House S07EP11 “Family Practice”
Midway through the current season of House, and what do we have? By my count, we’ve spent about half of the season on character development with the House/Cuddy relationship, a little progress with the House/Wilson “Bromance,” a newbie in House’s team which I feel has had some high entertainment value, and a couple of medical mysteries that have been sub-par. Coming up this week, via the fox.com episode synopsis: the House/Cuddy relationship hits a snag in the form of Candice Bergen as Cuddy’s incredibly domineering mother (brilliant!) but no apparent sign of Wilson. The individual members of the diagnostic team continue to have their individual life dramas. What about the medical mystery? Cuddy’s mom Arlene has mysterious symptoms, that leads House to an illegal and non-conventional course of treatment. As you might imagine, the by the book newbie Dr-to-be Masters has some issues with this approach. Meanwhile, House discovers that Cuddy’s mom has kept a secret from Cuddy and her sister for their entire lives! You know this is going to end badly.
OK, let’s recap: Arlene’s symptoms appeared to be heart related from the onset. A couple of potential diagnoses were tossed out there by House and his team, and the “B”-team that was hired after Arlene fired them when she figured out House’s initial diagnosis was that she was a hypochondriac. That quickly was ruled out when the symptoms returned in force after pulling the sugar pills, leaving us with a couple of alternatives. Number one: thiamine deficiency, brought on by alcohol abuse, and House’s best guess since she quickly accepted the possibility of blacking out last week when House slipped her a Mickey to incapacitate her. Number two: leukemia, suggested by the “B”-team as a real possibility, and by House as a ruse to take Masters out of the picture. Not a happy diagnosis if it works out. Number three: endocarditis, or infection of the heart tissue by an unknown organism, but likely something like Staphylococcus aureus, Streptococcus pyogenes, or Escherichia coli. Treatment would be relatively simple, put her on antibiotics and wait for her to improve. Of course, they have to do this by replacing her existing treatment for leukemia (prednisone) for an antibiotic without her knowledge, her new doctor’s knowledge, or Masters’ knowledge. Hijinks ensue, but you know we don’t have it yet, as it is only 8:40 at this point.
Arlene continues to go downhill, leading to a touching mother/daughter moment in the back of an ambulance, and House saving the day as he picks up a scapel and makes an incision on her hip. Remember back at the start of the episode and they mentioned that she’d had a hip replacement? I do too, now. It turned out that the implant had worn (possibly due to her active lifestyle that was the red herring about deep dark secrets in the recap above,) exposing the cobalt core of it, which had prompted a toxicity response in the body.
What’s going on here? Millions of artificial devices are implanted into people every year, from dentures, indwelling catheters, heart valves, arterial stents, and artificial joints. All of these devices are designed to be biologically inert, for several reasons. First, every foreign object that enters the human body will begin to elicit an immune response to that object. These devices are designed to minimize that immune response to diminish the odds of it being rejected by the body as transplanted tissue would. Second, these devices are also designed to minimize the ability of microorganisms to attach and form biofilms on them. Plastics are able to satisfy both of these requirements pretty effectively, although you could see pretty easily that a plastic artificial hip will never stand up to the stresses that the joint must withstand. The solution is to make a metal device with a plastic coating. However in Cuddy’s mothers case, the plastic had worn off, exposing the metal, and many metals are toxic to cells in large concentrations. So the resultant therapy (chelation therapy) was able to remove the toxic metal from her bloodstream, and the defective implant replaced.
Final evaluation? This seems feasible, although the drama was certainly prolonging the ability to make a correct diagnosis. I didn’t notice any evidence of fever, which would likely have been a red flag for the presence of infection (and help to confirm the endocarditis diagnosis.) The metal toxicity was kind of clever, but has appeared before in the series several times. I like it in this episode because it does help to demonstrate several critical points about implanted medical devices; namely that medicine is caught between two essentially contradictory demands. First, you have to have a device which is functional, and able to stand up to the physical demands of replacing a biological material. Secondly, it cannot react adversely with the body, and so must be innocuous and not elicit a biological response. And that is really the toughest part of the issue!