House Watch: The Dangerous Line Between Hypochondria and Illness

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It was a dark and stormy House M.D. Last night, Princeton-Plainsboro was in a state of near-dissolution: besieged by a thunderstorm (a slightly odd choice for February in New Jersey), the hospital was home to furious outbursts, illegal medical procedures, blackmail, assault, heartbreak—and even a dimly lit men’s bathroom strewn with dirty hand towels. This gloomy tableau served to heighten the stakes for a big guest star, Candice Bergen, who played Cuddy’s mom and, to say the least, a difficult patient. Now, on to the medicine.

Actually, on to a spoiler alert. If you haven’t seen this chiaroscuro episode, “Family Practice,” get down to the morgue, settle in with some junk food next to a corpse and watch it before reading on.

The episode begins with Cuddy trying on clothes (yet another chance to show off Lisa Edelstein’s smoking body). Arlene (Bergen) tells her daughter she looks slutty but (as if in punishment) soon feels her heart flutter. Cuddy takes her pulse and realizes Mom is experiencing artrial fibrillation, a condition in which the two small chambers in the upper part of the heart quiver instead of beating normally.

At the hospital, House is skeptical that Arlene is really sick because she constantly shows up at P-P’s clinic complaining of various ailments—come-and-go rashes, stomach problems, unexplained bouts of dizziness, all of which could add up to hypochondria, which is House’s first diagnosis. House says the only real problem Arlene has had is a bad hip, for which she got a replacement.

Still, Cuddy is worried, so Taub and Masters search Arlene’s house for environmental toxins (and for Cuddy’s high-school yearbook). They find no radon, no mold, no lead on the pipes—and no yearbook. Score one for hypochondria—until they find pictures of Arlene captured in flagrante delicto with Jesus, her married contractor. This suggests a sexually transmitted disease until Masters find a bottle of azarcon that Jesus had given to Arlene.

Azarcon (lead tetroxide) has been used in Mexico as a folk medicine for stomach problems, but it can also cause lead poisoning. Arlene disputes this diagnosis. After all, she has done some research on her MacBook Pro and found that lead poisoning couldn’t explain all her symptoms. (It seems everyone at P-P seems to have a MacBook Pro; my diagnosis is embedded advertisement.) But we discover later that the team ignores Arlene’s skepticism and treats her with chelation therapy, in which an amino acid called ethylenediamine tetraacetic acid (EDTA) is pushed via IV. EDTA binds to heavy metals and allows them to be peed away.

But when Arlene’s atrial fibrillation worsens, the diagnostic options get more dire. At the DDX, Chase says she could have leukemia, which could cause her anemia and A-fib. But House, always fond of the diagnosis that blames the patient most, offers up thiamine deficiency (beriberi), which affects the cardiovascular system and could be a result of heavy drinking.

Taub is skeptical: “You think she’s an alcoholic?”

House mentions that at dinner a few weeks ago (on this episode), Arlene fell asleep at dinner—and then the next day assumed she had just passed out from drinking too much. (In fact, House had drugged her to get her to shut up.) House thinks only an alcoholic would assume she had passed out from alcohol. (I don’t quite get his logic. Wouldn’t a light drinker be the one to assume that just two or three drinks could knock you out?)

Anyway, upon House’s urging, Cuddy decides to slip her mom thiamine pills. Meanwhile, tests rule out cancer.

But the thiamine doesn’t work, and Arlene’s fever spikes to 102.

At another DDX, Taub suggests Arlene isn’t a hypochondriac: “She says she gets a lot of rashes, and the fever sounds like autoimmune. SLE?” He means systemic lupus erythematosus, chronic inflammation of connective tissue that can cause problems in the blood, skin, and gastrointestinal tract. Steroids are the preferred treatment. In due course, another P-P  doctor—an internist Arlene has requested—prescribes prednisone.

House is unconvinced; after all, her heart problems preceded the fever. When Foreman suggests endocarditis, House likes the fit with the symptoms. Endocarditis is inflammation of the inside lining of the heart. Trouble is, one needs a robust immune system to help fight off endocarditis, so prednisone—which will suppress the immune system to help defeat SLE—could kill Arlene.

House wants to switch her to broad-spectrum antibiotics but mark the bag as prednisone so as not to tip off the internist. Foreman loudly objects. Then—in a scene as dark as House M.D. gets—House gloweringly says, “Do it, or you’re fired.”

The antibiotics fail, though, when Arlene has an allergic reaction to them. Cuddy surreptitiously switches her mom back to prednisone. But her A-fib returns, along with her fever. House now believes it’s not a bacterial infection but fungal endocarditis. He wants to put her on Amphotericin B.

Foreman is aghast. “It’s a poison!” he says. “That’s why it kills fungi. It will give her fever, chills—”

—“which she already has!” House thunders back.

But before any new drug can be administered, House and Cuddy discover a new symptom: Arlene can’t recognize sarcasm. House thinks this could mean a deficit in the right parahippocampal gyrus, although he is wildly extrapolating from the limited data on sarcasm. Anyway, via more wild extrapolation—hey, it was less than five minutes to the credits—House gets back to heavy-metal toxicity.

Cuddy: “It can’t be. We treated with chelation for lead.”

House: “And she got worse. She never stopped being poisoned.” House cuts into Arlene’s flesh near her hip. He reveals another symptom—muscle tissue with black spots, which strongly suggests metallosis, an immune system reaction to a metal implant. (Recall Arlene’s hip replacement?)

More specifically, the wear-and-tear on the artificial hip released cobalt into Arlene’s system, which leads us to the final diagnosis: cobalt poisoning. Chelation therapy will cure it, causing a bit of sunshine to return to P-P.

Overall, this was one of the best episodes of the season: taut writing, some chance-taking with the set design, and the usual fine performances from Laurie, Edelstein, and Peter Jacobson, who plays Taub. I almost always enjoy Robert Sean Leonard in House M.D. episodes, but the absence of Wilson in this noirish installment served the show well.

OK, see you next week….

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