Title: Fidelity
Original airdate12/28/2004
Episode: 107
Synopsis:
Patient: Elyse
Initial symptoms: excessive sleeping, extreme irritability

*****Spoilers below*****

Differential diagnosis:


Ed comes home from jogging with his friend to find his wife, Elyse, still in bed at 4 o'clock in the afternoon.  He tries to wake her, but all she does is mumble for him to call in sick for her. He persists, mentioning that she has not been to work or gotten out of bed for three days.  She becomes increasingly irritable, finally slapping Ed in the face.  She wakes up enough to realize something is wrong with her.

Cameron tries to persuade House to take the case, pointing out that Elyse has been sleeping 18 hours a day since her admission. House dismisses this as a symptom of clinical depression. Cameron says Elyse has been seen by three ER doctors, two neurologists, and a radiologist, none of whom can figure out the cause of her ailment.  She mentions that the blood work shows no signs of inflammation, but House interrupts, clearly disinterested.

Cameron is so persistent that  House becomes interested in her interest in the case. When the rest of the team is presented with the case, Foreman's first reaction is to ascribe Elyse's hypersomnia and irritability to depression, as well. House rules out depression because Elyse has a fever. Cameron notes that an elevated sed rate indicates inflammation (despite what she read out of the same file a moment earlier). Foreman thinks her symptoms of hypersomnia and personality changes indicate a brain problem. Cameron says that no other signs of inflammation make vasculitis unlikely.  Chase suggests a parasitical infection, possibly malaria or Chagas, but Cameron notes that Elyse has never been outside of the United States. Chase notes that she only claims she's never been outside the US, but Cameron says the blood and CSF smears show no signs of parasites.

House suggests a tumor, but Foreman thinks it is unlikely that the previous doctors would have missed such a thing.  House orders new blood work and an MRI with two-millimeter cuts through the mesodiencephalic.  Elyse finds this news distressing, despite Ed's attempts to comfort her. After the MRI, Foreman reports that there are no visible lesions or mass effect, but it means they still don't know what's wrong.  Moments later, as Ed voices his frustration, Elyse has a seizure. Cameron calls for Ativan. Elyse begins aspirating, and Foreman starts suction.

Sometime later, Foreman administers a test in which Elyse must draw circles and triangles, with which she has great difficulty. Wilson reviews the MRI, but he says it reveals nothing. Foreman notes that a small glioma might be missed by the contrast, and suggests a PET scan.  House thinks A PET scan would be a waste of time, noting that for a glioma to be missed on a contrast MRI, it would have to be smaller than a grain of sand, which would not make someone as sick as Elyse.

Chase suggests that Elyse is having postictal disorientation, but Cameron thinks Elyse's condition would have improved by this time. Chase then suggests late-stage Lyme disease as a cause of seizures. House asks how devoted Ed is to her, and rules out Lyme disease, noting that a husband as devoted as Ed would have noticed the characteristic rash.

Wilson asks if they have examined Elyse's breasts, suggesting paraneoplastic syndrome from breast cancer. House accepts this possibility, as Elyse's mother died from it. Elyse is considerably alarmed during the mammogram. She tells Cameron that her mother was the same age as she when she died. Cameron tells Elyse that much has changed in the intervening years, and not to give up hope.

The mammogram and MRI showed no cancer, only benign calcifications. Wilson thinks it is most likely a small-cell tumor which is difficult to find, and they should now do a PET scan of her lungs, and possibly her bones. He also mentions that paraneoplatic syndrome can occur with no tumor. This puzzles Chase, and Wilson tells him that this happens with 12% of cases.  Those patients, House notes, do not receive any treatment. House wants to treat Elyse's symptoms with IV immunoglobulin. Foreman seems to dislike the idea of not looking further for a tumor, but House points out that if there is one, it will eventually get bigger.

House asks Foreman to check out Elyse's workplace. Since Ed is not sick, if Elyse was exposed to a toxin, it would not have happened in the home. Meanwhile, Cameron is tending Elyse while Ed is out of the room. Cameron asks her several questions to test her memory. During this test, Elyse complains of itching from her IV site.  Cameron thinks this is a mild irritation for which she will bring hydrocortisone cream. She continues the memory questions, but Elyse says the itching has become more severe. As Cameron turns to leave for the cream, Elyse imagines a large bulge on her arm, which bursts, releasing hundreds of tiny spiders.  Elyse begins to scream and thrash, begging for someone to get the spiders off her. Cameron calls for five milligrams of Haldol. Elyse's outburst intensifies when she imagines the spiders are biting her. Cameron tries to tell Elyse there is nothing on her, to no effect, as Elyse can still see and feel the spiders. Cameron, Foreman, Ed, and three nurses rush to sedate and restrain her, to prevent her from ripping her skin off.

