It's Never Lupus: The Medicine of House

It's Never Lupus: The Medicine of House
Topic to discuss the medical issues on House. Enjoy! Topic title is obviously open for debate and discussion; it's my first new topic. And my birthday--yay!

Happy Birthday. Maybe Wilson's behavior in S3 was due to the fact that he was severely brain-damaged in Euphoria. Apparently naegleria has something like a 97% fatality rate and the survivors are brain-damaged.

My sister had sarkoidosis - she only got it because she used to travel to PNG a lot. It tool six months to diagnose her, but apparently it can be quite fast acting and deadly too. But it does take a really unique set of circumstances to get it.

Happy Birthday. Maybe Wilson's behavior in S3 was due to the fact that he was severely brain-damaged in Euphoria. Apparently naegleria has something like a 97% fatality rate and the survivors are brain-damaged. But ... but Wilson wasn't the one who got sick. That was, oh, what's his name again? Hee. Although there were times in S3 that I did wonder who had stolen Wilson's brain.

Foreman should have died a whole lot of times. As somebody in the DDx board mentioned a few days ago, he should have died from rabies once he became symptomatic. Maybe he's like Kenny from South Park...?

"Oh no! They killed Foreman!"

:lol: Or should that be, "Oh no! They killed House!"? My preference would be Foreman but the writers don't love me. :x Okay, to take Chai's Happy Birthday topic seriously...from what I've heard from people who know medicine (and even the smidgen I know myself) sometimes the least said about the medicine on House the better. Which of course doesn't stop us talking about it for a minute! :D While I find I'm happiest when I pretend that whatever they say on the show is true, I love hearing from people who know what they got right and what they got wrong. So, People Who Know, what have they gotten the most right so far and what has been their worst medical error?

I'm pretty involved in medicine; I'm not sure if I'd be People Who Know, but I'm People Who're Interested. I think they did better with the medicine in Season One and maybe Two, when they did cases that are hard to diagnose or have a long differential. Now the cases tend to be a little out-there (synaesthesia as a neurological symptom rather than congenital disorder is, AFAIK, fantastically rare) and the steps in between even more so (xeno-diagnosis for a parasite?) My vote? BEST: Socratic Method, with the most accurate presentation. Only thing that can't be explained by Wilson's disease is why she liked that frickin' poem. WORST: Good God, I would love to say ODOR, but I'll go with Insensitive instead. While it was an accurate presentation of CIPA, it was so wildly inaccurate on other counts (the B12 malabsorption was completely wrong, fish worms don't grow to that size, House couldn't perform the surgery no matter how brilliant/sexy he is, girl barely bled after he cut into her GI tract). As of season four I started watching this with a doctor, and I must say that it's probably a good deal better without a doctor. It's like watching CSI with a forensics expert. But House sure as hell beats out Grey's Anatomy!

WORST: Good God, I would love to say ODOR, but I'll go with Insensitive instead. While it was an accurate presentation of CIPA, it was so wildly inaccurate on other counts (the B12 malabsorption was completely wrong, fish worms don't grow to that size, House couldn't perform the surgery no matter how brilliant/sexy he is, girl barely bled after he cut into her GI tract). The B12 thing was fine (for the show), I thought. Tapeworm absorbed most of her own B12 and the docs gave her nitrous, which blocked her ability to absorb the B12 shot they gave her and any remaining B12 from her diet. And tapeworms do grow that big, trust me! I agree that no one would ever perform surgery to remove a tapeworm, even if it was that big.

Trust me, Diphyllobothrium doesn't grow that big. Most of the medical problems in this show come from a worm that size. Think: where would it live? She would have had a severely distended abdomen on presentation and would have died from infection caused by a MASSIVE obstruction. She wouldn't be absorbing anything because her small intestine was roomies with a worm, and B12 is definitely not the first thing to go. She would have to deplete her stores first, and in that kind of time, another deficency definitely would have presented. IIRC, they gave her B12 in the E.R. long before House gave her nitrous. The reason the B12 shot didn't work was not because the worm absorbed it (how could it absorb something already in the bloodstream?), but because it takes a while for B12 deficency to be resolved. Those neurological symptoms could well have been permanent, and often are. Smart money puts it on improperly cooked gefilte fish ;)

The length is mentioned as 'twenty-five feet long'. Trust me, Diphyllobothrium doesn't grow that big. They do, they have and they will. For an otherwise unremarkable GI presentation, twenty-five feet is big but in no way unheard of. I didn't have a problem whatsoever with the dimensions of the tapeworm – only the manner of treatment.

