House MD but medically accurate

Syncope

Temporary loss of consciousness caused by a fall in blood pressure.

aka fainting, passing out

Hypothyroidism

Reduction in the production of the two hormones produced by the thyroid, T3 (triiodothyronine) and T4 (thyroxine). 

The two hormones regulate the body’s temperature, metabolism, and heart rate. 

T3 is the active hormone, T4 is the precursor, both circulate through the bloodstream.

T3 functions include the 6 B’s:

Brain maturation

Bone growth

Beta-adrenergic effects

Basal metabolic rate

Blood sugar (glycogenolysis, gluconeogenesis)

Break down lipids (lipolysis)

Most commonly affects women above the age of 50.

Symptoms include:

Goiter: enlargement of the thyroid gland, it’s the characteristic neck mass shown in most tv shows, not to be confused with enlargement of salivary glands which show growth more along the jawline.

Metabolic: Cold intolerance, hypohidrosis (reduction in sweat production), weight gain, hyponatremia (reduced sodium in the bloodstream)

Skin/hair: Dry, cool skin (due to reduced blood flow), coarse, brittle hair, diffuse alopecia, brittle nails, puffy facies and generalized nonpitting edema (aka myxedema)

Ocular: Periorbital edema

Gastrointestinal: Constipation, reduced appetite

Musculoskeletal: Hypothyroid myopathy (proximal weakness), carpal tunnel syndrome

Reproductive: Abnormal uterine bleeding, reduced libido, infertility

Neuropsychiatric: Hypoactivity, lethargy, fatigue, weakness, central nervous system (CNS) depression, reduced reflexes

Cardiovascular: Bradycardia, dyspnea on exertion

Common underlying causes:

Iodine deficiency - because the hormones are basically composed of iodine with some extra spice.

Malfunctioning pituitary gland - because the pituitary gland signals the thyroid to produce hormones (through TSH-Thyroid stimulating hormone), classified as Secondary Hypothyroidism because the problem does not directly derive from the thyroid.

Trauma to the thyroid gland.

There are a lot of other etiologies/causes that I can’t go over one by one just by necessity because the list would add another 10 pages. But my favorite is definitely cretinism (congenital hypothyroidism) just because it was actually mentioned in Paternity (s01e02) as part of a crossword puzzle.

Colchicine poisoning

Pharmacy error in this case, a switch-up with the cough medicine.

Used to treat gout: a form of inflammatory arthritis, characterized by recurrent attacks of red, tender, hot and swollen joints. Due to persistently elevated levels of uric acid in the blood which form crystals within joints and kidneys.

Overdose begins with a gastrointestinal phase 10-24 hours after ingestion, followed by multiple organ dysfunction 24 hours to 7 days after ingestion.

Symptoms include: 

Burning in the mouth and throat, fever, vomiting, and abdominal pain.

Hypovolemic shock due to extreme blood/fluid loss through the gastrointestinal tract.

Kidney failure follows 

Alopecia: loss of hair, aka baldness

Bone marrow depression: decrease in production of cells responsible for providing immunity, carrying oxygen, and/or those responsible for normal blood clotting. 

Agranulocytosis: lowered white blood cell count

Diplopia:

aka double vision: the perception of two images instead of a single object

Common causes usually stem from issues with the eyes, muscles and nerves controlling the eyes, and the brain.

Night terrors:

As mentioned in the episode, there are two leading causes for onset teenage night terrors: PTSD and sexual abuse.

Personally I think there isn’t much reason for the patient to have experienced night terrors beyond the initial stages of SSPE causing changes in emotional behavior and personality.

Myoclonic jerk:

Brief, involuntary twitching of some muscles; generally in healthy persons it can be seen right before falling asleep (aka a hypnic jerk).

The patient presents it even though he’s not asleep or tired.

Multiple sclerosis (MS):

In the episode:

After testing some CSF, because of a buildup and blockage, they find high levels of IgG and assume multiple sclerosis, but find no evidence of lesions. A good assumption because over 80% of patients with MS show oligoclonal bands with high IgG.

Since the patients symptoms have only begun 3 weeks previously they determine it’s rapidly progressive MS.

They can’t definitively diagnose MS, because there are no specific tests for it. Generally doctors have to rule out every other possibility before they can confirm. What’s mentioned in the episode is waiting 6 months to confirm, most likely to see progression of symptoms as well as ruling out differentials.

More on Marburg MS s7e08 “Small Sacrifices”

MS is a chronic central nervous system disease in which the myelin sheath and nerve axons in the brain are destroyed. It’s referred to as a demyelinating disease. The damage disrupts the ability to transmit signals which can result in a slew of signs and symptoms.

