for the cause of the fluid build up, Jack had a seizure. Although he didn't know if the procedures caused the seizures, he knew something was setting them off. The biopsy did show a localized partially occluded artery, but no inflammation. This appeared to rule out cancer. Dr. Chase still thought it was an infection, but one that was antibiotic resistant. However, Dr. House noted that blood cultures, viral serology and ANA were all negative for infections. Dr. Cameron thought that he might have epilepsy. The original seizures were limited to his abdomen and were mistaken for abdominal pain. They didn't become severe until they spread to his motor cortex. Protein malnutrition would account for the fever. Dr. House and Dr. Foreman agreed it was their best idea and started the patient on gabapentin and keep him on continuous monitoring.However, the EEG ruled out abdominal epilepsy. In addition, Jack had developed red spots all over his chest. Dr. Foreman thought the spots might be an allergic reaction to the medication, but Jack had not received any new medicine in the 8 hour period before the spots appeared. Dr. Cameron thought it had to be lupus complicated by vasculitis. However, vasculitis would cause a stiff neck and would have shown up on the biopsy of the dura. Dr. Chase suggested polyarteritis nedosa - there was some inflammation in his skin biopsy and his diastolic blood pressure was slightly elevated. Although the evidence was weak, Dr. House suggested prednisone and a biopsy of his testicles, where inflammation would be more likely. However, just as Dr. Foreman ordered the procedure, Dr. House asked if the rash was on his penis. D.r Cameron noted that it was. Dr. House realized that they hadn't noticed the inflammation because it was only affecting the small blood vessels. However, this ruled out polyarteritis. He thought it had to be Degos disease, a terminal diagnosis.
- House: "Your son has Degos disease. Causes micro blood vessels in the brain, skin, GI tract to break down, clot off. It sometimes manifests early on with atrophic papules on the penis. In your son's case, we don't know why, but they came much later."
- Roy: "What's the treatment?"
- House: "There isn't one. It's incurable"
- — House breaks the news
Dr. House informed the father the disease was untreatable. They had re-checked the biopsies to confirm. The prognosis was death within one day. However, the father refused to accept the diagnosis. Because he believed that his great wealth was somehow responsible for the bad luck within his family, he signed away his fortune. However, Jack soon had a heart attack. They managed to stabilize him.However, when House was talking to Dr. Wilson about hearts, he realized something and ordered heparin and immunoglobulin. He realized from the heart attack that the same disease was affecting the vessels in his heart, which are large. This ruled out Degos. The positive biopies showing obstructed blood vessels were the result of primary antiphospholipid syndrome. There was no way to confirm except with treatment.
- House: "The cardiac arrest wasn't just a "everything goes to hell in a hand basket" arrest. It was a coronary event. Coronaries are large vessels. Means it can't be Degos."
- Foreman: "But the biopsies confirmed..."
- House: "Obstructed blood vessels. But they can't be obstructed because of Degos. Means it's primary antiphospholipid syndrome."
- — House reaches his eureka moment
The father was bankrupted, but Jack soon recovered and was eating again.
A reflection of House Edit
Jack isn't like House at all, but the relationship between Jack and his father contrasts against the relationship between House and John House that was explored more fully in the previous season. House is in awe about the relationship. It is doubtful he would have felt that John was capable of a similar sacrifice and has trouble doing more than recognizing the strength of the relationship Jack has with his father.
Reaching the diagnosis Edit
The patient's symptoms on admission were gradually worsening abdominal pain, fever, diarrhea, dehydration and weight loss. Although the patient's mother had died of kidney failure from diabetes mellitus, that had been ruled out. Foreman, at House's suggestion, ordered a new medical history.
However, Jack's only trip outside of the United States was to Montreal. He had not been camping our outside urban areas. However, a physical examination indicated a mass in his abdomen caused by constipation. The resulting X-ray of the area showed an impacted large intestine. This pointed to Hirschsprung’s disease. A barium enema and biopsy were ordered to confirm.
After the enema, Jack's appetite returned and his pain dissipated. However, although his abdomen no longer felt constipated, it appeared to be bigger. Jack's right pupil was fixed and dilated and he suffers a seizure. An examination of the optic disk indicated increased intracranial pressure. He needed emergency surgery to drill burr holes to relieve the pressure.
