- Natalie: "I don't know"
- Cuddy: "See, that’s not a good answer. Remember when you asked me if I had any kids? I don’t. I don’t know, maybe it has nothing to do with it, but I was good at school, good at work, lousy at life. I screwed up every relationship I ever had. I thought ‘why would I want to bring a child into this?’ But then I got older and… how you feel now will pass. Don’t let it screw up your whole life."
- Natalie: "It's already screwed up"
- — Cuddy discussing Natalie's vodka buying
Natalie has always been of above average weight and her body mass index is in the upper percentiles of her age group and peer group. She started puberty one year previously and it was accompanied by changes in behavior where she became less compliant and more sullen and uncooperative with her parents. However, she maintains high grades and does volunteer work as a food server for the homeless in her spare time.
Natalie is a sixteen year-old overweight high school student and the victim of frequent bullying, although she is an excellent student and a frequent volunteer. At the school Christmas show, she develops dizziness, has visual hallucinations, starts vomiting and collapses, although she remains conscious.==
After admission to the Princeton-Plainsboro Teaching Hospital, she is found to have the start of liver failure as well. Dr. Cuddy referred the case to Dr. House. The initial differential diagnosis was Dr. Kutner's suggestion of Wilson’s disease, but her ceruloplasmin was normal. Dr. Hadley suggested alcohol abuse, but Dr. Taub noted a 16 year old with alcoholism that severe would have been noticed by her teachers or parents. However, Dr. House believes her classmates probably deliberately drugged her. Dr. Kutner notes that the teachers had already asked the classmates, but instructs Dr. Kutner to question them again.
- Thirteen: "Do you think the kids slipped her something? Their teachers grilled them."
- House: "When do teachers ever know how to motivate their students?"
- — House, on his doubts about the teachers getting the truth from Natalie's classmates
Dr. Kutner enlists the assistance of Dr. Chase who gets the classmates together in the surgical suite. He pressures them by telling them Natalie's liver is failing and she might need a transplant. Sure enough, some of the kids in the choir do admit secretly giving her a hallucinogenic mushroom, which are being kept in Simon's locker. Dr. Kutner and Dr. Taub goes to search Simon's locker and Natalie's as well. Dr. Kutner finds the mushrooms in Simon's locker. The search of Natalie’s locker reveals a large bottle of Tylenol — an over-the-counter painkiller than can cause liver failure — raising the possibility of a suicide attempt.
Dr. Cuddy confronts Natalie, who denies any suicidal thoughts or intentions and said she only had them for headaches. Natalie is obviously upset about the way her classmates treat her and seems resigned to her illness.
- Natalie: "I didn't try to kill myself."
- Cuddy: "Then why’d you have all those painkillers?"
- Natalie: "In case I got a headache."
- — Natalie trying to explain why she had the large bottle of acetaminophen in her locker
Cuddy wants to go ahead and start her on acetylcysteine, the antidote for acetaminophen poisoning, but Mr. Soellner does not believe she would swallow the pills in a suicide attempt and refuse permission. However, Mrs. Soellner tells Dr. Cuddy that Natalie's demeanor changed a great deal when she hit puberty the previous year and she thinks it's plausible. She consents to the treatment.
Next, Natalie develops tachycardia with a heart rate of 150, and increased blood pressure to 180/110, with crackling lung sounds three-quarters of the way up her torso indicating pulmonary edema (fluid filling up in the lungs). This rules out a suicide attempt.
The mushrooms seem to be the cause of the hallucinations and are removed from the differential. Dr. Hadley suggests glue sniffing, but Dr. Kutner points out that causes immediate lung symptoms. Dr. House thinks it might be an infection, but Dr. Hadley points out Natalie has no fever. Dr. House thinks it also might be LSD or a toxin. When Dr. House discovers she has been volunteering at a homeless shelter, he sends Taub to do swabs of the residents and sends Dr. Hadley and Dr. Kutner to do an environmental scan of Natalie's home and school.
Dr. Taub returns from the homeless shelter believing that Natalie might have tuberculosis because one of the residents there has a severe case of it and Natalie had stood next to him while she volunteered. However, Dr. House is skeptical, but agrees to start her on the standard regimen of antibiotics. About this time, Natalie has a seizure. Dr. Cuddy orders 4 mg of lorazepam.
- Taub: "House. It's tuberculosis."
- House: "You got that from an anal swab? Man, you’re good."
- Taub: " It was a more subtle clue. Homeless guy, uncontrollably hacking up blood. Cough’s lasted two months. He was cachectic."