The three main characteristics are the formation of lesions/plaques in the CNS, inflammation and the destruction of myelin sheaths of neurons

Other specific symptoms usually include diplopia, blindness in one eye, muscle weakness, and trouble with sensation or coordination.

Some pathognomonic signs include:

Internuclear ophthalmoplegia (INO): an impairment in the lateral conjugate gaze, meaning that when both eyes are looking toward one side the affected eye cannot properly adduct (move toward the center). Caused bye a lesion in the medial longitudinal fasciculus (part in the brainstem).

To put it simply, if the right eye is affected, the patient should be able to look to the right, and cross their eyes, but upon looking to the left, the right eye won’t be able to move to the midline.

Positive Romberg’s sign: when the patient sways or falls with their eyes closed. It demonstrates a loss of postural control and proprioception (perception and awareness of one’s body) in the absence of visual input.

Positive Lhermitte’s sign: paresthesia/an electrical shock that passes down the back of the neck and spine, usually brought upon by bending the head forwards towards the chest.

Progression usually occurs as episodes of worsening lasting days to months, followed by improvement (relapsing episodes).

Subacute sclerosing panencephalitis (SSPE):

Early in the episode Cameron admits to not having taken a full history or family history which really would have solved the case a hell of a lot sooner, given his birth mother was the cause of the patients issues.

tbf, it was the whole point of the episode to focus on determining paternity, which, given all the daddy issues on the show is a good setup.

Then again, the patient is a 16 year old lacrosse player, and he figured out he was adopted at a much younger age, 10 if I remember right, just from having a cleft chin. Talk about selective blindness on the team.

aka Dawson disease

SSPE is a super rare complication from measles wherein there is chronic progressive brain inflammation caused by the mutated virus.

Patients generally have history of a primary measles infection in infancy (where the birth mother was not vaccinated and thus could not pass along the proper antibodies to protect the infant for up to 6 months), followed by an asymptomatic period that can last up to 27 years. Afterwards neurological deterioration ensues with behavioral changes, myoclonic seizures, visual disturbances, ataxia, and ultimately death.

Anti-measles IgG appears to increase as the disease progresses

There is no definitive cure, but if it is diagnosed in the first stage of the disease oral isoprinosine and intraventricular interferon alfa could help, it varies patient to patient. And the only accepted treatment are purely supportive: anticonvulsants.

Should not be confused with acute disseminated encephalomyelitis (ADEM), which can also be caused by the measles virus.

Another demyelinating disease, it is a rare autoimmune disease with acute inflammation of the brain and spinal cord.

Often triggered by a viral infection or specific non-routine vaccinations.

(I’ll be writing definitions/explaining each medical term mostly because its fun and good practice for me, thanks. It’ll go in chronological order for the episode even if it doesn’t pertain to the final diagnosis, which I’ll then explain itself.)

Conduction aphasia:

Patient is unable to articulate full words, she starts speaking gibberish

What’s important is that she recognizes that she isn’t able to form her words properly and that she’s still able to write on the white board legibly (”Call The Nurse”)

The previous point is important because there are different types of aphasia - “the loss of ability to understand or express speech”, I won’t go too in detail about all the different kinds except for what I reasonably think matches the patients symptom and another complementary type.

Broca’s aphasia, aka Expressive aphasia: the loss of the ability to produce language, although comprehension generally remains intact. So, in context of the episode, that’s why she wasn’t able to form full words/sentences, but was able to recognize it and write down a legible call for help.

Wernicke’s aphasia, aka Receptive aphasia: wherein individuals have difficulty understanding written and spoken language. Can demonstrate fluid speech but lacking meaning, for example, “Sugar may be house phone.” It’s technically grammatically correct, but doesn’t mean anything in context of a conversation. The individual might also be unaware of the lack of meaning in their speech (more in s2e10 “Failure to Communicate”)

I like to think of the previous two as “opposites” concerning types of aphasia. Which might be obvious by their names Expressive versus Receptive :)

Both types are common after an infarct (loss of blood supply to a specific region resulting in death of tissue), aka a stroke.

Grand mal seizure:

The most common types of seizures are as follows:

“Grand Mal” or generalized tonic-clonic: the one shown on all TV shows and movies (probably because it’s the most visually interesting), includes unconsciousness, convulsions, and muscle rigidity

Absence: a brief loss of unconsciousness 

Myoclonic: Sporadic (isolated), jerking movements

Clonic: Repetitive, jerking movements

Tonic: Muscle stiffness, rigidity

Atonic: Loss of muscle tone

If you’re familiar with latin roots a lot of the medical mumbo jumbo makes a lot more sense, for example these seizure names all look the same at first glance but the prefix a- means without, so knowing that tonic means “continuous muscle contraction”, you already know what kind of seizures tonic and atonic will be just from the name. P.S. myo- is for muscle.

