Foreman (case study)

This is a special case history for Eric Foreman's illness in the episode Euphoria (Part 2).
==Case History==
Dr. Foreman had been involved in the treatment of a patient who first exhibited euphoria, then blindness which the patient could not perceive, then tremendous pain.
Dr. Foreman was the only doctor who had been to the patient's apartment. Dr. House started becoming concerned about his behavior when Dr. Cameron reported unprofessional behavior around the patient and Dr. Foreman grinned when Dr. House performed an experiment by shooting a corpse. Soon after, Dr. Foreman started laughing when the patient became tachycardic and started bleeding.
Dr. Foreman was put in an isolation room with the patient in case the disease was contagious to prevent the infection from passing to anyone else. Dr. House planned to use the portable MRI to scan Dr. Foreman's brain and ordered him to take his body temperature every 30 minutes, eat his meals, and take any medication he was given.
The MRI showed increased T2 attenuation in the cingulate cortex which would explain the euphoria as that part of the brain controls emotions. Dr. Chase suggested West Nile virus or Eastern equine encephalitis. Dr. House ordered blood tests on Dr. Foreman, but thought a toxin from the other patient's apartment was more likely than a contagious illness given that none of the other doctors were showing symptoms. Dr. Cameron volunteered to do another environmental scan, but Dr. House just told her to test the samples Dr. Foreman had obtained on his visit.
Dr. Chase attempted to draw blood for testing, but had difficulty due to his isolation suit. Dr. Foreman decided to draw his own blood. Dr. Chase told Dr. Foreman their leading diagnoses and Dr. Foreman asked if there was increased inflammation in the ventricles. Dr. Foreman thought it might be a staphylococcus infection, but they would need antibiotics injected directly into their brains.
The samples from the apartment tested negative for toluene, arsenic, and lead. The tests for the viruses were also negative. Dr. Cameron wanted to go back to the other patient's apartment, but Dr. House forbade it due to the danger. He finally decided to give Dr. Foreman a brain biopsy. Dr. Chase objected because he thought Dr. Foreman was right about staphylococcus. However, Dr. House rejected the theory because Dr. Foreman had no fever and the other patient's fever was due to legionellosis. Dr. House went to argue the point with Dr. Foreman and noticed his euphoria had disappeared. He also argued if it was staphylococcus, it would be in one of his other organs, and they were all fine and there was no abscess on the MRI. He showed it to Dr. Foreman, who noted that the soft spot could have been the start of an abscess. Dr. House pointed out the lack of a fever, but Dr. Foreman showed his latest body temperature was 101.6°F. He demanded an ommaya reservoir. Dr. House pretended to comply, but merely used the opportunity to get the brain biopsy he wanted.
The brain biopsy showed only generalized inflammation. Dr. Foreman was also negative for staphylococcus. Dr. House ordered the samples retested, but still refused to allow a second environmental scan. He told Dr. Cameron to monitor Dr. Foreman to see if he went blind. She went to see Dr. Foreman and advised him that there had not been a second environmental scan. Dr. Foreman became angry about this. Dr. Cameron tested him and noticed his left side peripheral vision was reduced. Due to his frustration, he stabbed Dr. Cameron with a tainted needle in an attempt to speed get her to go back to the apartment.
Dr. Chase managed to rule out subacute sclerosing panencephalitis. Coxsackie B had also been ruled out. Dr. Cameron, against orders, went back to the other patient's apartment wearing an isolation suit. The other patient developed hyperalgesia - intractable untreatable pain and had to be put into an induced coma. Dr. Foreman suggested aureobasidium, but Dr. House ruled it out because Dr. Foreman hadn't seen its culture medium, cedar wood, in the apartment. Dr. House noticed Dr. Cameron was missing and wondered why Dr. Foreman wasn't angry with her. He realized she had gone to the apartment and when she came out of the door, she found Dr. House waiting outside in the corridor. She told him about the needle stick and Dr. House wondered why she bothered to wear an isolation suit if she thought she was infected too. He thought she went there in defiance of him. However, he asked for the samples and they went through them suggesting staphylococcus, toxocara, trichinella, and ergot poisoning. Dr. House wondered why there were three loaves of rye bread given the patient's poor diet and told Dr. Cameron to re-enter the apartment looking for birds. Dr. Cameron noticed pigeons flocking to bread, but no pigeon feces. Dr. House realized the other patient was using the feces as cheap fertilizer. Dr. Cameron found the storage which was to be tested for Cryptococcus neoformans. Dr. House started treating them both for it.
