House Episode 17 (Season 6: Knight Fall- Medical Review)

Tonight's episode of House wanted to be clever, but just ended up being muddled. It was a "let's throw everything against the wall and see what sticks" episode.


William is a knight at a Rennaissance Faire, and he's actually been living there full time for the better part of a month. After fighting Horace the Black in a tournament, he staggers then suffers a seizure; the whites of his eyes are also bloody. As luck would have it, he is admitted to House's service.


The initial diagnoses include concussion, subdural hematoma, or an allergic reaction to something at the Faire. House orders a head MRI, which is negative, but William starts vomiting during the test. This is a possible indication of food poisoning, but the idea is discounted as William is the only one with any symptoms. Meanwhile, Foreman and Thirteen check out the Faire. They find evidence that William had been sick prior to his battle — and also discover that the Faire’s king had a wicked sense of humor, forcing his knights to eat all kinds of disgusting foods. House suspects William may be allergic to one of these, so has the team perform scratch tests (an allergy test) for them. At the same time, he also wants to treat William with epinephrine to minimize his symptoms. Shortly after receiving the epinephrine and starting the scratch test, William suffers chest pain and develops an irregular heart beat (a tachycardia, according to Foreman). When William’s shirt is opened in preparation for defibrillation, a vesicular (blister) rash is seen.


The differential diagnosis now consists of an allergy to the preservative in epinephrine injections, Wolff-Parkinson White syndrome (a condition with a rapid heart rate), or MRSA (methicillin resistant Staph aureus — a nasty infection that spreads easily and can be difficult to treat). House suspects the latter — skin cultures are ordered and William is placed in isolation. Meanwhile his chest pain is getting worse and now he’s developing back pain.


House shows up and announces that the rash, and possibly the rest of the symptoms, is due to poison ivy. House found this out when he got a poison ivy from handling William’s sword, and now he wonders if they’ve been burning it in campfires, and William breathed in the smoke and got some in his eyes.


William develops heart problems again, only this time his heart rate is too slow. Chase injects him with a large amount of epinephrine despite the fact that he might be allergic. The heart stops for a second, but ultimately the treatment works. As bradycardia (slow heart rate) would not be symptom of poison ivy, this causes the team to once again re-evaluate their differential diagnosis. The new differential consists of leukemia, environmental toxins, or trichinosis (a parasitic contracted from undercooked pork). House has the team treat the suspected trichinosis and check a muscle biopsy. The tests for trichinosis come back negative and Foreman is starting to wonder if it may be a fungal infection. William now complains of leg pain, reporting that his legs feel like they are “on fire.” When the sheet is yanked back, it reveals grossly edematous (swollen) legs. Thirteen reports that William now has rhabdomyolysis complete with kidney failure. Taub suspects William has cancer. Foreman and Taub ultrasound the liver looking for the tumors while Thirteen and Chase investigate William’s apartment. The ultrasound reveals a number of lesions which at first are thought to represent tumors, but they appear more vascular than tumors would be. The investigation of William’s apartment reveals the chivalrous knight to have also been practicing the occult.


The team suspects William may have been poisoned by some of his occult rituals/concoctions while House suspects lead poisoning (until the past few years, most metal miniatures had a high lead content). Tests for lead poisoning are negative. Meanwhile, William’s heart rate and blood pressure are getting worse.

House visits the Renaissance Faire himself and heads to the Apothecary shop (basically, a medieval drug store). He finds a number of mislabeled herbs, the most concerning of which is water hemlock mistaken for a wild carrot. The Apothecary admitted selling a small amount to the Faire’s king. When questioned, the king replies that he thought it was a wild carrot and admits to using a small amount in one his knights’ challenges, but denies any poisoning attempt. None of the other knights became sick. Lab tests show a small amount of hemlock in William’s system, but the standard treatments aren’t working, and Taub insists that something else must be going on. A talk with Wilson’s ex-wife/current girlfriend gives House the inspiration he needs to realize that William has been abusing anabolic steroids. These made the hemlock more potent, explaining why only William suffered the ill effects. (So you got that? Rash was poison ivy. Heart, liver, muscle was the steroids. Hemlock was apparently everything else).


As usual, major complaints are in red, minor complaints are in blue, and nit-picking ones in green:

North American hemlock (water hemlock) has cicutoxin, which is not a piperadine (as opposed to European poison hemlock which has coniine, which is a piperadine). Thus tests that show piperadine in William’s blood would NOT be an indication of water hemlock poisoning.


Gastric lavage and activated charcoal wouldn’t do anything for hemlock poisoning 2+ days out.


What is the point of running allergy testing when you’re giving medicine to treat the allergies at the same time?


The patient is dying of hemlock poisoning and only suffers a single mild seizure? One of the classic signs of the condition?


There are two types of MRSA: community acquired and hospital acquired. Both are nasty, but the latter is much, much worse than the former (which is what William would have contracted)


Water Hemlock is extremely poisonous, even in small amounts. The other knights would have had some symptoms as well, even if not as severe as William’s.

Again, fungal tests take weeks to get results, not “spore tests” overnight.


What was up with that whole occult/witchcraft angle? That came out of nowhere and added nothing to the episode, other than proving once again that TV writers can’t separate the wiccans, pagans, and occultists.


Why would a king who thinks that making people eat cow brains, eyeballs, etc. is the height of fun, even conceive of making his men eat a small sliver of wild carrot as a “challenge?”


The medical mystery was a little better than average: C+. The final solution was a mess. Anything that takes three answers isn’t clever: D. The medicine was haphazard, but better than average: B-. The soap opera was pretty good: B.

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