- "So you hide in your office, refuse to see patients because you don’t like the way people look at you. You feel cheated by life so now you’re gonna get even with the world. You want me to fight this. Why? What makes you think I’m so much better than you?"
- ―Rebecca on House
The character was named after Irene Adler, the antagonist of the Sherlock Holmes short story "A Scandal in Bohemia". In turn, Adler was based on Lillie Langtry, a famous and beautiful actress who was, for a time, the mistress of the future Edward VII of the United Kingdom.
The patient did not have abnormal pathologies before a demonstration of oral aphasia. She has no family history of cancer. She is of Jewish heritage. Her mother died three years before from a heart attack. Her father is disabled due to a serious back injury from construction work. She owns a dog.
- Melanie: "You're lying aren't you?"
- Rebecca: "I wouldn't lie to you."
- ―Rebecca, about her boyfriend
The patient suffered a collapse and seizure following a display of oral aphasia while teaching her kindergarten class. The patient was admitted by James Wilson following an oncology consult in the emergency room. Her mental status continued to deteriorate after admission. She was diagnosed with a brain tumor despite the lack of protein markers for the condition. Dr. Wilson doubted that the diagnosis was correct given her young age and her lack of a family history of the disease. The patient also failed to respond to radiation therapy. Dr. Wilson convinced Dr. House to take the case, saying she was his cousin, although Dr. House also agreed with the diagnosis of brain cancer.
The patient's brain scan clearly did show a lesion. However, Dr. House began to doubt it was a tumor because the CT Scan was clear. Robert Chase suggested it might be an aneurysm or a stroke, and Dr. House agreed to a contrast MRI. Allison Cameron suggested Creutzfeldt-Jakob disease. Eric Foreman suggested Wernicke's encephalopathy and Dr. House agreed to re-do the lab tests as they were originally negative.
However, the contrast MRI had to be delayed due to the withdrawal of Dr. House's hospital privileges. After Dr. House agreed to catch up on his clinic duty his hospital privileges were restored.
- "I’ve gotta do four hours a week in this clinic until I make up the time I’ve missed. 2054. I’ll be caught up in 2054. You better love this cousin a whole lot."
- ―House, chiding Wilson
The team proceeded with the MRI, but during the procedure the patient had a reaction to the gadolinium contrast material and went into respiratory arrest. Dr. Cameron noticed what was going on and the MRI was aborted. When they realized that the patient wasn't breathing, Dr. Chase performed an emergency tracheotomy and the patient was revived.
- Cameron: "Rebecca? Rebecca? Rebecca! Get her out of there!"
- Chase: "Ah she probably fell asleep; she's exhausted"
- Cameron: "She was claustrophobic 30 seconds ago, she's not sleeping. We gotta get her out of there!"
- — Cameron realizes Rebecca is in distress during the MRI
Dr. Foreman and Dr. Cameron were directed to take the patient's medical history. Dr. House ordered that the patient be given high-dose prednisone because vasculitis would explain the results of her previous scans. Dr. Foreman was sent to the patient's classroom to perform an environmental scan. He discovered a parrot and considered Psittacosis. However, House dismissed the diagnosis because none of her students were sick and they would be less likely to follow basic hygiene precautions. Dr. House ordered Dr. Foreman to do an environmental scan of the patient's home, but he declined to do so as he would have to break in.
- "Should I discontinue the treatment boss?"
- ―House, chiding Cuddy after Rebecca improves
Dr. Cuddy challenged Dr. House's prescription of prednisone as he had no medical proof or evidence that she had vasculitis. However, when Dr. Cuddy checked the patient, she found that she had improved to the point where she had regained her appetite. The patient continued to improve. However, while Wilson was checking in on her, the patient spontaneously lost her sight and had another seizure followed by cardiac arrest. The patient was shocked to restore a heart rhythm. She initially showed an inability to perform mental tasks, but she rapidly improved showing her neurological symptoms are intermittent. The problem could be a tumor, infection, or vasulitis. Dr. House ordered that all treatment be discontinued because each of the three possibilities had their own time frame. The tumor was ruled out as the symptoms progressed too quickly. Dr. Foreman decided to perform the environmental scan of the patient's house with Dr. Cameron. House realised the patient was not Jewish (nor Wilson's cousin) when Foreman mentioned she had ham in her refrigerator. Dr. House had ruled out Neurocysticercosis because if the patient were Jewish and kept kosher, she would not eat pork, ruling out any possible exposure. This would explain why she initially improved on steroids, then got worse. A tapeworm larvae passed from her intestines to her bloodstream, became sick, and the immune system started to attack it, causing the inflammation that led to the neurological symptoms. However, the patient refused treatment as she did not want to be experimented upon - the previous treatment had caused paralysis below the waist and the inability to control her bowel movements. Dr. House confronted the patient with the diagnosis, but could not convince the patient that he was right. She still refused treatment. Dr. House accepted the patient's decision.
