Title: Paternity
Original airdate: 11-23-2004
Synopsis: A 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.
Patient: Dan
Initial symptoms: Double vision, night terrors, myoclonic jerk.

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

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."

After 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 flabbergasted.

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.

Both 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.

Later that 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.

House 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.

During an 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 slightly elevated.

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.

House finds 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.

Dan 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 the field.

Subacute sclerosing panencephalitis

Soap Opera: 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.


Clinic Patients:

Breast-fed baby
Yummy Mummy
Mr. Funsten

Everybody Lies:
Cameron: forges a letter from House to Dan's parents
Dan's parents omit information that Dan is adopted

PPTH People:

Other People


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