Sister Mary Augustine was the patient in the episode Damned If You Do
The patient came to the clinic late and was assigned to Dr. House. The skin on her hands was extremely rough and she had bleeding. The patient was assigned to washing dishes and Dr. House diagnosed contact dermatitis from exposure to dish soap. He prescribed diphenhydramine, an antihistamine and gave the patient samples. Dr. House diagnosed an allergic reaction to the antihistamine and went to change the prescription to steroids. The patient was complaining of a fast heart beat, which Dr. House believed was due to the epinephrine. However, he took her heart rate and realized she was suffering from tachycardia. She soon lost her pulse and her heart went into fibrillation. Dr. House called a code blue.
The patient was admitted. Dr. Cuddy reviewed the patient's file an accused Dr. House of giving her the wrong dose (1cc instead of 0.1cc - the clinic carries syringes with both doses). Dr. House claimed he gave her the right dose and her tachycardia was from a pre-existing heart condition. However, Dr. Cuddy noted that Dr. House did not chart the epinephrine dose. Dr. Cuddy agreed to keep the patient for 24 hour observation, but told Dr. House that if he couldn't diagnose the matter within that time that the lawyers would have to be notified.
Dr. Cameron thought the hands were the result of a skin infection, which could result in the tachycardia. However, Dr. Foreman pointed out there was no fever. Dr. Cameron then believed it might be a systemic allergic response, but Dr. House dismissed this possibility as it would not cause cardiac arrest. Dr. House then suggested Churg-Strauss disease, which would explain the symptoms. However, even with treatment, a five year life span would be optimistic. Dr. Foreman pointed out the heart symptoms would also be explained by an epinephrine overdose. Dr. House ignored the comment and ordered a CT Scan of the chest and prednisone.
Dr. Foreman was convinced that the patient's symptoms were the result of an epinephrine overdose.
During the patient's CT Scan, the patient complained of a bad smell which was initially put down to a previous patient's vomit. The scan showed no vascular abnormalities, ruling out Churg-Strauss. When the patient emerged from the CT Scan, she kept complaining about the smell, then started having religious vision hallucinations typical of frontal lobe swelling. Dr. Foreman called for ativan. She then had a seizure. Dr. Foreman noticed a rash on her thigh.
The patient tested positive for hepatic encephalitis, an indication that she was immunosuppressed. Dr. Cuddy put down the immunosuppression to prednisone, but Dr. Cameron noted the dose was too low to cause immunosuppression this severe. Dr. Chase suggested the immunosuppression could be caused by mixed connective tissue disease, which would explain why she initially improved on prednisone. This would explain her symptoms, but if she did have it, her ANA would not be normal, which it was. Dr. House ordered a new ANA test. Because she could not be given prednisone, Dr. House ordered her to be placed in a hyperbaric chamber to regulate her immune system. However, Dr. Foreman noted that this was not proper protocol. Dr. House overruled his objections and ordered her prepped and that the prednisone be discontinued. Dr. Foreman pointed out that the hyperbaric treatment could result in oxygen toxicity.
Dr. Foreman reported Dr. House's actions to Dr. Cuddy.
Dr. Cuddy challenged Dr. House about his diagnosis and once again accused him of giving her an epinephrine overdose. When Dr. House refused to admit he may have made a mistake, she removed him as attending and took the case herself.
Dr. Cuddy met with the team. The patient was having labored breathing and Dr. Cuddy ordered 40% oxygen as she believed it was pneumonitis from the hyperbaric chamber. Her creatinine, ALT and AST were all elevated. The patient still had the rash and joint pain she had at admission. Dr. Cuddy ordered non-steroidal anti-inflammatory drugs. Dr. Cuddy did not want to be advised of the previous differential and put the patient's symptoms down to Dr. House's previous treatment.
Dr. House checked the epinephrine syringes in the clinic and realized after speaking to Dr. Wilson that he would have to check every patient chart in the clinic and hope they were accurate.
Dr. Chase administered medication to treat her kidney dysfunction.