- House: "You found ham."
- Foreman: "So?"
- House: "Where there’s ham there’s pork, where there’s pork there’s neurocysticercosis."
- — House, noting Foreman hasn't thought things through.
Dr. Chase noted that larvae show up on x-rays. Dr. Foreman pointed out that they have not shown up on any other scans, and Dr. House pointed out that was because the larvae have the same density as matter in the brain. However, they have a different density from muscle. Dr. House suggested x-raying her thigh muscle because larvae often appear there. The patient was x-rayed and a larva was found in her thigh. The patient agreed to be treated with Albendazole despite the side effects. She rapidly improved and was eventually discharged, presumably resuming her teaching duties.
- Rebecca: "Two pills?"
- Chase: "Yeah, possible side effects include abdominal pain, nausea, headache, dizziness, fever, and hair loss. We’ll probably make you keep taking the pills even if you get every one of those."
- ―Chase, on the cure
Unlike most of the other patients in the series, there is very little in common between House and Rebecca. It appears that her character was an attempt by the producers to provide a sharp contrast against which House would stand out.
Rebecca feels it is wrong to tell lies. She has several close friends and is actively seeking out additional relationships. She enjoys her job teaching children. When confronted with a life threatening disease, she prefers to let it run its course rather than seek out any possible course of action that may save her.
Reaching the Diagnosis
Foreman was absolutely right - the most common cause of a lesion in the brain is a brain tumor (and he's the neurologist in the group). From the get go, a brain tumor was the most likely diagnosis and Wilson only became suspicious when he couldn't pin it down. Four different tumors account for almost 95% of all brain tumors - glioma, meningioma, pituitary adenoma and nerve sheath tumor. However, there are rare brain tumors and brain tumors can also be secondary from the metastasis of tumors elsewhere in the body.
Given the choice of a rare form of brain cancer that doesn't respond to radiation and "anything else", the former is, by far, the most likely, so House and his team have their work cut out for them. Chase starts the ball rolling by focusing on the aphasia. A lack of blood flow is a common cause, so a contrast MRI is a good idea. Creutzfeld-Jakob disease is a bit of a stretch and is also untreatable, but could also explain the neurological symptoms. However, it goes against House's usual modus operandi of focusing on treatable conditions first. Foreman focuses on House's dislike of HMO labs and figures the lab may have screwed up the thiamine test results because Wernicke's is also a good fit.
However, when those don't pan out, House has his first "eureka moment" of the series and comes up with cerebral vasculitis. It does explain the symptoms and slightly elevated SED rate, but if she did have cancer treating it with steroids would help the cancer along. Foreman doesn't buy it and starts looking for environmental causes and finds a source of psitticosis, but House rightly points out that it's unlikely Rebecca would be the only person in the class with the infection. When Rebecca improves on steroids, it would appear that House has it right.
However, Rebecca soon takes a turn for the worse, losing her sight, suffering a serious seizure, and suffering temporary cognitive difficulties. These point to a damaged brain stem which can be caused by most of the things that had already been discussed - tumor, infection or vasculitis. House takes a "wait and see" attitude because the progression of the symptoms for each issue is different.
Foreman is unwilling to take this attitude and finally, without further prompting from House, commences an environmental scan of Rebecca's apartment. However, the only thing he finds out seems to be medically irrelevant - Rebecca eats ham. That would appear to indicate she isn't Jewish or, as Wilson claimed, his cousin. Foreman is really only concerned about busting Wilson's chops about how he lied to House, but House sees the relevancy at once. Neurocysticercosis would fit her symptoms, but it's rare and he ruled it out because he believed Rebecca was Jewish and didn't eat pork. Although it's unlikely, it not only fits the symptoms, but explains why the steroids affected her the way they did.