Pulmonary edema:

Simply put, it’s when there is excess fluid in the lungs, so that it’s difficult for the oxygen exchange to occur. Meaning that the patient can’t get rid of the carbon dioxide inside their body and they can’t get new oxygen into their blood.

Can lead to a whole lot of complications because everything in the body needs oxygen and an abundance of carbon dioxide can cause respiratory acidosis (which is a whole other post because I love how the respiratory system works)

aka lung congestion, lung water, and pulmonary congestion

The most common cause is congestive heart failure (CHF), which is when the heart can’t properly pump blood throughout the body, so a backup of blood builds up, increasing the pressure in the small blood vessels of the lungs, causing a “leakage”

Symptoms will depend on the type/etiology of the pulmonary edema, but generally the patient will have a hard time breathing (technically it’s an issue with the oxygen exchange, not the actual mechanics of breathing) which means their body will try to compensate by breathing faster, aka hyperventilating (there are also so many different types of breathing which I won’t go into, but my favorites are Kussmaul breathing and Cheyne Stokes)

The patient “had an allergic reaction to the dye used in the contrast study.”

I’m not saying they’re wrong but...

People allergic to contrast dye usually show adverse reactions cutaneously, meaning skin symptoms: rash, redness, swelling, etc., and usually more than 24 hours after injection.

For the most severe reactions, which is what the patient might have had, anaphylaxis and death is a small possibility. It’s a 0.008% chance to develop pulmonary edema as a complication to contrast media.

It’s not a true allergy, rather a pseudoallergy, because there is no antibody that causes the reaction. It’s the contrast dye itself that directly stimulates histamine release.

... so they’re not wrong really, just super unlucky.

Vasculitis

I don’t even know why they suggested this as a differential and then started treatment for it. They don’t even mention what type of vasculitis it might be. I’m reasonably sure they only included this so that they’d start treatment with steroids (prednisone) so that they patient would get better then worse again.

Neurocysticercosis

First and foremost, the way that he phrases it in the episode, he would have realized it was neurocysticercosis sooner, if not for the fact that he believed she was jewish (because Wilson lied to get him to take the case)

Reasoning behind this: that the parasite for neurocysticercosis, Taenia solium, is mostly found in pork (which religious jewish people are not supposed to eat). Which, first of all, as a non-religious jew myself, that’s some supposition right there. Immediately thinking all jews are religious and/or don’t eat certain foods because other jews don’t. 

And secondly, that he didn’t double check her religion status, so immediately discarded a diagnosis based on that erroneous fact. Like, I get it’s the pilot and they wanted to establish personalities and relationships right off the bat, but that’s the one annoying part of the show, if only he had gotten to know his patient he probably could have diagnosed her earlier (but that’s why we love House, his charming personality)

Life cycle: Eggs or gravid proglottids (pregnant segments of the adult parasite [tapeworms as a whole have different segments to their body called proglottids, their “head” is called a scolex and is mostly different for each species, the head is connected to the neck, which then connects to the first immature proglottid. Depending on the species they all have different amounts of proglottids, ranging from 5 to 1000. The further away from the scolex they get the more mature they become, and when fully mature they’re impregnated, one segment at a time, with each segment breaking off from the previous so that they can find a nice home in the body]) are found in feces and passed into the environment, from there they’re ingested by an intermediate host, usually a pig, but in the case of cysticercosis, a human. The eggs hatch and liberate larvae, aka oncospheres, which penetrate the intestinal wall and circulate to musculature. They mature into cysticerci over 60-70 days, and can migrate to the central nervous system, which is what causes neurocysticercosis.

The same parasite can cause another disease called taeniasis. This differs primarily through the acquisition of the parasite. The pig is the intermediate host in this case and a human the definitive host. It is ingested through uncooked/undercooked pork containing cysticerci. Wherein they will evaginate and attach to the small intestine by their scolices (head and suckers). This disease will normally only cause intestinal issues.

A primary infection of taeniasis with Taenia solium can cause a secondary infection of cysticercosis which can lead to neurocysticercosis. So it is possible for the patient to have neurocysticercosis even though they explained it using taeniasis.

Neurocysticercosis is one of the main causes of epileptic seizures in many less developed countries (not so much for a pre-school teacher in New Jersey)