Original airdate: 11-23-2004
teenage boy suffers sudden double vision, followed by night terrors.
House is initially dismissive, but becomes intrigued by an
unusual symptom, and by the boy's familial relationship.
Initial symptoms: Double vision, night terrors, myoclonic jerk.
Differential diagnosis: Dan, 16, experiences sudden double vision
which causes him to get clobbered during a lacrosse game. Dan's parents
bring him to the clinic to see House, claiming to have an appointment.
When House attempts to brush them off, they show him a letter in which
he agrees to meet with them, but the letter was forged by Cameron.
House, however is intrigued when Cameron mentions the boy has been having night terrors
which remain unexplained,even after Dan was examined by two
neurologists. House gives Dan a cursory examination, which involves
looking in his eyes, flicking a finger at his eyebrows, and asking him
to name as many animals as he can that begin with the letter "B."
a long pause, Dan replies "baby elephant." House seems to interpret
this as meaning Dan isn't too bright. House says that the likely
causes of night terrors in teens are Post Traumatic Stress Disorder
and sexual abuse. Since there have been no shoot-outs at Dan's school,
and no trauma, all that's left is the sexual abuse. There is no reply
to House's query as to who's doing it, as the family is now
When Dan finally speaks, he tells House of the blow to the head at the lacrosse game. He dismisses Dan as having a concussion.
When Dan insists the double vision came before the blow to the head,
House is still disinterested, telling Dan to go see an ophthalmologist
to get some glasses, and walks away.
Cameron takes House's
disinterest as a personal insult, but while they argue over the point,
Dan, who is sitting a short distance away, gets a peculiar twitch in
his leg. Dan doesn't seem to notice it, but House is intrigued. He
tells Dan that the twitch is called a myoclonic jerk, which is a pulse
sent by the brain to wake the body, as the brain sometimes mistakes
falling asleep for the body dying. Since Dan is awake, this is
significant enough for House to admit him to the hospital.
House and Foreman think Dan may have a movement disorder or a
degenerative disease, while Chase suggests it might be a simple
infection. House thinks that the diagnosis may be compromised
because Dan's father is not really his father. Foreman thinks this is
unlikely, and they place a wager on it. Cameron (irritated by the
banter) suggests leukoencephalopathy.
Chase thinks the night
terrors could be mere nightmares, which would indicate a condition
outside the brain. House orders a polysomnograph, which confirms the
night terrors. (The night terror is a rather gruesome scene in which
House chops off Dan's big toe with an enormous pair of stainless steel
shears. It's good he won't remember it.)
Dan undergoes an MRI,
on which House sees a "clue," and challenges the team to find it.
Foreman and Cameron note no lesions, structural abnormalities or
tumors, and Chase finally guesses meningial enhancement, which would
indicate meningitis. (Wrong.) House directs their attention to Dan's
corpus callosum. Chase sees "bowing" (though Foreman
doesn't). House thinks there is a blockage of the cerebrospinal
fluid (CSF), which is confirmed with a radionucleotide
cisternogram. A surgeon places a shunt in a ventricle of Dan's brain to
relieve the pressure.
The surgery went well, but the young
Doclings disagree over the results of tests on Dan's CSF. The tests
show oligoclonal bands and intrathecal IgG, which indicate
multiple sclerosis (MS). However, there are no lesions on the MRI.
Cameron says the McDonald criteria require six months to make a
definitive diagnosis. Foreman argues that the VEP shows a slowing of
the brain. House says that if it is rapidly progressing MS, treatment
should begin immediately to slow the debilitating effects of the
disease. Dan and his parents are considerably distressed by this news,
though Chase tells them the diagnosis is not certain.
evening, Dan disappears from his bed, and is found on the roof. At
first they think Dan is suicidal from the dismal diagnosis, but they
discover that Dan is hallucinating. He thinks he is on the lacrosse
field, and nearly strolls off the edge, but is tackled by Chase.
sees this as good news, meaning Dan does not have MS, so the
oligoclonal bands must mean Dan has an infection in his brain. Cameron
suggests neurosyphilis, though his RPR was negative. House says the
false negative rate for an RPR test is 30%, but it is highly likely
that Dan is sexually active. House orders treatment with penicillin
injected into Dan's brain through a lumbar puncture, which is possible
to do without causing brain damage due to the shunt.
injection, Dan begins hearing voices, for which Chase orders Ativan.
The auditory hallucinations indicate the penicillin isn't working and
Dan is still deteriorating, sending House and the team back to the
white board. House writes the mnemonic MIDNIT, for metabolic,
inflammation, degenerative, neoplastic, infection, trauma. Each
is crossed off in turn as it is noted that Dan's LFTs, BUN, and
creatinine are normal, no diabetes and no gap; MRA ruled out
vasculitis, he's too young for a degenerative disease, MRI showed
nothing , CT showed no trauma. The only indications, the bands, are for
infection, though Dan has had no fevers and his white count is only
House orders an EEG, left and right EOG,
and esophageal microphones, largely to disguise that he is
stumped. Dan's parents find House drinking coffee outside the
cafeteria, and interpret this as callous indifference to their son's
condition. House stops their scolding by listing his up-to-the-minute
knowledge of Dan's condition. ("Blood pressure 110/70, shunt is patent,
well-placed in the right lateral ventricle, the EKG shows a normal QRS
with deep-wave inversions throughout both limb and precordial leads.
LFTs are elevated, but only twice the normal range. Oh...and he's
hearing voices.") The seem chastened by the barrage of doc-speak, and
leave their tray for House to dispose of, which he offers to do only as
a means to sample the DNA from their coffee cups.
the team in the lab. While Cameron is waiting for the results of
of CBC and Chem-7 tests, he briefly notes that Dan has no
epileptiform activity on his EEG, and orders Cameron (over her
objections) to run the DNA tests. Dan tests negative for West Nile and
equine encephalitis, which is not surprising considering the lack of
mosquitoes in December.
The DNA tests reveal that Dan's father
is indeed not his father, but also that his mother isn't his mother
either. While the parents are in Cuddy's office discussing moving Dan
to another hospital, House barges in and castigates them for not
telling him that Dan was adopted. They gave the medical history for
Dan's biological mother, but House asks if she was vaccinated. They
point out that Dan was vaccinated, but House explains that babies are
vaccinated at six months of age because they are protected for that
long by their mothers' immune systems. The answer appears to be that
she was not, or they don't know.
House determines that Dan is
infected with a mutated form of a wild measles virus,
causing Subacute Sclerosing Panencephalitis. They confirm the
diagnosis with a biopsy of Dan's retina. The treatment is
intraventricular interferon, delivered from an Ommaya reservoir, through
a catheter, directly into Dan's brain.
improves rapidly after the treatment. His immune system is responding,
and he can name three animals that start with the letter "O." (Ostrich,
ox, and "old elephant" just for fun.) Cameron asks how he's handling
the knowledge that he's adopted, and says he's known since the fifth
grade. He noticed he has a cleft chin and his father doesn't, and did
some internet research on inheritable traits. Since a cleft chin is
autosomal dominant, it's unlikely for a child to have this trait if
neither parent does.
Later, as House walks across the athletic
field, he imagines Dan, fit and healthy, playing lacrosse. He gazes
ruefully at his cane and, emerging from his reverie, limps away across
Diagnosis: Subacute sclerosing panencephalitis
House places a paternity wager on Dan's father, betting that Dad is not
Dad. He wins $600 from Wilson, $200 from Foreman, $100 from Cuddy, and
$100 from Cameron.
Cameron: forges a letter from House to Dan's parents
Dan's parents omit information that Dan is adopted
PPTH People: ppth