Keith Foster is the patient in the episode Detox. He is portrayed by actor Nicholas D'Agosto.

Case History

The patient was admitted after coughing up blood while riding in an automobile that was later involved in a collision. He continued to suffer from internal bleeding even after his injuries were treated. The patient also had hemolytic anemia, which made the bleeding life threatening. Dr. Cameron ruled out a genetic condition as it appeared the red blood cells themselves were normal. Something outside the cells was damaging them. His [[bilirubin[[ levels were elevated and he had low serum heptoglubin. Meningitis had already been ruled out. The patient did not have an artificial heart valve. Dr. House agreed to take the case. Dr. Foreman informed him that the patient's house had recently been thoroughly cleaned and he was using hypoallergenic sheets and pillows, which ruled out an environmental cause. In any event, if the cause was environmental, the patient would improve in the hospital. Dr. Foreman suggested an infection, but the patient had only a slight fever and his white blood cell count was normal. Dr. Cameron thought it might be lupus. Dr. Chase suggested methamphetamines, but Dr. Cameron pointed out that the patient would have to be using a lot of meth to account for the hemolytic anemia. Dr. House thought it might be cancer and went to see Dr. Wilson to test for lymphoma. He instructed Cameron to test for ANA, Dr. Chase to run a radioimmunoassay test for drugs, and Dr. Foreman to check for infections.

Dr. Cameron asked the patient's father about drug use, but the father denied any erratic behavior. However, he did point out the patient's girlfriend had been through rehab when she was 14. He also informed Cameron that his wife had died from pancreatic cancer. Dr. Chase took a hair sample for testing. However, the patient's hair tested negative for drugs. The patient's only trip out of the country was to China, but he had been vaccinated for diseases common in that country. Dr. Foreman ran a gallium scan to look for infection. The patient had not complained of the joint pain, sensitivity to light or rashes typical of lupus. The patient had no family history of lupus. The patient's ANA was also negative for lupus. The patient had never complained of tenderness under his arms or in his groin. Dr. Wilson did a lymph node biopsy to test for lymphoma, but it was negative for cancer.

Despite the negative tests, the patient's hematocrit was at 13. Any lower would starve his body of oxygen. Suddenly, the patient complained of fuzziness in his left eye. Dr. Chase examined it and found no problem, but the patient was soon blind in that eye. Dr. Foreman did a more complete examination and found a clot in the retina of the patient's left eye. Blood thinners to remove the clot were not an option because of the patient's internal bleeding. Surgery was also not an option. Dr. House started a new differential diagnosis. Dr. Chase pointed out that clots in a patient with bleeding didn't make sense - the processes oppose each other. Dr. Cameron still thought it might be lupus, but Dr. Wilson pointed out the negative ANA test. Dr. Chase pointed out that cancer and infection are the most likely candidates that cause clotting, but those had already been ruled out. Dr. Chase suggested that there might be an infection in the heart throwing off clots. That would not have shown up in the gallium scan. Dr. House ordered an echocardiogram and intravenous antibiotics.

The patient was not eating his food. He was afraid the blindness was permanent. In addition, there were no abnormalities on the echocardiogram and the patient did not respond to antibiotics. Dr. House wanted to increase the dosage, but Dr. Chase pointed out that a dose that high would likely damage the patient's kidneys. However, Dr. House increased the dosage in any case as the patient was dying. Dr. Chase suggested removing some vitreous humor from the left eye to allow the retinal artery to expand, perhaps dislodging the clot. Dr. House agreed. Dr. Chase performed the procedure and it worked - the patient's eyesight returned.

However, the patient started vomitting. His AST was at 859 and he was rushed into intensive care. His ADT and GLT were also much lower than normal. Dr. House realized the patient's liver was failing.

Dr. Cameron still thought it was lupus. However, Dr. House pointed out that lupus has a slower presentation. He thought it was hepatitis E. However, he agreed that lupus was more likely than hepatitis E. However, he wanted to rule out hepatitis E before treating the patient for lupus because if it was hepatitis, the lupus treatment would kill him. However, there is no treatment for hepatitis E. He wanted to put the patient on solumedrol. His theory was that if the patient did have hepatitis E, the patient would get worse, but not so bad that they couldn't cure him. If the patient didn't get worse, they could treat him for lupus. Dr. Foreman pointed out that they could not get the father's consent to treatment if they told him the truth. Dr. House told Dr. Cameron to get consent because the patient's father trusted her. Dr. Cameron finally decided to tell the patient's father that she didn't think it was hepatitis.

Dr. Cuddy admonished Dr. House for asking Dr. Cameron to lie to the patient's father. Dr. House also refused to let Dr. Cameron treat for lupus to pressure the father to provide consent. When the father learned that his son was too weak to transfer, he agreed to the solumedrol. However, before they started the treatment, the patient started having hallucinations about someone named "Jules". The doctors then noticed the patient was essentially lying in a pool of his own blood from a rectal bleed. The patient went into hypervolemic shock. His blood pressure dropped to 60, and his heart rate rose to 140. Dr. Cameron called for an angiography stat.

The angiography revealed severe bleeding throughout the digestive tract and severe hemodynamic compromise. The hallucinations seemed to indicate psychosis which was another diagnostic criteria for lupus. Dr. House once again pointed out that the disease was progressing too quickly to be lupus - lupus would take years to cause these symptoms, not a week. Dr. Cameron pointed out that due to the delay in treatment, the patient now needed a liver transplant. Dr. House had them put the patient on the transplant list and try to get him a new liver as soon as possible.

Dr. House asked the father about "Jules" and it turned out to be the family cat. As it was a real cat, Dr. House pointed out that it was not psychosis, but just a hallucination. He still didn't think it was lupus. The father said it was irrelevant because the cat was dead. Dr. House wondered what happened to the cat, but the girlfriend pointed out it was about 15 and died of old age. The cat slept with the patient and Dr. House ordered Dr. Foreman and Dr. Chase to disinter the cat's body. Dr. House started an autopsy on the cat.

A new liver arrived for the patient, and the patient was prepared for transplant surgery. However, Dr. House stopped the surgery as he determined the cat had died from massive internal bleeding and liver failure due to acute napthalene poisoning. He realized the patient's 14 pound weight loss in hospital released the napthalene from where it was stored - in his fat cells. When confronted by the father he told him that if the patient had the surgery, the napthalene would continue to be released. The patient just needed calories to stop him from burning fat. Dr. Cameron convinced the father to trust Dr. House. Dr. Chase and Dr. Foreman did the environmental scan and found the source of the napthalene - a huge nest of termites surrounding the patient's room. The patient was given food and his INR dropped and his red blood cell count started to climb. The patient's liver function was restored and his prognosis was excellent.

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