Sebastian Charles

Sebastian Charles is the famous tuberculosis physician who becomes a patient in TB or Not TB. He was portrayed by actor Ron Livingston. The character is involved in obtaining medication for sufferers of tuberculosis in Africa and his name has been mentioned several times as a nominee for the Nobel Prize for Peace.
==Medical History==
Charles has a lengthy history of travel in Africa and his medical practice exposes him to tuberculosis and other infectious diseases on a nearly daily basis.
==Case History==
While at a meeting at a pharmaceutical company, Dr. Charles collapsed. He was taken to the emergency room of Princeton-Plainsboro Teaching Hospital. Dr. Charles self-diagnosed himself with tuberculosis, but asked the chief of medicine Dr. Cuddy to obtain a second opinion. She convinced Dr. House to look at the file. He did not think it was tuberculosis, but had no immediate diagnosis.
Dr. Charles met with Dr. House and his team. He denied ever having a previous collapse. Dr. House wrote the symptoms on the whiteboard – vertigo, blurred vision and confusion. He then asked Dr. Charles to leave the differential, but Dr. Cameron noted that Dr. Charles was an expert in immunology and tuberculosis. Dr. House said it was difficult to be honest about the patient's condition when he's in the room. Dr. Charles was sure that it was tuberculosis, but Dr. House believed the symptoms were too varied. However, Dr. Charles insisted on a PPD and sputum sample to confirm, then imaging studies to track its progression, including a CT Scan of his lungs.
Dr. Cameron insisted that Dr. Charles give up his cell phone and told him there would be a phone in his room. The team was then paged back to see Dr. House. He wanted to start a new differential without Dr. Charles being present. Dr. Cameron reminded Dr. House that Dr. Charles was right – tuberculosis can present in many different ways. Dr. House noted that by that logic, everyone in the hospital should be treated for it. Dr. Foreman noted that not all the patients have been exposed to it for 20 years. However, Dr. House pointed out that Dr. Charles was healthy two weeks ago, but now has filled the whiteboard with symptoms. Dr. Chase suggested a metabolic disorder. Dr. Cameron pointed out that Dr. Charles' kidney, liver, and thyroid were all normal. However, Dr. Chase noted the patient's EKG showed variability that could indicate sick sinus syndrome, which would explain the collapse. Dr. Cameron agreed to telemetry, a stress test, and a further EKG.
Dr. Charles objected to the tests, but agreed. Dr. Cameron also started the PPD and scheduled him for an echocardiogram.
The stress test and echocardiogram were both normal, so Dr. House ordered a tilt table test. Dr. Charles reacted normally, so Dr. House turned up the speed above protocol levels. Dr. Charles started to feel nauseous and dizzy, but it showed the abnormal sinus rhythm. Dr. Charles needed a pacemaker and was scheduled for surgery.
However, Dr. Charles decided to walk down the stairs to surgery instead of riding in the wheelchair. However, on the way down, he started to have a severe headache. Dr. Cameron asked him to sit down while she checked his heart rate, which was normal. Dr. Charles said he was fine, but then immediately vomited and lost consciousness, falling down the stairs and pinning Dr. Cameron under him by accident. Dr. Cameron called a code blue.
The collapse ruled out sick sinus syndrome and meant Dr. House was wrong about the need for a pacemaker. Dr. Foreman thought the headache indicated a neurological problem, such as a brain tumor. Dr. House ordered a MRI.
The MRI was normal, but the PPD test was positive for tuberculosis. Dr. Cameron reported this to Dr. House, who admonished her for testing for it. He believed all along that Dr. Charles had tuberculosis, but also believed that tuberculosis was not the whole story. With tuberculosis confirmed, Dr. Charles would not agree to further tests. However, Dr. Cameron pointed out that Dr. Charles' LP2 results: low glucose and sed rate were also classic signs of tuberculosis. Dr. House was sure some of the symptoms were not the result of tuberculosis, but finally agreed that unless they treated him for it, they could not be sure which ones were caused by tuberculosis and which were caused by another underlying condition. Dr. Cameron was sure Dr. Charles would get better with treatment for the tuberculosis.