Tests of the subdural fluid showed no abnormalities. However, not only was there excess fluid in his skull, there was excess fluid in is abdomen, causing it to swell. A systemic infection, the most common cause, was ruled out because the patient had recently been on a full course of antibiotics. However, they noticed on the brain scan that the dural layer had started to separate before the fluid build up, indicating brain cancer.
However, the biopsy was negative. However, an adenocarcinoma of the stomach would cause the same set of symptoms. It also wouldn't have show up on the abdominal scans. However, during the abdominal biopsies, Jack suffers another seizure even though his intracranial pressure remained normal. In addition, after the seizures stopped, Jack did not regain consciousness. The biopsies were negative but the fluid accumulation in the brain and abdomen continued.
The team started considering a systemic infection, perhaps an antibiotic resistant strain. However, all the blood cultures were negative, as were the viral serologies. The ANA test was normal as were the nonspecific cross reacting antibody tests. They turn to abdominal epilepsy, which would cause seizures if it spread to the motor cortex. Although this wouldn't explain the fever, protein malnutrition from failure to eat would. They start a diagnostic trial with gabapentin and an EEG to look for confirmation.
However, the EEG is normal, ruling out epilepsy. However, Jack develops large red spots on his chest. An allergic reaction could have caused the spots, but not eight hours after administration of medication. Central nervous system vasculitis would have shown up on the dural biopsy and would have caused a stiff neck. Polyarteritis nodosa was ruled out due to the lack of any sign of inflammation. However, once House has realized that the spots appear on the patient's penis, he realizes it is a disease of the small blood vessels. The obvious candidate is Degos disease. The biopsies confirm the diagnosis.
However, House realizes that Degos could not cause a cardiac event - the heart is only served by large blood vessels. He realizes it must be antiphospholipid syndrome. He starts the patient on heparin and intravenous immunoglobulin. Jack eventually regains consciousness.
Explaining the Medicine Edit
- Clostridium difficile is ubiquitous in the environment and is carried in feces. It was once limited to very sick individuals, people in hospitals and those who used antibiotics. However, it is becoming increasingly common in young and healthy people, even those with no history of antibiotic use.
- Hirschsprung’s disease is a congenital genetic disorder where the nerves in the muscles at the end of the large intestine are absent. As a result, the large intestine often gets blocked and the patient cannot defecate. It is often diagnosed shortly after birth, but may not be diagnosed until later in childhood.
- Sixth nerve palsy or lateral rectus palsy is a disorder of the cranial nerve which controls the ability of the eyes to turn away from the nose. Double vision is the most common symptom. It can affect one or both eyes.
- The optic disc or "blind spot" is the point in the retina where the nerves and blood vessels in the retina converge to exit the eye. Normally, it is orange or pink in color. A "pale" disc can indicate several diseases.
- An arteriole is a branch of a main artery that leads to capillaries.
- Nonspecific cross reacting antibodies are antigens that react to more than one type of disease agent. They can point to either the primary disease the antibody was created to attack or the secondary disease that they react to that has a similar structure.
- Degos disease is an incredibly rare condition with only about 50 known cases. It manifests with papules that indicate blockage of arteries and veins, including those that provide the blood supply to the organs. It is usually the occlusion and lack of proper blood supply to the organs that results in the patient's death. The causes of the disease are not known and it is untreatable.
- Antiphospholipid syndrome is an autoimmune disease that creates antibodies that attach to phospholipid molecules. This makes clotting more likely.
Character Relationships Edit
- Son of Roy Randall
|#01||"Broken"||#08||"Ignorance is Bliss"||#15||"Black Hole"|
|#03||"The Tyrant"||#10||"The Down Low"||#17||"Knight Fall"|
|#04||"Instant Karma"||#11||"Remorse"||#18||"Open and Shut"|
|#05||"Brave Heart"||#12||"Moving the Chains"||#19||"The Choice"|
|#06||"Known Unknowns"||#13||"5 to 9"||#20||"Baggage"|
|#07||"Teamwork"||#14||"Private Lives"||#21||"Help Me"|
|August 2019||September 2019||October 2019|
|James Sidas||Jack Randall||Occam's Razor|
This article was the featured article for September, 2019.