Wilson says that "creepy-crawlies" are consistent with paraneoplastic syndrome, but Cameron notes that the hallucination statred immediately after the IVIG was administered.  House thinks this reaction could indicate an infection.  Foreman counters that the blood cultures rule out most bacteria, serololgy rules out viruses, and the blood and CSF smears showed no parasites. House points out that in the final stage of African trypanosomiasis, almost all of the parasites would be inside the brain, and likely wouldn't show up on smears.

Foreman thinks it is highly unlikely that a person who has never been to Africa would contract this disease, despite it fitting the symptoms.  Wilson notes that it is possible to to get the disease from a transfusion, but Elyse has never had one. Wilson asks about toxic exposure from Elyse's workplace. Foreman says the kitchen Elyse works in is immaculate, though her job as a rotisseur exposes her to rabbit meat, and suggests tularemia, also called rabbit fever.  Chase points out that tularemia would present with a rash or ulcer at the site of infection, but Foreman thinks it is possible she inhaled the bacteria and dismissed any respiratory symptoms as a common cold.

Since they have narrowed the possibilities to either tularemia or
African trypanosomiasis, Cameron suggests treatment for both. Chase points out that the treatment for tularemia can cause aplastic anemia and the treatment for Sleeping Sickness kills 10% of the patients.

Epiphany:
It occurs to House, while he is advising Mrs. Campbell that
African trypanosomiasis can be sexually transmitted, so it is possible she contracted it that way. House read about such a case in the Journal of the Instituto de Higiene e Medicina Tropical.

House sends Chase and Foreman to question Ed and Elyse separately. Both adamantly deny having an affair. The team starts her on IV chloramphenicol for tularemia, despite Elyse's lack of recent respiratory symptoms. While Cameron changes Elyse's IV, Elyse lapses into a coma. House states that the coma while on the medication means Elyse does not have tularemia, and that it must be Sleeping Sickness. House speaks to Ed alone. He again denies having an affair, a expresses his trust in his wife. House impresses on Ed the necessity that his trust be absolute, because without treatment Elyse will die by morning. Ed falters, and House orders the treatment. Chase and Foreman start her on melarsoprol, which requires glass syringes and special IV tubing. Foreman reads a list of potential side effects from the package insert, which include vomiting, abdominal pain, blood toxicity, neural damage, and cardiac arrythmia. Chase descibes the drug as "arsenic mixed with anti-freeze."

Ed confesses to Cameron that if Elyse recovers, it means she cheated on him, so part of him doesn't want her to recover.  He asks Cameron if that makes him a terrible person, She simply replies, "Yes" and leaves, visibly distressed.

Later, Elyse takes a turn for the worse.  She develops a fever of 104, an echo shows global hyperkinesis, and her blood pressure drops to 90 over 40. Chase gives her dopamine, to no effect after ten minutes. When House tells Ed that Elyse's condition is delincing, Ed goes to her bedside and begs her not to die.  To House's obvious surprise, Elyse begins to wake. Ed and Elyse have a private conversation, after which Ed takes his bag and walks out, leaving Elyse stricken and sobbing.

House asks Elyse for the name of her lover, as he needs treatment as well. He asks why she lied, knowing her life was at risk, but she doesn't answer. Cameron is sent to notify Elyse's lover, who turns out to be Ed's friend and jogging partner.

Diagnosis
:
African trypanosomiasis

Soap Opera:
House thinks Wilson is fooling around on his wife because he is wearing a new green tie and stylish French shoes. Lunch with oncology nurse.

Foreman thinks House is unusually critical of late. He becomes increasingly irritated, and finally questions House about it. When Foreman has an idea that House likes, House says, "That's why I ride you," which only irritates Foreman further.

Cameron blinds herself to the possibility that either Ed or Elyse had an affair because they appear to be utterly devoted to each other. Elyse told Cameron that she had been trying to get pregnant, so House thought Cameron might have emotional baggage (her aforementioned "damage") about babies due to her near emotional collapse during the epidemic in the maternity ward.  He tells Cameron that he checked her medical records to see if she'd ever been prescribed folic acid or if she had ever been pregnant, to Cameron's great indignation.

After the incident with Ed, House finds Cameron crying over a centrifuge.  He asks why she said what she did, and Cameron tells House of her short-lived marriage. When she was in college, she married a man who died six months later, of thyroid cancer which had metastasized to his brain.  House notes that he would have been diagnosed at least a year before his death, so she knew he was going to die, but she married him anyway. He tells her it's a symptom of her damage, not her actual damage because "no one can be that good a person and well-adjusted." Cameron chases after Ed as he leaves Elyse, telling him that he's lucky his wife is alive, and that she loves him. Ed simply states that you can't love someone and cheat, and leaves.


Clinic Patients:

Mrs. Campbell


Everybody Lies:
Elyse chose to risk death rather than reveal her infidelity.
Wilson evades House's questions about his spiffy appearance.


.
People: 

Ed
Ed's friend
Young Boy
Ed's friend's kid
Master Chef
Jacques

Sous Chef
X-Ray tech, Radiology Room 3 (paged)
Nurse

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