House Watch: Is Heroism a Sign of Brain Disease?

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House M.D. is back after a mid-season hiatus, which means House Watch is back. This week’s return episode, “Larger Than Life,” hews closely to House M.D.’s procedural formula, which is a safe but smart move after all that shipper business between House and Cuddy last year. But on to the medicine…

(Actually, onto the spoiler alert: If you haven’t seen this week’s episode, hurry over to the differential-diagnosis meeting before reading on. As usual, all possible diagnoses are in bold.)

The case this week is quite similar — almost gratingly so — to the case last November that posed the question of whether faith is a mental illness. In the opening scene this time, we see rock musician Jack Nash (Scream’s Matthew Lillard, all grown up) and his young daughter waiting for a New York City subway. When an epileptic woman falls onto the tracks, Jack is the only one in the crowd who jumps down to help her. A train is approaching; they survive because Jack lays flat over the woman in the mid-track gap, allowing the train to pass above. They’re O.K. But Jack passes out as soon as he stands up. (More on House Watch: What Causes Delusions?)

Masters finds the case in the ER and brings it to the team. “White male, mid-30s, loss of consciousness,” she says. “Normal EKG. And he’s the subway hero.”

House is unmoved, setting up the question of whether heroism is an indication of brain disease. Chase points out to Masters that House will count heroism as a symptom of disease unless she disproves him. Taub seems to agree with House: “The other hundred people stayed on that platform. That’s a normal response to danger.” And so House offers the first diagnosis: “Our patient’s problem is neurological: sympathetic stimulation — stress the brain, stimulates a response in the heart. Go forth, and look for masses in Clark Kent’s limbic system.”

But there are no such masses, so on to the differential (which is done this week not on the office white board but on a bus-stand ad that features Taub as the face of Princeton-Plainsboro). Because he is having cardiac arrhythmias, Masters believes he has vasovagal syncope, a sudden drop in heart rate and blood pressure (usually in response to a stressor like a train coming straight at you) that often causes fainting. Taub rejects the idea, saying vasovagal syncope would have manifested itself at a much younger age. (Which prompted me to wonder how often you get a stressor as serious as a train racing overhead. You would faint for the first time, too. Or at least I would.)

Taub says, “Could be drugs.” But the tox screen was clean, Masters tells him. (More on House M.D. Watch: Is Faith a Mental Illness?)

Finally Foreman: What about “autonomic nervous system [ANS] dysfunction?” The ANS controls the body’s involuntary actions, like the beating of your heart. If something goes awry in the ANS, it could lead to arrhythmias. House likes the idea, but it turns out Jack’s cortisol levels are normal.

When Jack momentarily stops breathing, they find a new symptom: a “mucus plug” blocking his airway (altogether now: ewwww). Chase points out that fluid in the lungs doesn’t fit with anyone’s theory.

House comes to believe that the woman on the subway, who’s named Chloe, must have given Jack the illness. True to form, his theory is that they were having an affair (Jack’s wife, Eva, has turned up to note that Jack was never the heroic type). That would explain why Jack risked his life to save her: he loved her, or at least loved having sex with her.

Taub and Chase break into Chloe’s home and find one of Jack’s band’s CD releases. And they find a can of roach killer, suggesting a diagnosis of toxic exposure. But Jack denies he’s ever met Chloe before, and when she appears to thank him, she mentions that one of her nurses gave her the CD. (More on Psychiatric Mystery: Diagnosing Jared Loughner)

Next, Masters wants Jack to cough up a sputum sample so that they can test for a pathogen infection that has spread to his mastoid, a grouping of cells behind the ear. To which House responds: “Great, we’ll confirm that in a week, when your secret cultures have sprouted.”

Masters: “Do you have a better idea?”

House: “Nope, which is why I’m going to pick one at random: Acoustic neuroma.”

Foreman: “Tumor in the ear. Makes sense. And if it’s putting pressure on the breathing centers in his brain, explains the lungs.”

House: “And the lungs explain the heart.”

This is my vote for the cleverest diagnostic possibility in the episode. It would have been wonderfully ironic for a musician to get a tumor in his ear.

But they’re wrong again (like I said, this episode returned to the format of multiple — really too many — diagnoses). When Jack gets a shot in his back, the pain in his ear disappears, suggesting he has referred pain. That can happen when pain signals from two areas of the body converge on the same nerve pathways. Or it can happen when wrong signals are issued by, say, the thyroid. (More on The Roots of Brain Diseases: One Team Finds 1,400 Culprits)

Chase says hypothyroidism would explain all his symptoms. The condition — in which the body produces insufficient thyroid hormone — could cause him to faint and his heart to flutter, since thyroid hormone keeps your metabolism running. But it turns out Jack’s thyroid levels are normal. Foreman then does a liver biopsy, since the wrong pain signals could originate in his liver. Foreman finds diffuse inflammation in Jack’s liver, suggesting autoimmune hepatitis, in which the immune system mistakenly begins eating up liver cells. So they start him on steroids, which will suppress his immune system.

And then poor Jack — one of the sickest patient we’ve seen on House M.D. this year — has a seizure. And then two more. And, Taub reports, he developed a raging fever overnight. Which means he has an infection.

Taub: “Four days ago, the guy was face-down in the subway. God only knows what’s in that sludge. Toxic fumes make him pass out. Rat pee does the rest.” That suggests leptospirosis, a bacterial infection that can be caused when humans come in contact with water polluted by animal urine.

Chase is skeptical. “If it’s leptospirosis, it’s the fastest moving case in history.”

But House comes back: “It fits, and since it’s the only idea on the table, I say it’s a winner.” He goes off to start Jack on doxycycline, an antibiotic.

But then Cuddy’s mother (played wonderfully by Candice Bergen) gives House his typical a-ha moment. She says she’s truncating her visit to Cuddy because Cuddy’s young daughter has given her a cold. House realizes that Jack might have contracted something from his daughter.

It turns out the daughter’s school has had an outbreak of the final diagnosis, chickenpox, or varicella. “Chickenpox is no big deal for kids,” House says, “but it’s a terrible, horrible, no-good, very bad deal for grown-ups.” The reason they missed it is that Jack is one of the 5% unlucky few who get chickenpox but don’t have the tell-tale blisters. House was wrong about heroism: it can be an expression of brave altruism and not just a sign of a neurological problem.

With that, the episode wraps up quickly. From my point of view, it was a bit exhausting. My favorite scene had nothing to do with medicine: it was when House sedated not only Cuddy’s mom but also his best friend Wilson so that he and Cuddy could have a quiet night together. See you next week.

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