- — Taub, justifying his diagnosis
Dr. House stars a new differential, adding the brain symptoms that had been ruled out earlier. Dr. Cuddy remarks that Natalie’s ALT is twenty times normal, her transaminase and PT are also elevated. She wants to put her on the transplant list and suspects hepatic fibrosis. However, Dr. Hadley points out her complement level is normal, as is the size of her liver. Dr. Kutner believes it might be an allergy, perhaps a severe mold allergy to the mushrooms she was given. However, Dr. Hadley points out that an allergic reaction would have abated once they kept her in the hospital. Dr. House believes that she suffered an allergic reaction, which then developed into a fungal infection. House has the team test for the allergy (the prick test) and start her on anti-fungal medication.
The allergy test is negative. Dr. Kutner notes that Natalie was feeling better because Simon dropped off some homework for her. Dr. Kutner wonders why Simon stopped by when he was bullying Natalie earlier. He orders security to detain him and confronts him. Simon tells him he and Natalie used to be friends until people started to make fun of him for it. He also mentions that she used to be a heavy drinker - he used his older brother's ID to get Natalie and other friends alcohol. He bought Natalie a few bottles of vodka every week, but he stopped a few months ago because Natalie said she got her own fake ID. This again raises the possibility of alcohol abuse, or possibly even alcohol withdrawal as it can cause seizures. Cuddy wants to start benzodiazepines (“benzos”) because they help with alcohol withdrawal, but Natalie says she quit drinking six months ago and that she didn't drink most of the alcohol she bought, she merely bought it to be close to Simon. However, she can't explain why she told Simon she got her own ID and Cuddy remains suspicious. However, her parents refuse the treatment. Dr. Cuddy reports this to Dr. House decides to go ahead and start the benzodiazepines for her seizures - that doesn't require parental consent.
- Kutner: "You helped bully this little girl and completely refuse to accept responsibility. No way you came here out of compassion. That only leaves guilt. What did you do to her?"
- Simon: "Nothing..."
- Kutner: " Stop lying or I’ll take the drugs I found in your locker down to the cops, you slimy little jerk. "
- — Kutner, acting uncharacteristically aggressive with Simon
Natalie's liver continues to get worse, and the atropine isn't raising her heart rate, meaning she will soon need a pacemaker. Dr. House realizes alcohol withdrawal wouldn't cause bradycardia, and Dr. Kutner has already performed an EKG, echocardiogram and electrolyte panel, but they were all normal - her heart is fine. Dr. Cuddy suggests multiple endocrine neoplasia, but Dr. Hadley pointed out Natalie's free T4 was normal. Dr. Hadley suggests a hypothalamic brain tumor, but Dr. Taub points out they would have seen it on the CT scan. Dr. House notes that the disease is hitting all her organs and asks for her alkaline phosphatase, which is at 300. This indicates leukemia.
Dr. Cuddy and Dr. House go to Dr. Wilson for a consult. Dr. Cuddy argues the high AL ploss might be a combination of liver failure and her normal bone growth, but Dr. Wilson says despite those factors it's still on the high side. Dr. House wants to do a bone marrow biopsy to confirm, but Dr. Cuddy want to start treatment for the suspected leukemia. Dr. House defers to Dr. Cuddy's judgment. However, Dr. Wilson reminds her that even if the leukemia is successfully treated, her heart and liver are probably irreparably damaged. She suggests a double transplant, but Dr. Wilson points out that the brain involvement totally rules her out as a transplant candidate. Dr. Wilson also reminds her there is no reason to give her a painful treatment that won't help her in the long run. Dr. House has realized that and doesn't want to cause Natalie unnecessary pain. Dr. Cuddy agrees to the biopsy.
Dr. Cuddy remains concerned that they may be missing something. She mentions autoimmune diseases, but Dr. House points out she has a normal complement level. Dr. Cuddy suggests microangiopathic vasculitis (inflammation of tiny blood vessels such as capillaries and arterioles), she wants to give Natalie high dose steroids. However, when House tells her about a clinic patient of his with whom he faked parthenogenesis in order to save her relationship, Cuddy suddenly has her own Eureka! moment and realizes that Natalie has eclampsia (toxemia of pregnancy).
- " It's not leukemia. Seizures, liver failure — It's eclampsia."
- ―Cuddy has her "House moment"
Dr. Cuddy breaks the news to Natalie and her parents. Mrs. Soellner realizes that eclampsia is related to pregnancy and Dr. Cuddy informs her it can arise up to a month after giving birth. Mr. Soellner rejects the diagnosis out of hand. However, if the birth had been premature, it may have been missed in a later physical exam. Dr. Cuddy asks Natalie if that's why she stopped drinking and if that's why she asked Dr. Cuddy if she had her own kids, and why she feels so guilty. She admits to the pregnancy and that Simon was the father, although he didn't know about it. She planned to give it up for adoption, but her classmates found out. She went into labor while working at the soup kitchen and went to an empty house down the street where she gave birth. Unfortunately, the baby was stillborn. Moreover, the damage to her liver and heart are permanent and the prognosis was that Natalie would die in the next few days.
