Last night’s House M.D. focused on the case of Nadia, a 33-year-old woman who can recall every moment of her life with perfect clarity. She waitresses at a diner, where she falls over one day, unable to move her legs. So which one will turn out to be the decoy symptom: the freakish memory (a.k.a. hyperthymesia) or the leg paralysis?
Before we get to the answer, a spoiler alert: if you haven’t seen this week’s episode, “You Must Remember This,” break into Wilson’s house and watch before reading on.
When House brings the case to his team, he mentions another symptom: high levels of creatine kinase (CK), an enzyme found in muscle cells that is released when a muscle (including the heart) is damaged.
The hyperthymesia (which the writers ripped from headlines like this one) fascinates House since it’s one of only a handful of cases, but Foreman points out that the condition first appeared when Nadia was in puberty, meaning it’s probably unrelated to her current symptoms. “Plus,” he says, “I don’t know of any diseases that cause great memory, only those that destroy it. No evidence of stroke or tumor, so probably a toxin.”
Taub: “She’s a waitress; they’re no strangers to botulism or alcoholism. We should search the diner and where she lives.”
In Nadia’s kitchen, Foreman finds an empty laxative box in the trash. The camera also lingers on the puzzles Nadia has — dozens of them — meaning you can bet those puzzles will play a role in the final diagnosis. For now, though, magnesium poisoning is the leading contender.
Taub suggests pushing fluids so her kidneys can clear the chemical from her blood, but House says her blood pressure is normal. High-dose magnesium would probably lower it, which means she took a normal dose of laxative to relieve another symptom: constipation.
“You are not pooping,” House says. “The question is, are you also a klutz?”
Nadia remembers stumbling or falling 11 times in 2008, 12 in 2009, and 20 in 2010. House says the constipation and spike in clumsiness suggests early-onset Parkinson’s. He orders a neural exam and levodopa, which will increase levels of dopamine in her brain (Parkinson’s is associated with low dopamine levels).
Meanwhile, House diagnoses Wilson with a serious case of unmanliness because he has adopted Sarah, a diabetic cat. House suggests the cat be put in a plastic bag and thrown in the river in order to cure Wilson.
But Nadia is still sick, and she’s got another symptom: arrhythmia. As Chase points out, cardiac involvement rules out Parkinson’s. He says an excess of catecholamines (hormones produced by the adrenal glands) could have set off the arrhythmia by inducing stress.
That means the diagnosis could be a pheochromocytoma, a tumor that causes the adrenal gland to release too much epinephrine and norepinephrine, hormones that help regulate heart rate. (The team also considered a pheo three weeks ago, in the case of the drill instructor with back pain.) But Foreman says it’s not a pheo because despite the arrhythmia, her BP is fine.
Masters thinks they’re missing the obvious: the heart. “If it’s not pumping effectively,” she reasons, “the muscles shut down. CK elevates. Coordination suffers … Her heart problems started when Nadia saw her sister. Stress-induced arrhythmia could be caused by long QT syndrome.”
House orders a stress test to confirm long QT, a rhythm disorder that can cause chaotic heartbeats. The sadist in House tells Masters to use Nadia’s estranged sister, Elena, to arouse stress. In order to get Nadia’s heart rate up, Masters start a fight between the sisters by mentioning the time Elena hit Nadia with a car.
The doctors start Nadia on a beta blocker to keep her heart rate under control. But then Chase notices the smell of ammonia on Nadia’s breath, which means another symptom: kidney failure.
At the DDX, Chase reasons that Nadia, who recently went vegan, lost her taste for protein, suggesting autoimmune amyloidosis (an excess of amyloid proteins that can cause food intolerance).
Masters notes that an autoimmune disorder could account for Nadia’s multiple organ systems failure and her paralysis. Taub says a number of autoimmune diseases would fit: “Guillain-Barre, polymyositis—”
Foreman cuts in and picks up the thread: “—MS. Polyarteritis nodosa.”
And Masters throws in SLE, systemic lupus erythematosus, chronic inflammation of connective tissue that can cause problems in the blood, skin, and gastrointestinal tract. (SLE also appeared on last week’s episode.)
House orders steroids, which will treat most kinds of autoimmune problems, and dialysis.
Back to the Wilson side story: he comes to work sneezing and says House put an allergen in his apartment so he would think he is allergic to Sarah. This time, House diagnosis toxoplasma gondii infection; toxoplama gondii are parasites that humans can get from cats and that can lead to paranoia and, possibly, schizophrenia. (Or, as House puts it, “Crazy cat lady disease.”)
Wilson says he’s not paranoid, just allergic to ragweed and dandelion. “You’re trying to gaslight me,” he tells House, bringing back a wonderfully quaint locution.
Meantime, Nadia can’t breathe. Chase points out that respiratory distress means it can’t be an autoimmune disorder. Masters suggests pulmonary edema from renal failures, but House notices that Nadia has hives.
“Can’t be,” says Chase. “We’ve pumped her full of steroids.” But it turns out she’s allergic to dialysis. This is very bad news: Nadia will need a kidney donation. Putting aside her grievances, Elena agrees to be the donor.
But after Nadia wakes up from surgery, she has a seizure (for which Chase orders 3 mg of lorazepam). He says the seizures mean the steroids aren’t working. Maybe she has acute porphyria, which can cause constipation and neurological problems.
But Masters says Nadia currently has no abdominal pain. Chase then comes up with another theory: her blood is clotting, which could explain the problems in her leg, heart, kidney and brain (the seizures).
But Nadia doesn’t feel better. Chase says it will take some time for the clots to resolve, but then he notices her hand moving involuntarily. That suggests chorea, a neurological disorder — but one that wouldn’t explain the other symptoms.
Masters says they may have missed something in the apartment, which prompts Foreman to mention, in an aside, all the puzzles. House wants to know how many puzzles; Foreman says dozens.
House has a hunch and orders a peripheral blood smear, a test to find abnormal cells. House asks if Nadia ever leaves a puzzle unfinished, and she says she doesn’t — it would bug her too much. He also notices that she keeps realigning her cup whenever he moves it.
This suggests OCD, which could (if you stretch it) explain her hyperthymesia. Some people with OCD hoard newspapers, Chase says; she hoards memories. House tells her she’s literally been obsessing over her own life. The reason — and the final diagnosis? McLeod syndrome, a rare mutation in the XK gene, which provides instructions for producing a protein in various parts of the body. When those instructions are mangled by the mutation, various organs can malfunction — including the brain (explaining the seizures and the OCD), the muscles (explaining the leg paralysis), and the heart (explaining the arrhythmias).
There’s no cure, and Chase tells Nadia she will live for only about 20 more years. He gives her a bottle of SSRIs to control the OCD. Controlling her OCD would dial down her hyperthymesia, but it’s unclear whether Nadia will take them: “My memory is the only thing that ever made me special,” she says.
Chase leaves her to make the decision. And scene.
I liked “You Must Remember This,” but more for the character development than the diagnostic possibilities, which felt like a rehash of the same diseases we have heard about in the past few weeks. I’m a little puzzled by what the writers are doing with Taub. Somehow he has financial woes (doesn’t Cuddy pay her doctors well?), and he’s so pathetic in the wake of his marital split that he has to cheat to pass a recertification test. Maybe he’s headed for a spiral that will culminate in the season finale later this year.