Dr. House advised Dr. Chase that the patient had been identified as a hypochondriac by one of the other nuns. Dr. Chase noted that if the patient had a secret, her mother superior would probably know. Dr. House went to the monastery to do an environmental scan and talk to the mother superior. Dr. House doubted the story about the patient spending her entire life with the church as she had a tattoo. The mother superior admitted that the patient left foster care at 12. She lived on the streets, used drugs, and had a miscarriage at 15. She then entered the monastery at 18. Dr. House admitted the information was not medically relevant. However, after tasting the tea, he realized it was an herbal blend of figmore tea that had a Medicine interaction with any dose of epinephrine. He reported this to Dr. Cuddy who agreed it was the cause of the cardiac arrest. All the other symptoms could then be explained by a long term allergic reaction. Dr. Cameron had suggested this earlier, but did not press it when Dr. House dismissed it.
The allergic reaction was now life threatening, affecting her ability to heal and breaking down her organs. It also had to be something she was exposed to both at the hospital and at the monastery as if it had been the dish soap she would have improved. It was agreed that the patient should be put in a clean room and then exposed to allergens one at a time. However, the patient soon went into Anaphylactic shock despite not being exposed to any allergens. The team managed to stabilize her.
The team managed to rule out anything in the clean room as being the allergy. Dr. Wilson suggested mast cell leukemia, which can cause anaphylaxis, but Dr. House had already ruled out that and any other cause of anaphylaxis.
The patient was extubated and wanted to be discharged. Dr. House met with the patient to convince her to trust in medical treatment. However, she told him that at 15 she was on every type of birth control and still got pregnant. Dr. House then realized that she might have an allergy to something inside of her. However, she had no history of surgery. Dr. House ordered a full body scan. They found an object in her uterus - an IUD. It was a copper cross. Although she had an abortion, the IUD must have become embedded in the uterus and was not removed. She was allergic to the copper and the copper pots she was washing and eating from set off the severe allergic reaction. She first noticed her rash when she was washing the pots. They scheduled surgery to remove the IUD. Her heart rate and kidney function soon returned to normal.
Reaching the Diagnosis
However the asthma, particularly after taking antihistamines, points to a more serious condition. Adrenaline is the appropriate response as it relaxes the airwaves. However, when tachycardia presents, the most obvious answer is overdose. House rejects this as he believes he gave the patient an appropriate dose. He believes she must have had a pre-existing cardiac condition.
Given the lack of fever, no evidence of an infection, the cardiac arrest and an elevated eosinophil granulocyte count, Churg-Strauss syndrome is the best fit. House orders a chest CT Scan to confirm and steroids to treat.
The CT scan is clean, but Augustine suffers a seizure which indicates temporal lobe swelling. Other tests come back showing herpes encephalitis, showing a compromised immune system. However, Cameron dismisses the possibility it could have been the steroids given how compromised it is and the fact she only received two doses. Chase points out the symptoms point to mixed connective tissue disease and would also explain why she improved on steroids. Foreman points out her anti-nuclear antibody test was normal, but House orders it re-done. The treatment for the disorder is steroids, but given her compromised immune system, House instead treats her in a hyperbaric chamber despite risk of oxygen toxicity..
However, after Cuddy takes over the case, she blames all the symptoms on adrenaline overdose and orders the team to treat the symptoms.- 40% oxygen and a non-steroidal anti-inflammatory cream.
Undeterred, House does an environmental scan of the monastery. While there, he discovers Augustine lived on the streets from the time she was twelve until she entered the monastery at eighteen and, during that time, abused drugs. She also got pregnant and tried to self-abort. He also finds out Augustine regularly drinks figwort tea, which reacts with adrenaline to cause tachycardia. As that caused the cardiac arrest, all the other symptoms are explained by a long term allergic reaction. At that point, they just need to find out what the allergy is. Given that the symptoms persisted after she was removed from the monastery, it has to be something she was exposed to at both the monastery and in the hospital. They decide to put her in a clean room and introduce allergens one at a time.
However, while in the clean room, she goes into anaphylaxis. The team quickly rules out anything that was in the room, and also rules out several other non-allergic causes of anaphylaxis. However, after talking to the patient, House realizes the allergen could be inside her. He orders a full body scan and the team finds a copper IUD, an obsolete and discontinued contraceptive device. It only caused low grade symptoms until she was exposed to the copper cookware as well, which caused the hand rash.
Explaining the Medicine
- Contrary to the episode, figwort doesn't have any interaction with epinephrine. However, it does have adverse effects in people who suffer from ventricular tachycardia. It also should be avoided when taking diuretics as both lead to potassium loss.
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|Neurology||Sister Mary Augustine||Amyloidosis|
This article was the featured article for August, 2021