As big a fan of the House MD show I am, let me start off with the disclaimer that I consider this to be one of the worst ever episodes of House MD to come on air. EVER! And that is not just because of the sucky medical mystery, but also because of the very ordinary levels of drama, poor acting and overall, a not altogether Housean feel to the whole episode. Sorry folks, if you missed this episode, it is not going to be a big deal. I guess the only purpose this episode serves is to spring House out of jail. Other than that, and the very poorly kept secret that Lisa Cuddy has left for good and Eric Foreman has become the Dean of Medicine at PPTH, there is nothing of significance in the episode. Do not take my words for granted, take a look at the graphic presentation of the Medical Case for this week:

Now for my thoughts on the medical issues in this episode:

1. The issue of saving the “lungs in a box” is dramatically startling and medically intriguing. While I personally have no experience whatsoever in dealing with lung transplantation, it seems like a little too over simplified to be possible. From my cursory knowledge of ex vivo lung preservation prior to transplantation, I would say that the only way this could be done would be by using some kind of an extracorporeal membrane oxygenation (ECMO) system.

It seems that though the process of pulmonary transplantation, though quite popular over the last four decades, there have been few breakthroughs in the methods of ex vivo storage. I found this interesting paper (1) from quite some time back, dealing with the ex vivo storage of rabbit lungs, but then again, the “store in a box” would not work as they needed to perfuse the lungs (which it did not seem to be the case in House’s patient).

The case in the episode itself is very similar to this paper I dug out from not so distant past (2), where a 19 year old man was declared brain dead following a road traffic accident. He had ongoing intratracheal bleeding, with x-ray evidence of bilateral pulmonary contusions (right>left). After optimizing ventilator treatmentand suctioning the airways, PaO ₂ was 9 kPa (67.5 mm Hg) onFiO₂ = 0.7. The left lung was edematouswith bleeding spots in the lower lobe, and the mediobasal segmentwas atelectatic. The left lung was reconditioned ex vivo andkept in topical extracorporeal membrane oxygenation. The lungs were rejected by all transplantation services in the Nordic countries and were harvested for research purposes by the authors.

The interesting thing is that these authors seem to have used a new system of cryopreservation which they have termed as TOPICAL ECMO!

The authors discarded the right lung owing to the extensive hemorrhage and damage to it. They cleared the atelectatic portions using transiently elevated Positive End Expiratory Pressure (PEEP). The left lung was transplanted into a 70 year old man suffering from chronic obstructive pulmonary disease (COPD) 17 hours after harvesting them! The recipient showed a normal left lung after 3 months of the procedure, as evidenced by CT Scans and transbronchial biopsies!

This paper seems very identical to the case shown in this episode, aside from the drama. This seems to be one of the few papers that have successfully managed to recondition a damaged and rejected, untransplantable lung ex vivo and then successfully transplanting it into a proper recipient.

2. The diagnosis of something like a Humeral Rhabdomyosarcoma is a typical House zebra! Rhabdomyosarcoma, though the commonest soft tissue tumor in the pediatric age group, is in itself a very rare disease, with about 300 new cases in the USA every year. Also, there appear to be no specific paraneoplastic lung diseases associated with RMS. So, House’s differential, though definitely possible (hardly anything is impossible in medicine, as my old Medicine Prof would say!), is a long shot. (3,4)

3. When Park, House’s resident stained the biopsied lung for iron, she saw a bunch of white blood cells on the smear. This leucocytic infiltration pointed to an infection and House jumped to the conclusion of Brucellosis and started on the big guns. IVIg! It seems very unlikely to happen in the real world. Not at least in the kind of medicine set up I have been trained. At the least, another smear should have been done to see WHAT kind of cells are actually in the infiltrates. There are SO many types of WBCs, after all, its normal to want to know the TYPE of cells. If they had done that, they would have seen the eosinophilic predominance and we would not have had to wait for House to have his moment of epiphany. To be honest, this was some really shoddy medicine work.