Trust me, Diphyllobothrium doesn't grow that big. They definitely do get that big - they are the longest species of tapeworm affecting humans. Trust me - I taught parasitology and we had quite a few huge specimens for students to gawk at. One of them (a measly, 5 foot specimen) came from one of our other teaching assistants. And she only realized she was infected after suffering from a B12 deficiency. They reach over 10 meters in length: http://www.dpd.cdc.gov/dpdx/HTML/diphyllobothriasis.htm Most of the medical problems in this show come from a worm that size. Think: where would it live? She would have had a severely distended abdomen on presentation and would have died from infection caused by a MASSIVE obstruction. She wouldn't be absorbing anything because her small intestine was roomies with a worm, and B12 is definitely not the first thing to go. She would have to deplete her stores first, and in that kind of time, another deficency definitely would have presented. Here is what the link I posted above has to say about symptoms: Diphyllobothriasis can be a long-lasting infection (decades). Most infections are asymptomatic. Manifestations may include abdominal discomfort, diarrhea, vomiting, and weight loss. Vitamin B12 deficiency with pernicious anemia may occur. Massive infections may result in intestinal obstruction. Migration of proglottids can cause cholecystitis or cholangitis. It would be perfectly reasonable for her to present with no symptoms for many years except a slightly distended abdomen and no need to diet, since she had only one worm. IIRC, they gave her B12 in the E.R. long before House gave her nitrous. The reason the B12 shot didn't work was not because the worm absorbed it (how could it absorb something already in the bloodstream?), but because it takes a while for B12 deficency to be resolved. Those neurological symptoms could well have been permanent, and often are. Smart money puts it on improperly cooked gefilte fish ;) Of course the worm didn't absorb the B12 that was administered, there's no way it could have. The nitrous blocks receptors that are involved in the utilization of B12. It's perfectly reasonable that a patient receiving nitrous a few hours after getting a B12 shot would not show a measured improvement. I'm not trying to harp on you, I just don't think the medicine in this ep was all that unreasonable :wink:

I followed the link, of course, and read the same thing you did. Still came back to "infection resulting from obstruction." She couldn't report abdominal pain, but she had no intestinal symptoms from a 25 foot worm. No vomiting, diarrhea, weight loss. Her mother was very observant; I think they would have rushed her to a hospital if she started showing those kind of symptoms. I looked it up; apparently my attending was wrong about the length of diphyllobothrium. We have to assume that the worm was blocking almost the entirety of the small intestine (the proglottids are even wider than their length in diphyllobothrium, no?) which absolutely would have given her other deficencies before her B12 store was exhausted. This worm was in her a long time; common medical sense tells us that you'd have more problems than deficency of a single vitamin if you have a 25-foot worm in your gut. The patient would not have shown improvement regardless of the nitrous. If her stores were so depleted that she was showing sever neurological symptoms, a single shot of B12 wouldn't have helped jack. Come to think of it, did they just not do a CBC? That kind of severe B12 deficency without megaloblastic anemia seems a little unlikely to me. The point is that if you compare this case to the neurocysticercosis case in the pilot, you see the change that the writers have taken in presenting the medicine. While all of these cases are theoretically possible, they all stretch it a little. This one stretched it a lot, that's all.

I followed the link, of course, and read the same thing you did. Still came back to "infection resulting from obstruction." She couldn't report abdominal pain, but she had no intestinal symptoms from a 25 foot worm. No vomiting, diarrhea, weight loss. Her mother was very observant; I think they would have rushed her to a hospital if she started showing those kind of symptoms. Obstruction usually only occurs when there are multiple worms infecting the person. This most often happens when a person is exposed repeatedly, usually because they live in substandard conditions or rely on a food source that is an infection source. CIPA girl had only a single worm. Worms grow huge in patients precisely because there are so few symptoms. I looked it up; apparently my attending was wrong about the length of diphyllobothrium. We have to assume that the worm was blocking almost the entirety of the small intestine (the proglottids are even wider than their length in diphyllobothrium, no?) which absolutely would have given her other deficencies before her B12 store was exhausted. This worm was in her a long time; common medical sense tells us that you'd have more problems than deficency of a single vitamin if you have a 25-foot worm in your gut. Proglottids are the sections of the tapeworm, so they are exactly as wide as the worm - a single worm is made up of a number of proglottids. The most common deficiency associated with tapeworm infestation is anemia, which is bad, but tends to have more general symptoms than B12 deficiency. The other teaching assistant I was talking about - the one with the worm - was also anemic, but dismissed it because she thought she was just tired. When she started having neurological problems, she finally went to a doctor. The worm eats your food, true, but people who are well-fed and otherwise healthy will be able to provide for themselves and their worm, so to speak, for quite a while before noticing deficits.

It makes perfect sense that an obstruction usually occurs when there are multiple worms; however, this worm is big enough that it is pretty likely (GI doc says "absolute") that she would have an obstruction. My point about the anemia is that it would have shown up on a CBC. Given them more clues, since decreased RBC, increased MCV, and normal reticulocyte count tends to indicate megaloblastic anemia. House was looking for diseases in this patient. I find it difficult to believe that he would have missed severe anemia. The worm eats your food, true, but people who are well-fed and otherwise healthy will be able to provide for themselves and their worm, so to speak, for quite a while before noticing deficits. I think by the time the worm gets to 8 meters, you're going to start noticing a whole lot of deficits.

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