Ryan has lost weight over the past year.
Ryan was brought to Princeton-Plainsboro Teaching Hospital when he spit up blood while playing basketball. The emergency room found no bleeding in either his lungs or digestive tract which would account for this and the case was referred to Dr. House. Ms. Masters suggested vasculitis, bronchiectasis and inhaled particles. Dr. Taub suggested angiodysplasia. Dr. House ordered a pill camera and a scan of his upper digestive tract.
Dr. Taub explained the pill camera to Ryan. He went over Ryan’s history of weight loss, but Ryan had been eating less since he was on the swim team. Ryan complained he had to get up too early to do swimming. Dr. Taub sent Ryan’s parents out of the room, ostensibly to talk to Ryan about his sex life. However, when they were alone, Dr. Taub asked if Ryan had been self-cutting because he noticed several scars on his abdomen. Ryan said they were from skateboarding. However, Dr. Taub got him to admit that he didn’t eat as much as he used to, his sleep patterns had changed, and he had given up an activity he enjoyed. Dr. Taub reported the patient had admitted to depressed and had smoked marijuana. If the marijuana had been laced with formaldehyde or lead it could have caused a pulmonary hemorrhage which could account for the blood he spit up. Dr. House ordered a test of Ryan’s lead level and that Ryan be given 5 litres of fluid intravenously.
To protect the patient’s privacy, Dr. Taub told the parents that Ryan had been exposed to chemicals and there was no way to know how it happened. The patient admitted he knew he had been depressed, but had been fooling his friends and parents for months. He was impressed it only took Dr. Taub a few minutes to figure it out. He told Dr. Taub he couldn’t talk to his parents about it because they would blame themselves. Dr. Taub admitted to the patient that when he was in med school, he thought everyone but him was able to handle the pressure and, as a result, he hurt himself - the stupidest thing he ever did. However, Dr. Taub noted a new symptom - red spots in Ryan’s eyes. He was sure they weren’t there before.
The red spots in the eyes were more hemorrhages. Dr. Foreman noted that a lot of diseases cause coagulopathy, but Ms. Masters noted only a few cause coagulopathy and depression. She wanted to focus on his mood swings, but Dr. Taub noted mood swings are common in teenagers. Dr. Taub wanted to focus on his weight loss and sleep issues that had started about a year ago. Dr. Chase thought it was just an infection - he would have had exposure to staphylococcus. Dr. House agreed with Dr. Chase and ordered nafcillin.
However, another student came to confront Ryan. When Dr. Taub asked what it was about, Ryan admitted he had sold the other student some prescription medication, had taken payment, but was sent to the hospital before he could deliver. He said he had only done it that one time. Dr. Taub gave him the money so he could give it back.
However, the patient soon had blood in his urine. They realized if he had an infection, the antibiotics would have prevented that. There was no sign of bleeding in his bladder, so they started focussing on the kidneys. Dr. House thought there must be a mass, but Dr. Chase pointed out that would not explain the hemorrhages or the coughing up blood. Dr. Chase suggested antiphospholipid syndrome, but that wouldn’t rule out a mass. Ms. Masters thought that Dr. House was suggesting cancer, but Dr. House assured her that there were other types of masses that could cause the symptoms, such as renal hematoma. Dr. Taub thought it might be heroin induced nephropathy. However, the patient had no withdrawal symptoms. Dr. House agreed with Dr. Chase again and ordered plasmapheresis. He also allowed Dr. Taub to do an environmental scan.
Dr. Taub and Dr. Foreman did the environmental scan of the patient’s home. However, they were called back when the patient lost all feeling in his right arm. As they were leaving, Dr. Taub found the patient’s yearbook filled with drawings of violent imagery.
As the patient was on steroids when his arm went numb, an autoimmune condition was ruled out. Dr. Chase thought it might be a clotting problem and not a bleeding problem. That would explain the symptoms. Dr. Foreman suggested an angiogram of Ryan’s brain to look for blockages. Dr. House agreed.
Dr. Taub wanted to focus on the violent imagery he found, but the rest of the team felt it was both irrelevant medically and typical behavior for a teenager.
However, Dr. Taub also found a video made by Ryan where he was setting off home-made pipe bombs. The video also had Ryan speaking about blowing up his school. Dr. Taub wanted to bring the video to the attention of the police, but Dr. Foreman and Dr. Chase noted that the video didn’t depict any crimes and the drive containing the video had been stolen from the patient. Ryan was also not responding to streptokinase, and it was clear that the damage to the kidneys would soon be irreversible. They figured they had to either increase the dosage or do surgery to remove the clot. However, Dr. House was missing.
Dr. Taub went to the parents to get consent for an embolectomy. They agreed. Dr. Taub also wanted to discuss the violent videos and recommend psychiatry, but the parents thought that Ryan wouldn’t hurt anyone and that if the information got out Ryan could be suspended.
Ms. Masters, who holds a doctorate in applied mathematics, explained to Dr. Taub that it was extremely unlikely that Ryan was going to hurt anyone. Dr. Chase and Dr. Foreman started the embolectomy, but the moment they touched the blockage, it disintegrated. Even worse, the patient immediately slipped into a coma.
The patient’s liver started to shut down as well. Ryan was started on lactulose, but given his rate of liver function decline, he would most likely be dead within a day. Dr. House was busy with his girlfriend, who was having surgery. Ryan tested negative for barbituates and acetaminophen, and he was not on a high protein diet. Ms. Masters suggested acute intermittent porphyria, which would result in uremia which could damage the liver, but it causes abdominal cramps, not abdominal bleeding. Dr. Chase suggested fucosidosis, but it was ruled out as well. Dr. Chase suggested type 2 citrullinemia, but there were no signs of hyperlipidemia or pancreatitis. However, as those symptoms can take years to develop, Dr. Foreman ordered treatment for it anyway - sodium benzoate to reduce Ryan’s ammonia levels and a genetic test to confirm.
However, Dr. House returned and ordered the medication discontinued. He was sure that Ryan merely had a staphylococcus infection. The reason the antibiotics didn’t work is that they couldn’t affect bacteria trapped in abcesses, which just fed more bacteria into his bloodstream. However, they weren’t sure where the abscess was until Dr. Taub remembered the scars on Ryan’s abdomen and the pipe bomb. Most likely, small pieces of the pipe bomb has penetrated the skin. They wouldn’t show up on scans because they were plastic, would provide a perfect breeding ground for staph, and could break off and go to other parts of the body, like the brain (where it was mistaken for a clot and disintegrated on touch) and the liver. He just needed surgery and more antibiotics, but would recover.