Fox, Jan. 11
Episode: "The Down Low"
Mickey (Ethan Embry) is conducting a drug deal when he suddenly drops to the ground and hits his head. In the hospital, he experiences noise-induced vertigo and blacks out again from the noise of Dr. Gregory House's (Hugh Laurie's) cane tapping. House thinks this could all be due to cocaine, especially when Mickey has a seizure during a hearing test.
Mickey insists on leaving the hospital but then returns with a high fever, subsequently undergoing a lumbar puncture that shows nothing amiss. But his heart rate is low, and House discovers he has been medicating himself with a beta blocker, which lowers both blood pressure and heart rate and which may suppress anxiety. House now thinks that Mickey's unmasked high blood pressure, heart rate and anxiety could be due to a tumor in his adrenal gland (pheochromocytoma), and he orders an MRI. That too fails to identify the symptoms' cause.
Later, after confiding to House that he is really an undercover cop, Mickey begins gasping for air. Further tests reveal a clot in the superior mesenteric artery in the abdomen, causing dead loops of bowel. After the bowel segment is removed, Mickey begins to cough up blood. A bronchoscopy reveals multiple aneurysms (dilated weakened arterial walls), which Dr. Robert Chase (Jesse Spencer) thinks are due to a fungal infection. But anti-fungal drugs don't help, and Mickey's condition worsens. Ultimately, House realizes that the problem is Hughes-Stovin syndrome, an untreatable autoimmune disease. Mickey soon dies.
The medical questions
How commonly is vertigo (room spinning) and sensitivity to noise associated with cocaine use? What are the symptoms of pheochromocytoma? Can a fungal infection cause blood clots in the arteries that supply the bowel? Aneurysms in the lung? How common is the autoimmune condition Hughes-Stovin, and is it uniformly fatal? Would an undiagnosed condition like this be treated with steroids or antibiotics before confirming the diagnosis?
Vertigo is fairly common in heavy cocaine users. Sound-induced vertigo mostly occurs in patients with ear problems but can be associated with drugs that can damage hearing, including cocaine. Further, cocaine can cause people to be more sensitive to noises and can damage the cochlea (hearing center in the inner ear), says Dr. Stephen Rothstein, a clinical associate professor of otolaryngology at New York University's Langone Medical Center.
Common symptoms of pheochromocytoma include headaches, palpitations and excessive sweating, says Dr. Run Yu, co-director of the carcinoid and neuroendocrine tumor program at Cedars-Sinai Medical Center. Most patients have hypertension as a result. Blackouts can happen as the show portrays (due to wide fluctuations in blood pressure), but they're unusual, Yu says. And an MRI of the adrenals would be preceded by blood tests to look for the hormones that the tumor secretes. Only if these tests are positive would an imaging study, looking for the location of the tumor, be done.
A fungal infection could cause clots in arteries to the bowel or mycotic (infected) aneurysms, but both conditions are more likely to be caused by bacteria than by a fungus.
Hughes-Stovin syndrome, an autoimmune connective tissue disease, is extremely rare, characterized by large clots and, sometimes, multiple aneurysms in the lungs. These aneurysms frequently cause massive bleeding (hemoptysis) and death, but recent case reports suggest the condition can sometimes respond to immunosuppressive drugs, including steroids.
Finally, antibiotics or steroids are often used in life-threatening conditions even before diagnoses are confirmed, especially when waiting would imperil the patient's life. Of course, House engages in this practice far more often than most doctors.
Siegel is an associate professor at New York University's School of Medicine and author of the e-book "Swine Flu: The New Pandemic."