Unfortunately, there does not appear to be any way to prove to Rebecca that she has tapeworms except by treating her. When she refuses treatment or further tests, Chase remembers that tapeworm larvae show up on x-rays. They find one and Rebecca agrees to treatment. The treatment works and she starts to improve.
Explaining the Medicine
- Rebecca's seizure and aphasia are a manifestation of Landau-Kleffner syndrome, a rare condition that usually affects children, but can also be caused by neurocysticercosis and low-grade brain tumors, so either the original diagnosis or the final diagnosis fits.
- Wilson is right that a brain tumor in a 29 year old female is unlikely - the rate for females up to the age of 50 is 5 per 100,000 population. It's even rare at the peak age for the condition, about 75, where it affects about 25 per 100,000 population.
- There are several different types of brain tumors and merely seeing one on imaging doesn't help the differential diagnosis very much. For this reason, a doctor may order tests for protein markers, which are specific to the particular cancer involved. However, although the testing isn't invasive, it is time consuming and even some large cities don't have the necessary equipment.
- House disparages the "HMO lab". In the United States, a "Health Management Organization" is a particular form of health insurance where you pay a fee to be part of a "network" that deals with all of your health issues at a flat rate. However, they have come under criticism for cutting corners and making non-medical decisions to deny medical care recommended by a physician.
- Since brain cancer is rare, and is particularly rare in a 29 year old, a doctor doing a differential would next determine if she had any family history of the disease. After that, the doctor would check her for other diseases that are often associated with brain cancer, then for lifestyle factors (both work environment and bad habits like smoking). Having ruled all of these out, Wilson would question his diagnosis even though the symptoms fit.
- Despite the horrendous side effects of radiation therapy, the symptoms caused by the tumors will usually improve with radiation. The fact that Rebecca didn't respond to radiation doesn't mean she doesn't have brain cancer, but it also points to another problem.
- Allergic reactions to gadolinium contrast are exceedingly rare, occurring in about 7 out of every 10,000 cases.
- Just about everything the brain does has to travel through the brain stem. When it suffers damage, it results in serious mental and physical impairment, which is usually permanent. When only one sense is affected, it can point to localized damage in the cerebellum, but when multiple cognitive and sensory systems are involved, it usually points to the brain stem.
- Although it helps the story, in reality steroids don't affect patients with neurocysticercosis in this manner. In fact, in most cases, patients with the condition are given steroids along with the anti-parasite medication. This is done for two reasons. First, the steroids reduce the inflammation caused by the larvae, which is the mechanism that causes seizures. Second, the steroids prevent an immune reaction that can occur when the anti-parasite medication kills the larvae, which is often life-threatening. Rebecca's reaction would only fit if she were given steroids and the anti-parasite medication, then the steroids were discontinued.
- In most cases, parasites, including those involved in neurocysticercosis, trigger the production of eosinophil granulocytes, a type of white blood cell. In most patients with the condition, the count is higher than normal..
- The relationship between tapeworms and the immune system is somewhat more complicated than House makes it out to be. It is known that tapeworms are often asymptomatic, and this appears to be because, depending on the relationship between the worm and its host, the immune system may not recognize the worm as having antigens it can bind to. However, he is right about what happens if the worm dies - this often unleashes a huge immune reaction as the dead parts of the worm will trigger a reaction in any host. This is why steroids are usually given together with the anti-parasite medication.
- Dead larvae calcify in the body and, as such, show up on x-rays much like bone does.
- Neurocysticercosis is an extremely common disease worldwide. In some cases where it is endemic, cystericercosis can infect up to 20% of humans and 37% of pigs. It is the primary cause of symptomatic epilepsy. However, in the United States, it is exceedingly rare (220 deaths in 12 years) and generally only affects immigrants from areas where it is endemic.
- Although Jews don't eat pork, they can still get the disease from people who do. In New York City in the early 1990s, four Orthodox Jews got the disease from their Latin American housekeepers.
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