House 102: Paternity Review

2008 July 2

by Jeffrey

This one is pretty interesting how they jump on one provisional diagnosis to another. But you kind of get the pattern how they are doing this entire TV series. They shoot the first scene of the patient, exhibiting some symptoms, and somehow he or she presents to the hospital. They take on the case, come up with differentials, and they order tests to ascertain what’s going on. They get it wrong a couple of times, and the producers take the chance to insert short snippets of drama in between. It could be Dr House irritating Dr Cuddy the hospital CEO, or something like that.

In this 2nd episode, a 16-year-old high school student, who plays lacrosse, Dan presents with sudden onset double vision and night terrors (as in “big scary monsters”) with no apparent cause. When House is in consult with the patient, he mentioned that in teens, there are two reasons for night terrors: post-traumatic stress and sexual abuse. When House finds out that he has had a knock at a recent game, he dismisses the symptoms as a concussion and bad vision (resulting in the knock) and is about to send him home when he notices Dan’s foot twitching (a myoclonic twitch), something uncommon in awake people. House immediately admits Dan and begins to run tests.

A myoclonic twitch is a brief, involuntary twitching of a muscle or a group of muscles. It is usually caused by sudden muscle contractions. The most common time for people to encounter them is while falling asleep (hypnic jerk), but myoclonic jerks are also a sign of a number of neurological disorders. Hiccups are also a kind of myoclonic jerk specifically affecting the diaphragm. Most often, myoclonus is one of several signs in a wide variety of nervous system disorders such as multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, Subacute sclerosing panencephalitis and Creutzfeldt-Jakob disease (CJD) and some forms of epilepsy. (Wiki)

The brainstorming begins. House is pretty sure that the father is not his biological one. He bets with Foreman about it. Cameron suggests leukoencephalopathy (just cos he’s a 16y.o.) WHAT? Last i checked, the patient is not immunocompromised, undergoing chronic steroidal treatment, or has cancer, Hodkin’s disease, lymphoma, or sarcoidosis. So why the sudden DDx of leukoencephalopathy? Just weird. Detailed polysomnography (a sleep study) was ordered to check out the night terrors.

After the night terrors were confirmed, a CT brain, MRI, CBC (FBE), CHEM-7. Ok, so why order a CT-B when MRI was going to be done anyway? Talk about wasting money. Apparently the corpus callosum has a large blockage in one of Dan’s blood vessels. They want to do a radionuclide cisternogram. This involves injecting a radionuclide by a lumbar puncture into a patient’s CSF (the liquid that baths your spinal cord and brain) to determine any abnormal flow. House and his team relieve the pressure as fast as they can, by placing a shunt, but they find that the blockage isn’t what is causing the other symptoms. It is, in fact, a symptom itself. The surgery was unremarkable but CSG was tested. It has increased IgG and oligoclonal bands.

Typical findings in MS and acute disseminated encephalitis include 0-50 mononuclear cells on cell count, 25% elevated protein, normal glucose level, selective increase in immunoglobulin G (eg, oligoclonal bands, free kappa chains), and an abnormal colloidal gold curve. (Emedicine)

Meanwhile, House faces a young mother who doesn’t want to vaccinate their kids. She thinks some multinational company want them to think that they work. House scares her and tells a good business is also baby coffins. The antibodies from her breast milk only protects the baby for 6 months. Several physician bloggers have blogged a lot on this issue. Among the more prominent ones is Respectful Insolence.

During the night, Dan suddenly disappears from his bed. Cameron, Chase, and Foreman search frantically to find him, soon locating him on the roof, where he is hallucinating that he is on the lacrosse field. Chase tackles him just before he steps over the edge of the building. House is excited by this new development – it rules out House’s previous diagnosis of multiple sclerosis. He was in an acute confusional state, which doesn’t fit with MS. Cameron thought it could be neurosyphillis. It can’t be because RPR was negative.

Rapid plasmin reagin is a test that can detect the 2 types of antibodies that syphillis infections produce (Ig E-mediated and specific antitreponemal antibodies). Rather sensitive test.

To treat this, they inject penicillin directly into Dan’s brain, which is contraindicated otherwise but because of Dan’s shunt, its OK. During an injection, Dan suffers an auditory hallucination, which rules out this diagnosis. (Its funny how they act out this scene. How can Dr Cameron know he has an auditory hallucination when she can’t hear them? Its really retarded)

House is stumped by this new development, and admits his problems to Wilson. Dan’s parents are angered to discover House having coffee with Wilson while their son is dying, but House rebukes them with his intimate knowledge of Dan’s current condition. He tells them to go and support Dan, after which he takes their coffee cups to run DNA tests to decide his bet on Dan’s paternity. The tests show that neither are Dan’s parents (winning him his bet with Foreman, Wilson, and everyone else who joined), and a new idea hits him. He remembers a baby he treated earlier whose mother did not want to vaccinate the child.

House thinks that infant Dan caught the basic measles virus from his biological mother (who possibly had never been vaccinated) that had mutated, laid latent for 16 years and reappeared in his brain. It is subacute sclerosing panencephalitis (SSPE). Avoiding a dangerous brain biopsy to confirm this unusual case they biopsy Dan’s retina to find the virus, confirming House’s theory.

They treat him with intraventricular interferon. More specifically, it should be combined with oral isoprisnosine. An intrathecal injection of interferon alpha is also possible. Dan recovers fully, and reveals that he already knew he was adopted, due to his cleft chin, and neither parent having one.

The initial MRI scan (A and B) reveals a focal abnormality in the subcortical white matter of the left frontal lobe, consisting of a hypointense signal on the T1-weighted image (arrow in A) and a hyperintense signal on the T2-weighted image (arrow in B). In the followup scan, the focal abnormality in the left frontal lobe is less obvious than previously (arrow in D), but advanced and diffuse cortical atrophy is present, signified by the ventriculomegaly and markedly enlarged sulci (arrowheads in C).