House MD Cases

Case 1: Clarence (Death Row Inmate)

Symptoms & Findings:

• Bluish nails and lips → Hypoxia

• Tachypnea (RR 50), pulmonary edema

• Sudden rage attacks, violent behavior

• MRI → Adrenal tumor

Diagnosis:
Pheochromocytoma — adrenal medulla tumor secreting excess catecholamines (epinephrine/norepinephrine).
→ Triggers episodic rage, tachycardia, hypertension, sweating.

Treatment:

• Adrenalectomy (tumor removal)

• Symptom resolution post-op

Key Concept:
Endocrine disorders can mimic psychiatric or behavioral syndromes.

Ethical Question:
If biology drives violent behavior, is the patient still morally responsible? (Foreman vs. House debate)

Case 2: Senator with Seizures and Brain Lesions

Presentation:

• Speech difficulty, weakness, confusion

• MRI → brain lesion

• Initially thought to be toxoplasmosis (often linked to HIV)

Workup:

• Patient denied HIV → tested secretly

• Low antibodies, normal T-cell count

Final Diagnosis:
Common Variable Immunodeficiency (CVID) — secondary to long-term Phenytoin (Dilantin) use and EBV infection.
→ Toxoplasmosis as secondary infection due to immune suppression.

Treatment:

• IV Immunoglobulin (IVIG) therapy

• Ongoing infection monitoring

Key Concepts:

• CVID: ↓ B & T cells → ↓ antibody production

• Toxoplasmosis: opportunistic parasitic infection

• Lesson: Immunodeficiency ≠ always HIV

Case 3: Man with Recurrent Tongue Swelling & Neuropathy

Symptoms:

• Repeated tongue/throat swelling

• Itching, burning

• Peripheral neuropathy

• Renal involvement

Differential:

• Allergy → ruled out

• Autoimmune (Lupus) → ruled out

• Heavy metal toxicity → confirmed

Final Diagnosis:
Gold poisoning (Chrysiasis) — from gold sodium thiomalate injections (arthritis therapy).
Wife administered it secretly “for his health.”

Findings:

• Heavy metal screen positive for gold

Lesson:
Consider toxic or iatrogenic causes when symptoms affect multiple organ systems (neuropathy + renal + mucocutaneous).

Case 4: Couple with Severe Abdominal Pain & Edema

Symptoms:

• Both with intense abdominal pain, hallucinations, swelling, and lactic acidosis

• Throat edema mimicking anaphylaxis

Workup:

• Allergic, autoimmune, and infectious causes ruled out

• Family link discovered

Final Diagnosis:
Hereditary Angioedema (HAE) — C1 esterase inhibitor deficiency
→ Recurrent airway, GI, and facial swelling.
Couple were half-siblings, sharing same genetic defect.

Treatment:

• C1 esterase inhibitor replacement therapy

• Androgens / antifibrinolytics for prevention

Lesson:
Genetic disorders can imitate allergic reactions.
Family connection can explain similar rare presentations.

Key Takeaways

Concept	Explanation
Hypoxia	Low blood O₂ → cyanosis, confusion, tachypnea
Pheochromocytoma	Catecholamine-secreting adrenal tumor → episodic HTN, rage
CVID	Low immunoglobulins → chronic infections; not HIV
Toxoplasmosis	Parasite reactivates in immunodeficiency
Gold Poisoning	Heavy metal toxicity → neuropathy, renal damage
Hereditary Angioedema (HAE)	C1 inhibitor deficiency → recurrent non-allergic swelling
Adrenaline Surges	Cause sympathetic overdrive symptoms
Clinical-Ethical Theme	Biology vs. responsibility — when illness drives behavior