Dr. Foreman wondered how he missed the feces. He also noted that the other patient appeared to still be experiencing pain even though he was in a coma. Dr. Cameron had not developed any symptoms. Dr. Foreman's fever started to drop and his white blood cell count improved.
However, the samples collected were negative for Cryptococcus. The other patient died of multiple system failure before he could be diagnosed. None of the other members of the team or the hospital staff appeared to be affected. Dr. House realized that whatever the source of the illness was, it was in the other patient's apartment.
Dr. House went to Dr. Cuddy to ask for a bone saw so that Dr. Foreman could perform an autopsy on the dead patient. However, she refused permission. Under CDC protocols, anyone who died of an undiagnosed contagious illness had to be autopsied in secure conditions to prevent the further spread of the disease. This would take at least three days. Dr. House reminded Dr. Cuddy that the dead patient had progressed from first symptoms to death within two days. She also told her it could be a non-contagious toxin.
In an attempt to circumvent the CDC, Dr. House provided Dr. Foreman with an ice pick and told him to do a frontal lobotomy on the dead patient to get a sample of his brain tissue. Dr. Cuddy found out and tried to intervene. However, when Dr. Foreman attempted to do the lobotomy, he instead took a sample of the dead patient's bed. Dr. Foreman was blind, but didn't realize it. The disease was progressing faster than it did in the dead patient.
Dr. Chase reiterated that Dr. Foreman's eyes were physically okay - the problem had to be in his brain, particularly the occipital lobe. Dr. Cameron wanted to re-test him for bacterial meningitis, but if it were meningitis, the entire team would be ill. Dr. Cameron suggested a lumbar puncture to get a sample of cerebrospinal fluid, but Dr. House realized that would be pointless - the brain biopsy was a more dangerous test and would have shown if anything was wrong with the fluid. Dr. Chase suggested toxic mold, but it is blood borne and Dr. Cameron would be sick. This seemed to rule out all blood borne diseases. Dr. Cameron suggested Guillain-Barré syndrome, but neither Dr. Foreman nor the other patient showed any signs of paralysis. Dr. Chase suggested arbovirus. Dr. House ordered them to treat Dr. Foreman for anything they could think of. Dr. Chase warned about medicine interactions and Dr. Cameron pointed out that many drugs would most likely damage his kidneys and liver. However, Dr. House grew angry - he pointed out he knew the proper procedure was to autopsy the dead patient, but since he couldn't do that, he had to do what he could. He realized that it had to be a bacteria, toxin, fungus, parasite, or virus.
Dr. Chase told Dr. Foreman that the dead patient was being removed to a secure location. He told Dr. Foreman he had left medication for him in the airlock, and that the most likely suspect was toxic mold, although they had not ruled out Guillain-Barré. However, Dr. Foreman recognized some of the medications by touch as antibiotics, acyclovir, and fluconazole and realized he was being treated for everything. When Dr. Chase told him that Dr. House thought the multiple medications were the best course of action, Dr. Foreman accused him of being desperate. However, he finally agreed to take the medication.
Dr. House went back to the dead patient's apartment in an isolation suit and called Dr. Foreman to find out where he had been in the apartment, asking him to retrace his steps precisely. Dr. House exposed Steve McQueen to everywhere Dr. Foreman had been. Dr. Foreman called his father to let him know how ill he was.
Dr. House took Steve back to his own apartment, where he put water on the floor and turned up the air conditioning to full. He monitored Steve over a webcam and planned to kill and autopsy him once he exhibited symptoms.
Dr. Cameron went into isolation to examine Dr. Foreman. He asked if her sed rate was elevated, but she said she was feeling fine. However, they realized Dr. Foreman's sight had returned. Dr. Cameron reported this to Dr. House, who realized one of the medications was working and they should wean him off of them one by one. However, Dr. Chase came in to report that the latest lab tests showed that Dr. Foreman's amylase and lipase levels were three times normal. All the medication was shutting down his pancreas.