Dr. Cuddy went to the abandoned house to retrieve the dead baby. However, remarkably, a couple squatting in the house found it and managed to revive it and take care of it. Dr. Cuddy convinced them to let her bring it back to the hospital to show it to Natalie. Regrettably, the transplant committee refused to put Natalie on the transplant list due to the severity of her illness and her admission of under-age drinking, and she passed away two days later.
- Natalie: "Who is that?"
- Cuddy: "It's your daughter. She was alive. People found her and took care of her."
- Natalie: "...She's beautiful."
- — Cuddy reunites Natalie with her baby
Neither Natalie's parents nor Simon's parents wanted the baby and put her up for adoption. Dr. Cuddy decided to seek foster parent status for the child with the intention of adopting her.
A reflection of House
Like House, Natalie is isolated from her peer group due to her intelligence. In addition, she engages in anti-social behavior in an attempt to fit in. Like House, she is overly hard on herself if she feels that she has done something wrong, in this case, blaming herself for the loss of the baby.
In addition, Natalie's relationship with Simon has some parallels with Huddy. Although they are attracted to each other and have been friends for a long time, their differing social situations prevent them from being together.
Reaching the diagnosis
Had Natalie received pre-natal care, her eclampsia would most certainly have been detected starting with pre-eclampsia which would have meant additional monitoring. In modern medicine in developed countries, undiagnosed eclampsia is uncommon because the symptoms are easy to detect and the medical history is obvious. Pre-eclampsia itself is very common, occuring in up to 8% of all pregnancies, and has well defined risk factors, including being more common in first pregnancies and obese women. This study found that over a thirteen year period, there were only 790 preeclampsia and eclampsia deaths in the United States, with African Americans being three times more likely than Caucasians to be victims. Lack of pre-natal care was the most common contributing factor. In 2004, preeclampsia and eclampsia accounted for about 18% of all maternal deaths during pregnancy.
It should be remembered that preeclampsia, although common, has no outward symptoms. Its primary symptoms, high blood pressure and protein in the urine, are obvious only when a patient is tested for them. By the time Natalie's first obvious symptom, nausea, occurs, the disease is already well developed. Even had eclampsia been thought of earlier, it's primary outward symptoms, convulsions and seizures, are still more likely to be caused by other conditions that would have to be ruled out. Many patients with eclampsia lapse directly into a coma before showing any other outward symptoms.
In retrospect, Natalie's mood swings, attributed to her puberty, were just as likely due to her anxiety and hormonal changes over her pregnancy. If Mrs. Soellner was right, Natalie became pregnant only a few months after entering puberty.
An overweight woman can gain less weight during pregnancy than a woman of normal weight or one who is underweight. An otherwise healthy overweight woman may only gain 15-25 pounds during a pregnancy, which would not have been unusual in and of itself for an overweight person, particularly one going through the early stages of puberty where rapid growth can often be accompanied by equally rapid weight gain.
However, kudos to Cuddy for reaching the right diagnosis after having her "House moment". This is the only episode where Cuddy reached the correct final diagnosis.
Explaining the medicine
- Ceruloplasmin is the protein that carries copper in the blood. In Wilson's disease, the level of ceruloplasmin is abnormally low so Natalie's normal level would appear to rule it out.
- Liver failure from alcohol related cirrhosis usually requires heavy drinking for a period of ten years or more. As such, it is highly unlikely even in an alcoholic sixteen-year-old.
- Chase is not entirely correct about the lethality of psilocybin mushrooms. The several species of mushrooms that contain psilocybin are rarely poisonous. However, several species of poisonous mushrooms do resemble psilocybin mushrooms and can be dangerous in even low doses. However, none of the poisonous mushrooms cause liver failure.
- The large bottle of acetaminophen was an obvious explanation for the liver problems as acetaminophen has to be processed by the liver and is fairly toxic to the liver.
- Crackling sounds in the lungs, heard on a stethoscope, indicate airways and air sacs in the lungs opening after being filled with fluid. They are typical of pneumonia or similar diseases.
- "Polys" are another word for white blood cells. In a patient with an infection, there will be WBCs in their sputem visible under a microscope. The lack of WBCs in Natalie's sputem ruled out an infection.
- Rising levels of ALT, transaminase and PT are all typical of declining liver function.
- Complement proteins are produced by the liver, and in patients with cirrhosis, all of the complement proteins are found in abnormally low levels. Low complement levels also appear to have a role in the development of autoimmune conditions and are clinically signifigant in a diagnosis.
- Severe allergic reactions create by-products that have to be processed by the liver, whcih can lead to liver damaged or reduced liver function. In addition, mold and fungal allergies are among the most common.
- Normal T4 tests show normal thyroid function. With an endocrine neoplasm, the level would be elevated.
- High alkaline phosphatase levels can indicate leukemia, but don't rule out other diagnoses.
|July 2014||August 2014||September 2014|
|Pilot||Natalie Soellner||Known Unknowns|
This article was the featured article for August, 2014