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The obvious is easy to miss

MEDICINE | THE UNREAL WORLD

February 12, 2007|Marc Siegel | Special to The Times

"House," Feb. 6, 9 p.m., "Needle in a Haystack."

The premise: A 16-year-old is brought to the hospital after experiencing breathing difficulties while making out with his girlfriend. When a chest X-ray reveals fluid in the pleural space (lining of the lung), Dr. Gregory House and his team conclude that the fluid must be blood, so they shoot dye into the teen's veins (venogram) and then his arteries (arteriogram) searching for the source. They discover a blockage in the liver and perform an MRI scan that reveals what appears to be an inflammatory patch (granuloma). They suspect the patient has Wegener's Granulomatosis (a vasculitis or inflammation of the blood vessels) and treat him with chemotherapy, which appears to cause his bladder to bleed. House then recommends FT 28, an experimental immunological treatment. Before the teen can swallow the pills, however, his spleen ruptures and he is rushed to the O.R., where House continues to search for granulomas by feeling the small bowel. Afterward, the doctors perform a colonoscopy (again without the parents' permission), finding a toothpick lodged in the colon. Dr. Eric Foreman explains that the toothpick couldn't be visualized on a CT or MRI because wood is the same consistency as human tissue.

The medical questions: Would bleeding studies be the first tests to evaluate effusions of the lung? Would vasculitis be diagnosed and treated without a tissue sample? Can a toothpick elude detection and damage major organs while being mistaken for an inflammatory disease?

The reality: X-rays followed by a CT scan and a pleural tap would be the standard initial work-up of a fluid collection in the lung, because an unknown fluid could be due to heart failure, tumor or infection rather than blood. It is also crucial to obtain special blood tests, and a tissue sample to confirm vasculitis before considering a toxic chemotherapy like cyclophosphamide, not to mention an experimental therapy.

Too much consideration of rare diseases such as Wegener's (in which 95% of patients have lung or sinus disease) can cause doctors to ignore more common culprits such as a swallowed toothpick. There have been several reports of toothpicks perforating bowels. It is also plausible that a toothpick could travel through the peritoneal cavity and damage other organs.

But reports in the radiological, pediatric and emergency medicine literature indicate that ultrasound, CT scan, or MRI can visualize toothpicks in body cavities.

Dr. Marc Siegel is an internist at New York University's School of Medicine.

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