4. Eosinophilic Pneumonitis triggered by cigar smoke was the final diagnosis and there are so many case reports in this genre that show radical improvement following the use of corticosteroids, that House’s decision to irradiate the lungs (and then come up with almost MAGICAL results, immediately!) is difficult to digest. Also, the patient would have shown a peripheral smear eosinophilia. I am hoping that though he was admitted as an acute trauma case, a routine hemogram was sent for sometime during his stay in the hospital. If not then, at least when his lungs were considered to be transplanted. Actually, Wilson says they saw the smears to be ‘clear’ when House proposed Ehrlichiosis. So they had done the smears, and how they decided to ignore the Eosinophilia that should have shown up on the peripheral smear is beyond me. Alright. Maybe the course of the disease was too rapid for the eosinophilia to spill over onto the peripheral smear, but a simple bronchoalveolar lavage (hey the patient is a couple of lungs anyways!) would have clinched the diagnosis a lot earlier. I am not sure what kind of tests they run on lungs that are about to be transplanted but if they are running out of options and are going to free a maniacal doctor from prison to do it, its worth the while to do a BAL before trying that! Once again, shoddy medicine for the sake of drama. From a real life example:

(A) Bronchoalveolar lavage fluid showed more than 25% eosinophils. (Wright stain, ×400). (6)

(B) Lung biopsy specimen on the third day shows that many inflammatory cells are present in the alveolar spaces and septae, which are admixed with fibrous exudates. The majority of the infiltrated cells are eosinophils (Hematoxylin-eosin stain, ×400). (6)

There are a lot of interesting reports which bear extreme  similarities to this case. Like the two patients (5) who smoked flavored cigars (one was a non smoker and the other had quit 17 years ago and they had never smoked cigars before) and then came down with a bad case of acute eosinophilic pneumonitis. They were treated with antibiotics on the suspicion of community acquired pneumonia, but after they showed no improvement and a peripheral eosinophilia >45%, they were started on corticosteroids on a suspicion of AEP and responded almost immediately.

In conclusion:

A very badly done episode where House maniacally jumps from one differential to the next with nothing more than a flight of fancy to justify it. The Medicine is itself of very poor quality. The idea that the victim had so severe a disease that exposure to the cigar smoke would kill him in hours and yet, he had no history of previous illnesses is unbelievable. Who in this world is not exposed to second hand smoke? And which high school kid has not experimented with smoking cigarettes or weed? He surely did not seem to be the type that does not.

Anyways. Another thing that I nearly LOLed out was when Wilson came in to meet House at the end. While in the show he punched House in the face (as he had been requested to earlier, to “get it out of his system”), his expressions conveyed all the right signs of wanting to plant a big one on House’s lips!

Now that Cuddy is gone and Huddy is but a myth, can we expect the Houseson (or Wilouse) romance to bloom? Finally?

As usual, a big hat tip: Scott over at Polite Dissent.

References:

1. Wang LS, Yoshikawa K, Miyoshi S, Nakamoto K, Hsieh CM, Yamazaki F, Guerreiro
Cardoso PF, Schaefers HJ, Brito J, Keshavjee SH, et al. The effect of ischemic
time and temperature on lung preservation in a simple ex vivo rabbit model used
for functional assessment. J Thorac Cardiovasc Surg. 1989 Sep;98(3):333-42.
PubMed PMID: 2770316.

2. Steen S, Ingemansson R, Eriksson L, Pierre L, Algotsson L, Wierup P, Liao Q, Eyjolfsson A, Gustafsson R, & Sjöberg T (2007). First human transplantation of a nonacceptable donor lung after reconditioning ex vivo. The Annals of thoracic surgery, 83 (6), 2191-4 PMID: 17532422

3. Hayes-Jordan, A., & Andrassy, R. (2009) Rhabdomyosarcoma in children. Current Opinion in Pediatrics, 21(3), 373-378. DOI: 10.1097/MOP.0b013e32832b4171

4. PINKEL D, PICKREN J. Rhabdomyosarcoma in children. JAMA. 1961 Jan
28;175:293-8. PubMed PMID: 13735854.

5. Al-Saieg N, Moammar O, Kartan R. Flavored cigar smoking induces acute
eosinophilic pneumonia. Chest. 2007 Apr;131(4):1234-7. PubMed PMID: 17426233.

6. Youn JS, Kwon JW, Kim BJ, Hong SJ. Smoking-Induced Acute Eosinophilic
Pneumonia in a 15-year-old Girl: A Case Report. Allergy Asthma Immunol Res. 2010
Apr;2(2):144-8. Epub 2010 Mar 24. PubMed PMID: 20358030; PubMed Central PMCID:
PMC2846739.