House S07EP16 “Out of the chute”
Here at YCPMicro we’re not too sure what is going to happen with the main characters after last week’s bombshells. The promos that have been airing since Cuddy kicked House out for relapsing on Vicodin showed him standing on the railing of a hotel balcony, 5 floors up. Maybe we’ll change the title of the show to “Wilson, MD” next season. The summary from Fox.com for this episode though is as cryptic as usual.
A young professional champion bullfighter is admitted for treatment after being attacked by a bull. After conducting multiple inconclusive tests, the team enlists House’s advice outside of the hospital while he attends to a few issues away from the case. Back in the hospital, the bullfighter’s condition continues to worsen, but with disappearing symptoms and the patient’s more frequent mini-seizures, the team’s last option is risky open-heart surgery.
I’ll start off with guessing that the injury was due to a pre-existing condition, that hindered the bullfighter’s reflexes. If he was gored by the bull, the most significant risk is by something like a Staph infection. We can rule that out, since that was the disease from last week, so I will go with toxemia due to Clostridium infection. Check back Monday at 8 to see if we are right!
Here we are back again on the other side! Let’s recap, shall we? House engaged in tons of risky displacement behavior, and Wilson vacillated back and forth in trying to enable and hinder House in his hotel scenes. The diagnostic team conducted most of their differentials over the phone, but ultimately Lane (the bullfighter) is OK at the end. Symptoms that arose during the course of the hour included: momentary blackouts (suggesting a neurological defect,) bleeding from the gums, masses that appeared on X-rays, but then disappeared, nausea, low-grade fever, and discoloration of the sclera of the eyes. The masses that were there and then were not were the ultimate clue, as they represented intermittently swollen lymph nodes, an indicator of an underlying infection. House finally diagnoses a Bartonella infection, which has likely resulted in an aneurism of the aorta. The team needs to open Lane’s chest to stress the heart into rupturing the aorta, and be in a position to repair the damage before he can bleed to death. The procedure is successful, and the condition is resolved. House then jumps off of the hotel balcony into a swimming pool.
What is Bartonella? It is a genus of Gram negative bacteria that can infect humans, and exist in the body as facultative intracellular parasites. That means that once the organism breaches our primary defenses and begins to grow in the body, they can enter cells and multiply inside our cells, and thereby evade the immune system. Wikipedia notes that the range of symptoms due to Bartonella infection is remarkable for its breadth; one potential complication from bloodstream infections caused by different bacteria is a mycotic aneurism, where the arterial wall becomes damaged by the infectious process. Surgery is of course necessary for treating the arterial damage, however antibiotics such as tetracycline can be used, although the efficacy of antibiotics in an immunocompetent individual is uncertain.
Bartonella infections are caused by at least 8 species of bacteria, which are all transmitted to humans via the action of blood sucking arthropod vectors. The reservoirs for infection are a number of other mammals, including cats, dogs, rats, squirrels, and mice, and two species of Bartonella use humans are their primary reservoir. Over 1 million soldiers during World War I were infected by Bartonella quintana, developing a disease called “Trench Fever.” The bacterium was passed from individual to individual via the body louse. The form of Bartonella infection that we’ve probably heard of is (NOT the Ted Nugent album), which as you might have guessed is hosted by the domestic cat, but is not transmitted via cat scratches, but by being bitten by infected fleas.
I think most of the patient’s history (long list of injuries, metal plates, etc.) were red herrings in this; there was no clear cut indication of how the infection initially occurred, and my Wikipedia searching turned up no indication that large mammals such as bulls would be appropriate reservoirs for these infections. The case, causes, and resolution are certainly plausible, but I think most of us probably couldn’t have anticipated the diagnosis beforehand!