A very somber (but sadly, not sober) episode this week. As usual, there are significant spoilers for this week’s episode of House ahead, so don’t come crying to me claiming nobody warned you.
A husband returns home to find his wife Kara have a
seizure in the bathtub and their four-week old son Mikey drowning. By the time they reach the hospital, Mikey has resumed breathing and Kara has stopped seizing. Mikey is taken to the neonatal intensive care unit (NICU), where Chase happens to be working. Kara’s case is tackled by House, Cameron, and Foreman. Her
calcium is elevated, and the initial concerns are
hyperparathyroidism, cancer, and a “calcium-mediated neurotoxicity” — but apparently all those were ruled out in the ER. The next diagnoses considered include
polyarteritis nodosa (a rare inflammation of blood vessels),
Whipple’s disease (a rare type of bowel infection), a
Strep infection, and
vasoconstriction (a sudden narrowing of important arteries). The
Strep test is negative, and when she is undergoing angiography, Kara suffers some sort of massive muscle contraction/seizure.
Meanwhile, Mikey’s oxygen levels suddenly drop. Chase listens to his lungs and diagnoses a collapsed lung (
pneumothorax). He performs a
needle thoracostomy and then acquires x-rays. He thinks the x-rays show a
chemical pneumonitis (an inflammation of the lungs caused by an inhaled — or swallowed — irritant), but House disagrees and thinks the x-rays look like a
bacterial pneumonia. He suggests placing Mikey on antibiotics and ECMO. Chase decides that House must be correct and starts the antibiotics and
ECMO (extracorporeal membrane oxygenation — a big machine that oxygenates the blood and removes carbon dioxide).
In terms of Kara, the doctors are now considering a
lithium toxicity and a
myelogenous meningitis (a rare complication of leukemia where the cancer cells invade the lining of the brain). An MRI shows no brain tumor, but it does show a
subarachnoid hemorrhage. It turns out that Kara has a
bleeding disorder and her blood is not clotting as well as it should. Foreman’s search of Kara’s apartment turned up no lithium, but it did show a hidden bottle of
vodka. When the team discovers that Kara is a former alcoholic, House suspects that she started drinking again and is now suffering from
delirium tremens (a dangerous form of
alcohol withdrawal). The liver damage from the alcohol would cause her bleeding problem (though they never seemed to run any liver tests). Foreman thinks it may be a
conversion disorder, basically her body is having seizures to cope with the severe stress in her life. House overrules him and they place Kara in a
phenobarbitalcoma to essentially sleep off her delirium tremens.
Kara’s feeling better when she awakens from her coma, and she is delighted to see her son (who appears fully recovered) and her husband. A short time later, House discovers her trying to suffocate Mikey. Chase resuscitates the baby and rushes him back to NICU. The team is now concerned that Kara has
postpartum psychosis, especially after she admits that she hears voices telling her to kill her son. To ensure there is not some other neurological condition going on as well, they attempt to cause a seizure in her with sleep deprivation and strobe lights. Ultimately they succeed in setting off an atypical seizure that causes them to think that Kara is suffering from some sort of progressive
delirium. The possible diagnoses at this time includes
Wernicke’s Encephalopathy (neurological disease caused by a severe thiamine deficiency – common in alcoholics),
lithium toxicity,
Whipple’s Disease, and
pellagra (neurological disease caused by a severe niacin deficiency). Pellagra is the best fit, so they start her on niacin supplementation.
In the NICU, Mikey is not doing well. The lack of oxygen has severely damaged his kidneys and he has developed
hyperkalemia (high potassium). Chase tries
medication to bring the potassium level back to normal but it doesn’t work, and Mikey suffers a fatal arrhythmia (an abnormal heart rhythm —
ventricular fibrillation in this case).
Kara is not improving despite the niacin, and complains of
stomach pain shortly before
vomiting blood. House has an idea but needs an intestinal biopsy. Because he suspects a disease that has a genetic component (and because Mikey has been breastfeeding and essentially eating the same food as mom), he can test the baby. A post-mortem examination of Mikey’s intestine reveals
celiac disease, an autoimmune disease tied to eating food with gluten (wheat protein). This has caused malabsorption of vitamins (niacin, leading to pellagra and vitamin K, leading to a clotting disorder) as well as led to the development of a
stomach cancer.
As the episode ends, both Kara and her husband are trying to come to terms with their son’s death — and having a hard time of it. Foreman is struggling to regain the skills he lost, and did I mention that Cuddy is looking for a sperm donor?
Kara’s medical care wasn’t that bad, but the pediatric medicine was sub-par. First, Chase is an adult intensivist, not a neonatologist, and the two are not interchangeable. Second, why did Mikey develop a pneumothorax? Infection (or pneumonitis) are not causes of a collapsed lung. Third, speaking of a collapsed lung, a needle thoracostomy is for treatment of a tension pneumothorax, not a spontaneous pneumothorax. The needle simply converts the tension pneumothorax into an open pneumothorax, which they neglected to treat. Fourth, I know ECMO machines look cool, but pneumonia is not an indication for using one (though bacterial sepsis can be an indication).
In terms of Kara’s treatment, isn’t it ironic that she was found to have a cancer after we were told in the beginning that the ER had categorically ruled out cancers? For Foreman, I’m glad to see he’s recovering, albeit slowly, but why is everyone convinced it was the biopsy alone that caused his problems. Meningitis takes at least a month of convalescence (which does not include going to a stressful job) before a person is anywhere near recovered. Finally, shame on House and Wilson (especially Wilson, as an oncologist he should know better). Tumor markers can be used to follow an established cancer or to check for a recurrence, but have no use in screening for tumors (except maybe the PSA — prostate specific antigen — in men, and even that’s open for debate).
