House 101: Pilot Review

I got to watching House M.D. Season 1 (yes i know i’m extremely back dated) and decided to start blogging about it. I will focus what i see and the comparison to what actually happens in real hospital life, as far as i know. Also, i’ll present the final diagnosis and how the signs and symptoms fit, and whether the diagnostic tests ordered were appropriate. I hope this series will be educational in nature…

Sidenote: Polite Dissent already has an entire series on House M.D., but it doesn’t really talk about the final diagnosis which i will. It does provide a lot of astute observations which are certainly reliable since the author of Polite Dissent is a family doctor.

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In this first episode, a 29-year old preschool teacher (guest star Robin Tunney) starts to experience difficulty speaking (dysarthria). This alone can generate a list of differential diagnoses. Shortly after, she realises something is terribly wrong and has the mental capacity to grab the chalk, and write “Call the nurse”, before collapsing in her classroom from a seizure. She is taken to Princeton-Plainsboro Teaching Hospital, where Dr. House and his team of experts grapple to solve the mystery.

The first CT (i think) shows this and the team starts to give their take:

Tumour was the first suspect, but House doesn’t think so. “First year of medical school you learn, If you hear hoof beats, think horses, not zebras.” House wittily replied, “Are you in first year med sch?”

The differentials thrown out: aneurysms, stroke, CJD, Wernicke’s Encephalopathy. House shot down Wernicke’s because “thiamine levels are normal”. Somehow i doubted this, looked it up and found that:

“Patients with Wernicke encephalopathy present with altered mental status and other neurologic abnormalities. Careful history, physical examination, laboratory workup, and radiographic evaluation are essential to exclude other causes of CNS dysfunction. No specific laboratory test is available for diagnosing Wernicke encephalopathy. Wernicke encephalopathy is a clinical diagnosis, and normal electrolyte levels may only give false reassurance and delay therapy. This is particularly the case where malnutrition is likely to be present. The motto should be “If in doubt, treat,” as administration of thiamine does not pose potential harm.”

House proceeds to order a repeat blood test, and a contrast (gadolinium) MRI.

Gadolinium is a paramagnetic metal ion. Paramagnetic ions, such as gadolinium, tend to move into magnetic fields. This trait makes paramagnetic ions such as gadolinium useful for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA). Gadolinium is approved for use with MRI as a contrast agent to provide a clearer picture of body organs and tissues. It is also used for MRA, another imaging procedure.

Gadolinium-containing contrast agents are manufactured by a chelating process, a procedure in which large organic molecules form a stable complex around the gadolinium. The chelate reduces the chances of toxicity that could result from exposure to free gadolinium. This stable complex is eliminated via the kidneys in patients with normal functioning kidneys. Source: FDA

The patient suffers an allergic reaction to gadolinium. More specifically, an anaphylactic shock. Management was an infusion of adrenaline. That should help in most cases, but she still wasn’t breathing so an emergent tracheostomy was performed. (Steps are listed in the link; i wonder when i’ll get to do one. Tried it on a cadaver before) Interestingly, the one shown in this episode of House has Dr Chase (an intensivist) slice the neck vertically instead of horizontally. I suppose that’s still OK as long as you get to the trachea huh? Below is a video showing how it’s done. It shows a vertical incision too.

“Truth begins with lies.” House asks the team to take a history to find out any genetic or family issues that can trigger the inflammatory response. Hmph. I think they inserted as a filler.

House then sees two patients in the clinic – a patient who has turned orange and a young kid who’s not taking his asthma medications. The mother thinks “such strong medication isn’t very good for development of young children”. Oh yeah. She probably didn’t vaccinate him at all. I like it when House told her “Oxygen is a pretty important ingredient for development too, isn’t it?” when explaining what an asthma attack could do.

House then comes up with a hunch that high-dose prednisolone should be given, suspecting it could be vasculitis. I suppose he was referring to isolated CNS vasculitis.

Of course, the start of the break-ins. House tells Foreman to break into the patient’s house to check for “contaminants, garbage, medication”.. from which in the end the diagnosis is arrived. Foreman reported back something about her ham.

The patient is responding well to the steroids. But she gets worse after a couple of days. She seizes yet again, and presents now with altered mental status. Its getting interesting. They decided to stop treatment to see how fast she dies. I’m sure this will get through any ethics committee.

Cut the crap, it turns out to be neurocysticercosis. It is actually the most common parasitic disease of the nervous system and is the main cause of acquired epilepsy in developing countries.

Pathophysiologically speaking, NCC is the result of accidental ingestion of eggs of Taenia solium (ie, pork tapeworm), usually due to contamination of food by people with teniasis. Larvae or cysticerci is part of its life cycle and when they are ingested by humans through poorly cooked infected pork. Cysts evaginate in the small intestine, attach to the wall by its suckers and hooks, and develop strobila or chains of proglottids. From the distal end of the strobila, fertile eggs are excreted into the gravid proglottids. Up to 60,000 eggs may be contained in a proglottid. Pigs ingest stool contaminated with Taenia eggs, the embryos actively cross the intestinal wall, get into the bloodstream, and are transported to most tissues, where they reside as cysticerci. Larvae are found most commonly in the CNS, but they can also be located in the eye, muscle, or subcutaneous or other tissues. (Source: Emedicine)

The above is a T2-weighted MRI of the brain showing the presence of increased signal as a result of edema in the right frontal region; subsequent studies found a cysticercus in that location.

To add spice to the drama, the patient refuses treatment after the diagnosis has been reached. They do an X-Ray of her leg to show her the worm.

They treat her with albendazole, an anti-cysticercal medication. Albendazole works by decreasing ATP production in worm, as well as inhibits polymerization of component of microtubules, thus preventing their formation. This will cause energy depletion, immobilization, and finally death. To avoid inflammatory response in CNS, patient also must be started on anticonvulsants and high-dose glucocorticoids.

End of case. Hope you had fun reading and learning.

For more on this series of reviews on House M.D., please go to my “House M.D. Reviews” page.