House 106: The Socratic Method
In this episode of House, Lucille Palmeiro, a 38 year old mother suffering from schizophrenia, feels a sharp pain in her leg, a result of a blood clot. The clot moves to Lucille’s lungs and she collapses. (Pulmonary embolism)
The team is curious why House takes on the case. Foreman spells out the treatment: put her on IV heparin to prevent future clots. Is schizophrenia related? House dismisses it. How can abnormal dopaminergic pathways be related to clots forming? House is just puzzled why a 38 y.o. can get DVT…
At night in the hospital, Lucille vomits blood (haematemesis). Her clotting studies came back normal, except a prolonged PTT. House wonders if a Vitamin K deficiency explains the delay between the blood test and the vomiting. Foreman and Chase check the patient’s home for unused Ampicillin, which was prescribed earlier this year for a sore throat. Foreman finds a strongbox filled with medicine, including an untouched bottle of Ampicillin and a freezer full of microwave burgers. House’s theory about Vitamin K is becoming stronger. They are going to infuse her with Vit K.
Chase and Cameron ultrasound Lucille’s liver and find cirrhosis and a cancerous tumor. Of course, as Polite Dissent mentions in his review, why are specialists doing this U/S and interpreting them? What was the radiologist/US technician doing?
To circumvent surgical guidelines (5.8cm tumour should no be resected, apparently), House injects 95% ethanol into the tumor to temporarily shrink it. After the surgery, Social Services comes to the hospital to take Luke. House accuses her of calling Social Services for her son and believes that her decision is inconsistent with her schizophrenia. Finally, they decide its not schizophrenia; for women, they start in the mid-20s to early 30s
Late that night, House has a revelation. Wilson’s disease is marked by high copper levels in the body, and explains the cirrhosis. Seeing that Lucille canceled an eye exam last year, they give her a quick test. This is what they see:
The copper-colored rings, aka Kayser-Fleischer rings around her corneas confirm the diagnosis. Within a few days, a healthy Lucille is happily reunited with Luke and House blames Cuddy for the call to Social Services.
More on Wilson’s disease: (Source)
Wilson’s disease is a rare autosomal recessive inherited disorder of copper metabolism. The condition is characterized by excessive deposition of copper in the liver, brain, and other tissues. The major physiologic aberration is excessive absorption of copper from the small intestine and decreased excretion of copper by the liver. The genetic defect, localized to chromosome arm 13q, has been shown to affect the copper-transporting adenosine triphosphatase (ATPase) gene (ATP7B) in the liver.
The Kayser-Fleischer rings are formed by the deposition of copper in the Descemet membrane in the limbus of the cornea and they consist of electron-dense granules rich in copper and sulfur.
To clinch a diagnosis:
The presence of Kayser-Fleischer rings and ceruloplasmin levels of less than 20 mg/dL in a patient with neurologic signs or symptoms suggest the diagnosis of Wilson disease. If a patient is asymptomatic, exhibits isolated liver disease, and lacks corneal rings, the coexistence of a hepatic copper concentration of more than 250 mg/g of dry weight and a low serum ceruloplasmin level is sufficient to establish a diagnosis.
Treatment:
Chelating agents, e.g. Penicillamine (Initial: 1.5-2 g PO qd, Maintenance: 750 mg to 1 g/d PO qid 30 min ac)
Prognosis:
A prognostic Index in Fulminant Wilsonian Hepatitis exists. Check it out to determine if transplantation is necessary.
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