Dr. Charles' tuberculosis was a resistant strain that required streptomycin and other expensive antibiotics that would cost over $10,000 for a two year course of treatment. However, to make a point about the worldwide problem with tuberculosis, he refused treatment. He also refused further tests.
Dr. House started a new differential nevertheless. Dr. Chase though it might be a problem with the autonomic nervous system, but they already ruled out a brain tumor. Dr. Foreman suggested Fabry disease and autonomic disregulation syndrome and Shy-Drager syndrome.
Dr. House went to see Dr. Cuddy about Dr. Charles' refusal to take treatment, but she noted that Dr. Charles was only refusing treatment for tuberculosis, and Dr. House didn't think it was tuberculosis. In addition she had agreed to be at a press conference to confirm the diagnosis and prognosis.
Dr. Cameron explained the progression of the disease to Dr. Charles and ask him to accept palliative care. However, Dr. House came in to turn up the thermostat and take away his television to treat him just like he was at a clinic in the developing world. Dr. Charles insisted he was not going to give in. Dr. House said he couldn't act like he was in the developing world and then call a press conference. However, Dr. Charles said that he would be stupid not to take advantage of the media's interest in him to fight for his cause.
Dr. House watched the press conference on television. He thought the color of the set was off because Dr. Charles looked too red and wondered why Dr. Charles was sweating when the tuberculosis should have affected his autonomic nervous system and his ability to regulate his body temperature despite the fact the room he was in was very warm. Dr. Wilson assured him the color settings were accurate. Dr. House rushed to Dr. Charles' room to find him sweating with increasing disorientation and increased heart rate. He realized Dr. Charles was going into cardiac arrest and called for a crash cart. They managed to shock him back to sinus rhythm. Dr. House then announced to the press that Dr. Charles didn't have tuberculosis.
Dr. Charles agreed to tests, but Dr. House insisted on treating the tuberculosis. Dr. House still didn't think tuberculosis was the whole problem as it does not cause cardiac arrest on hot days, and Dr. Charles should have realized that. However, he needed to eliminate symptoms that could be the result of tuberculosis. Dr. Charles still resisted, but Dr. House told him he would do an autopsy after he died and announce that tuberculosis wasn't what killed him. Dr. Charles finally consented to treatment.
As he improved, his symptoms started to disappear. However, the irregular heart rhythm, syncope, headaches and low cerebrospinal fluid glucose levels persisted even though the final symptom is an almost certain sign of tuberculosis. Dr. Chase suggested that high insulin levels could explain the low sugar levels, but Dr. Cameron said they would have to be very high and the blood sugar level levels they took were all normal. It couldn't be glucagonoma because the characteristic rash was missing, and it was almost certain that Dr. Charles wasn't self-injecting with insulin. A tumor was also ruled out because the scans were negative. However, Dr. House still thought it could be a tumor – a micro nesidioblastoma – a tumor on the insulin secreting cells of the pancreas that responds to stress, such as the tilt table test. It could be surgically removed, but with it being too small to see, it would be nearly impossible to find.
Dr. House suggested to Dr. Charles that they try to inject calcium into the pancreas induce the tumor to produce insulin so they could spot it. However, the test would be risky because his blood sugar could drop quickly. Dr. Charles agreed to the test. They started it, but he did not react to the first ampule. They gave him another ampule and his blood sugar started to drop. Dr. Charles complained his arm was shaking. Dr. Foreman prepared to give him a glucose drip to prevent a seizure, but Dr. House ordered the test to continue. The blood sugar level started to drop and Dr. Charles had a seizure, but they continued and they found the tumor.
Dr. Charles quickly recovered from his surgery and was supplied with a six month supply of antibiotics, which he said he would use in two months. Dr. Cameron figured he was going to give the pills to his patients.
==A Reflection of House==
The patient is a world famous doctor. He has a great deal of confidence in his own abilities.
