House MD 8×01: Twenty Vicodin

So, like I said in my last post, House is back, and with a bang. The new season starts off on a bleak note with House serving out the last few days in his 8 month old sentence, and being on the verge of getting paroled. After the rather weird season finale for season 7, I think this is more like the House MD show I love to watch. (P.S.: There is some irony in the fact that a guy named House is jailed for driving into a, well, house!).

The case itself is quite interesting and goes through a lot of twists and turns before House serendipitously lands on the diagnosis. For the benefit of the visual learners like me, here is a flow chart summarizing the progression of the case:

Now for pointing out the things that struck me while watching this episode:

1. I have not come across too many cases of disseminated Gonococcal infections (which is a prerequisite for getting a Gonococcal arthritis), but all the cases that I have encoutnered were VERY sick. In contrast, Nick seems to be in fine form except for the pains and the fever.

2. While thinning of eyebrows and body hair does occur in SLE, considering the fact that this is a middle aged male patient with unknown family/previous history, it is unlikely to jump straight to SLE. From House’s wisdom from previous seasons, we all know:

Anyways, conventional medical wisdom that we have been taught dictates not to jump to Lupus when it is a middle aged male with no specific red flags for the same, but then again, since when has House MD been a show about conventional medical wisdom?

3. The application of auscultatory percussion of the chest was a good physical examination clue. Unlike the normal House episodes, where the doctors order MRIs and other imaging studies at the drop of a hat, it was good, for once, to see that the doctor was willing to take a look and examine the patient. There are several interesting papers in this field. Like this one:

Bohadana AB, Patel R, Kraman SS. Contour maps of auscultatory percussion in healthy subjects and patients with large intrapulmonary lesions. Lung. 1989;167(6):359-72. PubMed PMID: 2509825.

Or this old paper in The Lancet which states the obvious superiority of auscultatory percussion over conventional percussion:

Guarino JR. Auscultatory percussion of the chest. Lancet. 1980 Jun
21;1(8182):1332-4. PubMed PMID: 6104133.

4. Parenchymal Intrapulmonary Lipoma of the Lung is a rather rare condition, and even them, it is almost impossible to identify using the Chest X Ray. From a real case:

Image credit: Guermazi A, El Khoury M, Perret F, Meignin V, Masson J, Rilli M, Frija J,
Espie M. Unusual presentations of thoracic tumors: Case 3. Parenchymal lipoma of
the lung. J Clin Oncol. 2001 Sep 1;19(17):3784-6. PubMed PMID: 11533104.

Even on CT scans, though a fatty density maybe apparent, it may well be very confusing with a thymic mass. The only way to be sure is to have a biopsied diagnosis. How the prison docs jumped to a diagnosis of lipoma without doing one is a mystery to me. Also, I would, in classic Housean manner, like to point out the fact that going to a diagnosis of Lipoma in a guy who was in prison for drug peddling seems to be a little too… “trusting” of the patient’s nature! Where is House ranting about how this might be a fungal ball from a drug abusing peddler?

5. The bleeding time vs lung cancer scenario was not something that I think can be taken too seriously. Though it is well known that lung cancer may precipitate a state of thrombophilia (Gouin-Thibault I, Achkar A, Samama MM. The thrombophilic state in cancer patients. Acta Haematol. 2001;106(1-2):33-42. Review. PubMed PMID: 11549775.) and prethrombosis, and that there is a huge role of this in the prognostication of the lung cancers as well (Buccheri G, Ferrigno D, Ginardi C, Zuliani C. Haemostatic abnormalities in lung cancer: prognostic implications. Eur J Cancer. 1997 Jan;33(1):50-5. PubMed PMID: 9071899.) I am not convinced of the diagnostic power of the tests.

I am not even going into the ethical side of the Housean tactics of dealing with patients considering the fact he is in jail. I know that is not a good reason anyhow, but given how House acts recklessly outside jail, inside, he might as well be given a bit of leeway!

The drama is not typically tense, and at times, things slow down a bit. There are some awesome shots though, like this one:

House is contemplating quitting medicine but he is still doing the whole differential diagnoses thing on the bunk of his (homicidal, psychotic) cell mate. This is of special mention because this goes to show people do not change. House, no matter how much he wants to straighten up and go do a PhD in Physics researching dark matter, will not be able to do that. Medicine and human interactions has well nigh destroyed his life, but it gives him a high that even Vicodin does not give… ok, maybe that is second to vicodin only.

But anyways, overall, I think the diagnosis though it came about in the ultimate Housean manner was a good fit with the symptoms. It was a good change of scene from the usual settings, where House orders tests left, right and center on his patients in a bid to get at the diagnosis. It was especially nice to see him do auscultatory percussion (though the way he did it without the stethoscope, in a loud and public place, I doubt if that would have helped).

Overall: a very watchable episode, with a decent medical mystery, and of course, the typical Houseisms thrown in! Watch it!

Hat tip: Polite Dissent