Dr. Foreman was vomiting frequently when Dr. House came in to tell him that their only choices were a course of treatment where he would die in four hours and one where he would die in fourteen hours. Dr. Foreman reminded him that his vision was almost fully restored, but Dr. House told him the medication was also destroying his pancreas. Dr. Foreman said he could take lower doses and deal with the pancreatitis, but Dr. House told him if they kept him on the medications any longer, his pancreas would be permanently destroyed. Dr. Foreman agreed to go off the medication to give them more time, even though it would mean the blindness and pain would return.
At that moment, Dr. Foreman's father showed up. He took him to see Dr. Cuddy to try to pressure her into allowing the autopsy. However, Dr. Cuddy explained the situation to the father, and he accepted her explanation and dropped the matter.
Dr. Foreman's father went to talk to him, and Dr. Foreman explained what was causing his symptoms, but he lied to his father about the pain the disease caused. He didn't care about seeing his brother, but it bothered him that he wouldn't be able to see his mother. His father told him that his mother wouldn't be able to deal with the situation given her dementia. The father believed in an afterlife and wasn't afraid that his son was going to die. Dr. Foreman admitted that he was no longer sure about the existence of an afterlife. The father suggested prayer.
Steve McQueen wasn't developing any symptoms. Dr. House was trying to get access to the dead patient's body, but he couldn't get past the security guard. The dead patient's body was finally removed from the hospital.
Dr. Foreman's vision rapidly deteriorated, and he reached an 8 on the pain scale. The disease appeared to be progressing faster in Dr. Foreman than it did in the dead patient. Dr. Cameron thought it might just be a different strain. However, Dr. House dismissed this suggestion. Dr. Chase suggested the dead patient's immune system was stronger because he worked out in his job as a police officer. Dr. Cameron suggested that the quicker progression in Dr. Foreman was because he was black. Dr. House agreed it was a possibility and told them to look for bacteria, fungals, parasites and toxins with a demonstrated racial disparity. He checked in on Steve McQueen, who was completely healthy. However, Dr. House realized the dead patient wasn't - he also had legionellosis.
Dr. Cuddy went in to check on Dr. Foreman, but he just got angry with her for not allowing the autopsy on the dead patient. He reminded her the penalty for failure to comply with regulations wasn't death. Dr. House came by and told Dr. Foreman that the dead patient didn't get worse until they cured the legionellosis. He wanted to expose Dr. Foreman to it because it appears to slow down the progress of the disease. Dr. Foreman protested that he just wanted to be put under so he wouldn't be in pain, but Dr. House said he had to keep him conscious to monitor his pain levels. Dr. Foreman said he wouldn't consent to exposure, but Dr. House went into isolation and broke open a vial of the legionellosis bacteria.
Dr. Foreman soon started exhibiting the symptoms of legionellosis. However, his body temperature was dropping and the pain wasn't getting any worse. It appeared that the progression of the other disease had slowed. Steve McQueen was still healthy. Dr. House asked Dr. Cameron if there were diseases that affected humans, but not rats. Dr. Chase realized some bacterial infections don't affect rats, but Dr. Foreman had tested negative for any bacterial infection that could affect his brain. However, Dr. House asked which of those could have been false negatives. He realized that the deadly disease had not been recognized by the immune system. However, when legionellosis showed up, the body's immune system released white blood cells and antibodies to fight it off, which had the side effect of also fighting off the other disease. The most likely candidate was listeria - it doesn't affect rats and often doesn't set off the immune system. He wanted to start Dr. Foreman on ampicillin and gentamicin, but Dr. Foreman realized that those antibiotics would destroy the legionellosis as well. If the other disease wasn't listeria, he would get worse again. He took the drugs anyway. However, he asked Dr. House to do a white matter brain biopsy as well, but Dr. House realized this could destroy his higher reasoning functions. Dr. House said he would do it, but only if it became absolutely necessary. Dr. Foreman agreed to take the antibiotics.
Dr. House went to see the father to tell him what was likely to happen. He also told him that they might have to induce a coma if the pain got too bad. The father told Dr. House that his son had told him he was a manipulative bastard, but he was also the best doctor he had ever worked with. He told the father that once Dr. Foreman was unconscious, he would be his medical proxy. The father said that given his lack of medical knowledge, he would be happy to do whatever Dr. House wanted.
