House 104: Maternity

In the 4th episode of House M.D., we have Dr House sitting in the lounge overhearing conversations of other doctors. One doctor was telling the other how a baby gets a fever, and had a seizure. He discusses the baby’s bowel obstruction. House overhears their chat and quickly leaves…

House presents Maxine to Cuddy as Exhibit A. Exhibit B is Baby Hausen, another newborn who is also ill, brought into the NICU for FUO. House thinks it is a nosocomial infection, but Cuddy doesn’t believe it’s the beginning of an epidemic. They fell sick within 4hrs of each other, in the same delivery room. House takes his team in the maternity ward to check the other newborns in the hospital, and they find one more baby with a sudden fever and similar symptoms. Later, they find another infant who is developing symptoms as well.

House and crew discuss four sick babies and the symptoms. With a spike in fever and low blood pressure, these children could be dead in one day. They rule out parasites because the infection is spreading too quickly They query viruses, because the kids are too sick, no lymphocytosis in blood tests, and they are not responding to Acyclovir and Ribavirin. Now this brings out questions already! Why are the infants being treated for herpes and hepatitis C, respectively?

The group thinks it might be a bacterial infection, and since it is not responding to broad spectrum antibiotics, they think of what other bacterium could be responsible. Foreman reckons “It’s MRSA, it’s always MRSA.” This i feel is a little unfounded, because MRSA typically presents with small red bumps that resemble pimples, boils or spider bites. These can quickly turn into deep, painful abscesses that require surgical draining. (image credit)

They continue to brainstorm. Cameron says it could be some contaminated food/water source: pseudomonas aeruginosa. Chase suggests VRE. Foreman thinks it could be haemophilus influenzae. Since there’s no time to wait for test results (48hrs) , House orders two treatments to be started. Each baby gets an MRI. Nothing shows up on the scan, so the doctors continue to administer two antibacterials: vancomycin for the MRSA, aztreonam for the rest.

The drama begins. One of them starts causing the kidneys to shut down in two of the four babies. House says there’s no point in guessing, so take Baby Hartig off the aztreonam medication and Baby Chin-Lupino off the vancomycin, deciding which baby will get which drug with a coin toss. House call its a therapeutic trial. Of course, this is met by strong rejection by the team. The duty of care is owed to these babies, and more sick babies, of which 2 more have already started showing symptoms. House asks the hospital lawyer, “You want 6 dead babies or a missing consent form?!” Medico-legal inclusion and medical ethics in this show are probably added in for some added drama. 

Meanwhile, Dr Cuddy is getting the medical students to swap the hospital. Its funny how one med student had his tie on, it was in the sink, and he gets told off by Cuddy for it. He doesn’t heed her advice to take it off or get a tie clip, and this was what happened. (I reckon we shouldn’t wear ties in the hospital! Do you?)

Later, the Chen-Lupino baby’s health begins to worsen with a falling heart rate and blood pressure. The doctors rush in and try to shock the baby back to life, to no avail. The aztreonam doesn’t work. House instructs his staff to cover the rest of the babies with vancomycin.

The team try to defibrillate the baby’s heart back into sinus rhythm. 

House instructs Cameron to tell the deceased baby’s parents (Kim Chen and Judy Lupino), that their son has saved five more babies’ lives. But instead, Wilson tells the shocking news, causing the parents to be devastated, Cameron feeling sorry for them and House is completely disappointed with what she’s done.

Chase informs the team that the vancomycin isn’t working either as Maxine’s getting worse. House performs an autopsy on Baby Chen-Lupino and devises a theory that it is a virus that is affecting the babies’ hearts. Foreman complains that it could be any one of thousands of viruses. However, with the amount of blood in the babies’ bodies, they can only run five or six tests. So House tries to narrow down the list of possibilities, and ends up with eight. House also has Cuddy take blood from the one healthy newborn in the hospital to use as a control group.

The sick babies all test positive for Echovirus 11, CMV, and Parvovirus B19. The healthy baby tests positive for Echo and CMV antibodies. House realizes that these infants still have their mothers’ blood and immune systems, so he orders a test on the mothers to see what they have antibodies for. Whatever the women are missing is what is killing their kids. After more testing, the doctors settle on Echo. They have an experimental anti-virus in the hospital and give it a shot.

That night, House observes an elderly hospital volunteer coughing and wiping her nose as she pushes around a cart of baby toys and blankets, and realizes that she was the original source of the virus.

Episode 104 shows how viruses can be transmitted from a sick hospital worker to the paediatric population.

More on Echovirus 11.

An echovirus is a type of RNA virus that belongs to the genus Enterovirus of the Picornaviridae family.  It is highly infectious, and its primary target is children. The echovirus is among the leading causes of acute febrile illness in infants and young children, and is the most common cause of aseptic meningitis (source: emedicine). Infection of an infant with this virus following birth may cause severe systemic diseases, and is associated with high infant mortality rates. The echovirus can mimic symptoms caused by other common bacterial and viral infections, so echovirus infections are often treated with therapies aimed for other infections. This can lead to the evolution of antibiotic-resistant bacteria.

Related links:

• House 104: Maternity Plot (Wikipedia)
• Polite Dissent’s Review of House 104: Maternity