Medical House Review Episode 19 Season 6 'The Choice'

This episode of House started off strong, with an interesting mystery, and kept the moment — for the first half, anyway. Then it settled into its all-too-common mishmash of acronyms and quasi-medical reasoning.

Ted is a twenty-seven year old about to get married. As he stands at the altar, he suddenly finds that he is unable to speak, and then he collapses. He is admitted to the Emergency Department, where House’s team evaluates him for his “aphasia” and “syncope.” He is told that the initial work-up has excluded infection, vocal cord damage, stroke, low blood pressure, low blood sugar (hypoglycemia), and dehydration. House clearly suspects Ted got a case of cold feet about the wedding and is faking his symptoms. Surreptitiously, he stabs Ted with a needle causing him to scream out loud. Ted seems amazed that he is now able to talk. This sudden resolution of his symptoms lends credence to House’s suspicions and Ted is discharged from the hospital.

Of course, this is House, and being discharged is a sure sign that worse things are about to happen, and — sure enough — once outside the ER, Ted suddenly starts coughing and then gasping for air. Once again, he collapses. A chest x-ray reveals a substantial pleural effusion (extra fluid building up around the lung). House is reminded that the ER found no evidence of infection and Chase insists that there are no parasites (the eosinophils, a type of white blood cells which are usually elevated in parasitic infections, are normal), but House wants to make sure. He orders the pleural fluid cultured, and run through cytology (looking for infection and cancer). He has half the team search the house Ted shares with his fiancée, and the other half check the apartment he used to live in. Apparently, the search of his current home showed nothing because it was never mentioned again. The search of the old apartment turned up some interesting things: possible lead poisoning, possible asbestos exposure, and an old ex-boyfriend.

The lab tests on the pleural effusion show that it is the result of a mono (mononucleosis) infection. This is an unusual presentation for mono, so the team wonders if Ted may be immunosuppressed — in particularly, if he has HIV (the virus which causes AIDS). The subsequent test is negative. When questioned, Ted tells Thirteen that he was gay once, but was “cured” by attending intensive conversion therapy which included aversion therapy (looking at gay porn while receiving emetics, i.e. drugs that cause vomiting), male hormone injections, and ultimately, electroconvulsive therapy (ECT, i.e. “shock therapy”). The team wonders if the ECT may have caused some brain damage, so an EEG is ordered.

It is normal, but then Ted suddenly suffers a cardiac arrest; luckily he is resuscitated with the help of a handy defibrillator. The team now evaluates why Ted suffered the cardiac arrest (which they keep calling, incorrectly, a heart attack). His EKG is normal, as is an electrophysiology study (a look at the electrical pathways within the heart). They decide to proceed with a cardiac catheterization (evaluating the arteries which supply the heart with blood). While they are describing the procedure to him, he suddenly faints. They sit him up, and he faints again. This leads House to diagnose him with POTS (postural orthopedic tachycardia syndrome). According to the team, this diagnosis explains virtually all of his symptoms. It can be caused by infections such as mono, which is probably how he developed it. He is started on fludrocortisone for treatment (fludrocortisone increases sodium retention leading to improved blood pressure and blood volume).

A short time later, Ted starts complaining of a severe headache. Infection is considered a likely cause, so a spinal tap is ordered. This offers no answers and only seems to make the headache worse. House now suspects that Ted has a CSF (cerebrospinal fluid) leak where the spinal tap was performed, leading to low CSF and a spinal headache. He has the team apply a blood patch to stop the leak. About this time, Ted develops left-sided facial drooping. The rest of his neurological exam is normal (except for the headache).

An MRI is obtained, but is normal. Various diagnoses are considered including sarcoidosis, scleroderma, histoplasmosis, and MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis, and Stroke syndrome — a genetic neurologically degenerative disease), but none seem to fit. House decides to have the team get a good history from Ted, but this time with both his fiancée and ex-boyfriend present. With prompting, it turns out that Ted had a fainting spell at least once before, and he has had some erectile dysfunction (trouble getting an erection) with his fiancée. The team wonders if there may be an underlying vascular problem causing his symptoms, including his erectile difficulties. A penile plethsmyograph is ordered, but is normal. However, Thirteen notices that Ted is now suffering from galactorrhea — in other words, he’s lactating.

Thyroid diseases, including Graves and Hashimotos, are considered but then discarded. Taub suggests a pituitary tumor. It makes a certain amount of sense, so a pituitary MRI is ordered and a prolactin level is checked. Once again, everything is normal (were there any abnormal tests or radiology in this episode at all?) Meanwhile, House is having a conversation with Wilson that leads to his Aha! moment of the week: Ted has a Chiari malformation. This is a narrowing of the skull which puts pressure on the cerebellum, cutting off normal CSF flow. Ted had not previously had any symptoms, but the slight swelling of the brain caused by the electroconvulsive therapy was enough for the malformation to cause his symptoms. Some surgery and Ted’s symptoms resolve.


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