However, Dr. Foreman had anticipated that Dr. House would attempt to manipulate his father. The next time Dr. Cameron came in, he asked her to get the paperwork done to appoint her as his medical proxy. He told her that although he disliked her for being too compassionate and too cautious, in his situation these were positive virtues. Dr. Cameron tried to resist, saying his father would be the appropriate proxy, but Dr. Foreman realized that Dr. Cameron would be in a much better position to understand what was going on than his father would be. He was also worried that she was still mad about him stealing her article. She said that she would agree to be his proxy, but she was still mad about the article. She said that he was only apologizing because he was dying, but he could apologize once they treated him.
Dr. Cameron reported that Dr. Foreman's legionellosis symptoms were improving, but not the other symptoms. She suggested they do the white matter biopsy. Dr. House thought it was premature.
Dr. Chase went to Dr. Foreman's father to inform him that they were about to put him in a coma. This might be the last time they would have a chance to speak. He didn't know what to say, but Dr. Chase said the appropriate thing was to remind his son that he loved him. The father got into an isolation suit and told him that he was going to be okay, and that he didn't want to miss him. Dr. Foreman told his father that he loved him too, and reassured him it was going to be okay. They put Dr. Foreman into a coma, and Dr. Cameron told him he accepted his apology about the article.
Dr. Wilson went to Dr. House to recommend that he do the biopsy. He told him that he wasn't being objective and that he would have done the biopsy on any other patient. Dr. Cameron reported that Dr. Foreman was in the induced coma and his EEG showed he was still in pain. She wanted to do the biopsy. Dr. House disagreed, but Dr. Cameron showed her medical proxy authorization and said it was her call. Dr. House went to Dr. Cuddy to overrule it because Dr. Foreman wasn't in a stable mental state when he signed it, but Dr. Cuddy told him that if he wanted it overruled, he could hire a lawyer to fight it. The father wanted to know why his son didn't trust him. When Dr. House tried to manipulate Dr. Cameron, Dr. Cuddy told him to stop. She gave Dr. Cameron permission to do the biopsy, but Dr. Cameron snapped back that if it wasn't for her decision, they would be biopsying the brain of a dead man rather than Dr. Foreman. However, she apologized.
Dr. House asked for another hour. He pointed out Dr. Foreman's O2 stats were still at 94% and that the risk of arrhythmia didn't increase until that figure dropped below 90%. Dr. House planned to go back to the dead patient's apartment to find a dead animal to autopsy. Dr. Cameron agreed, but told him that she wouldn't wait once Dr. Foreman's O2 stats dropped below 90%. Dr. Cameron asked where Dr. House's isolation suit was, but he said he didn't need one - one way or the other they would get the answer.
Dr. Foreman was prepared for the brain biopsy. His O2 stats dropped to 93%.
Dr. House went back to the dead patient's apartment and saw some pigeons that were having trouble flying. He figured they were blind. He called Dr. Cameron who said that Dr. Foreman's O2 stats had now dropped to 92%. Dr. House tried to catch the pigeon, but it flew away before he could get it. However, he also noticed a water collection system leading to the roof. He called Dr. Cameron. He realized that the irrigation system for the dead patient's marijuana grow-op was the source of the disease. Dr. Foreman came through when it was active. When Dr. Cameron went, it was six hours before and when he and Steve went the first time, they were two hours late. Dr. Cameron protested she had checked the water supply and it was clean.
Dr. Foreman's O2 stats dropped to 89%. Dr. Cameron ordered them to proceed with the biopsy.
However, Dr. House continued to investigate. He realized the irrigation system wasn't being fed by the city water system, and he traced it to a tank on the roof. He found pigeons drinking the water and when he looked at it, it was obviously contaminated with naegleria causing primary amoebic meningoencephalitis. He called Dr. Cameron with the news but she had already completed the brain biopsy with the same results. She had started Dr. Foreman on anti-parasitics. It was obvious he would recover from the naegleria with no ill effects from that, but there was no knowing what the effect of the brain biopsy was.
Dr. Foreman was soon reacting to light and regained consciousness. He was able to talk and told everyone he wasn't in pain. He was able to follow Dr. House's finger with his eyes. He was able to identify Dr. Cameron, his father and Dr. House. His reflexes appeared normal, but he couldn't wiggle his left toes. Dr. House realized that his ability to move the left and right sides of his body had become crossed.
==Follow up==
Dr.Foreman's brain/muscle coordination soon returned. He had some initial short term memory loss, but soon recovered from that as well. He suffered no long term effects from his illness.
Category:Patients
Category:Males
Category:Season 2