==Reaching the Diagnosis==
The patient, an expert in tuberculosis, was convinced that he had the disease. However, House was unconvinced because many of the patient's symptoms did not match TB. The patient insisted on a PPD and a lung sputem culture to confirm the diagnosis, together with radiology to determine its extent, including a CT Scan.
After the patient left, House re-convened his team to do a differential diagnosis. Cameron argued that tuberculosis can have varied symptoms, but House countered that it is also very slow and that two weeks ago the patient was perfectly healthy. Chase suggested a metabolic condition, but Cameron shot down the suggestion because the patient's kidneys, thyroid, and liver were all functioning normally. Diabetes mellitus had also been ruled out. Chase suggested a heart condition and pointed to a P-R variability on the EKG, a symptom of sick sinus syndrome. Cameron agreed to put him on telemetry and to perform a stress test and an echocardiogram.
However, despite the EKG abnormality, the stress test and echocardiogram came back normal. House orders a tilt table test. After taking it well out of protocol range, the P-R variability appears, confirming sick sinus syndrome. The patient is scheduled for the installation of a pacemaker. However, after a short exertion that doesn't raise his heart rate, he gets a headache, starts to vomit and then collapses.
This makes it clear the problem isn't sick sinus syndrome. Because of the headache, Foreman believes it might be an acoustic neuroma, which would also explain the other symptoms. House agrees and orders an MRI.
However, the PPD comes back positive, showing that it's TB. In addition, low glucose levels and an increased sed rate also pointed to tuberculosis. House was still not sure it explained all the symptoms, but agreed that until the tuberculosis was treated they could not do a proper differential.
When the patient refused treatment for TB, House points to at least three symptoms that don't fit the diagnosis - increased heart rate, night sweats and loss of consciousness. Foreman noted a number of conditions could cause these such as Fabry disease, autonomic disregulation syndrome, or shy-drager syndrome, all of which would require the patient to agree to tests.
However, when House takes away the patient's air conditioning, he continues to sweat and he suffers a heart attack, neither of which is an indication of TB. The patient agrees to be treated for TB.
After being treated, the only remaining symptoms are the P-R variability, fainting, headaches, and low blood sugar. The low blood sugar is a surprise because it could be explained by the tuberculosis. However, House quickly realizes that this outlying symptom eliminates a lot of conditions that could be explained by the other three symptoms. High insulin levels could cause it, but they would have to be incredibly high and his daily tests for blood sugar level were all consistent. A glucagonoma would cause a rash. It almost certainly isn't self-induced insulin, and they could not find a tumor on any of the scans. However, House realizes a small nesidioblastoma would explain all the symptoms, even if it were too small to show up on scans. Something very stressful like the tilt table test could trigger it.
The only way to find it is to trigger it again. House suggests injecting calcium into the pancreas. This would trigger it, but the risk is that it could drive the blood sugar so low it could be life threatening. The patient agrees to the procedure and has an adverse glucose reaction to the calcium, confirming the tumor. He is schedule for surgery to remove it.
==Explaining the Medicine==
*The tuberculosis PPD (or, more properly, the Mantoux test as PPD tests of different types were used in the past) consists of injecting a small amount of purified protein derivative of sterilized tuberculosis cells under the skin between layers of the skin, then checking in 72 hours to determine if there has been a reaction that turns the injection site hard and rough to the touch. This reaction to the derivative was first observed by Robert Koch and was turned into a diagnostic test in 1909. In a patient like Charles with high risk factors, any area over 5mm in diameter constitutes a positive test. In a patient with no risk factors, the area would have to be at least 15mm in diameter to be considered positive.
*A fast progression of the disease is not unusual in a person with a secondary condition, such as AIDS or another autoimmune disease.
*It is not well understood why, but tuberculosis can interfere with the body's ability to regulate blood sugar levels. There is a high co-morbidity between tuberculosis and diabetes mellitus. Glucose levels in TB patients should be regularly monitored.
*The increased sed rate in tuberculosis patients is caused by inflammation.
*Very low blood sugar can cause seizures, loss of consciousness, or even death.
This article was the featured article for September, 2020.
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