Dr. House CME Hematology — S1E6 The Socratic Method : 38-year-old Schizophrenic female with sudden respiratory failure (Topic : Acute thromboembolism)

Medical Review by Huai-Chueh Gem Wu M.D.

I’m a hematologist who takes great interest in diagnosing, treating patients, and watching series. It saddened me when the former medical review on Dr. House by Polite Dissent had been closed. Therefore, I decided to rebuild a mini-hematology-specialized version of medical review on House with contemporary understandings on medicine.

Case Descriptions

• Initial presentation : A 38-year-old female with history of schizophrenia was experiencing auditory hallucinations, had sudden onset of calf muscle spasms. Her son gave her a bottle of Vodka. Later, she developed chest discomfort, and fell to the floor. EMT reported that she had respiratory arrest, and had poor oxygen level despite intubation. She was found to have a deep vein thrombosis (DVT) from her calf, which migrated to her pulmonary arteries causing pulmonary embolism (PE).
• Lab : blood alcohol 0.12 (FYI : DUI detection limit = 0.08). Protein C, protein S levels were normal. Her PT time was prolonged. (It’s quite wired that they did not perform CBC/DC, liver function test, and tumor markers.)
• Follow-up : The patient answered House’s question with completely incoherent sentences, “Don’t lie to him limpy. Lively Lucy never lies to Lucas. Look what I do to him.” This is a well-written, rhymed world salad from a delusional character. House found some cut wounds and had suspected the patient performed self-phlebotomy. Hours after she received Haloperidol as chemical restraint for blood draw, she developed massive hematemesis and/or hemoptysis.
• Medication history : Trifluoperazine, Chlorpromazine, Clozapine. Dietary history : she only ate hamburgers, which could not provide enough vitamin K.
• Exam : abdominal echo revealed scaring of liver and a hepatic mass about 5.8 cm.
• Treatment : the team performed percutaneous ethanol injection (PEI) to shrink the hepatic tumor without any tissue biopsies a priori (very scary! please avoid!). The tumor shrunk into 4.6 cm, and she could finally receive tumor resection (with or without partial hepatectomy).

Differentials and Final Diagnosis

1. Vitamin K deficiency : this can explain coagulopathy, but not psychosis. Considering her dietary habits, her vitamin deficiencies might also include B1, B6, B12, folate, which might result in Wernicke-Korsakoff syndrome (esp. in B1 thiamine deficiency). If this is the case, her coagulopathy and psychosis would be reversed by vitamin supplements.
2. Alcoholic liver cirrhosis (ALC) : it’s common for patients with ALC to have bleeding and neuropsychiatric presentations at the same time. In cirrhotic patients, House and his college should make more effort on performing full liver function survey, including bilirubin, albumin, ammonia, viral hepatitis tests, copper, ceruloplasmin, iron, TIBC, ferritin...etc.
3. Wilson’s disease (final diagnosis) : It’s possible in patients with WD to have treatment-reversible psychosis and coagulopathy at the same time. Her disease course was rather hopefully well considering the miracle effect of chelating agents (in many cases, end-organ damages like brain or liver could be irreversible).

Medical Topics : Etiologies of VTE

Mechanism of VTE could be described with Virchow’s triad, "stasis". “hypercoagulability”, and “venous endothelial injury”.

Triggers and risk factors of VTE could be listed according to the VITAMIN-ABCDEFG method

1. Vascular : presence of foreign body inside or compressing vessels (e.g., stent, CVC)
2. Infections : an example of infection-induced thrombosis would be Lemierre Syndrome, implicating deep neck infections causing carotid septic embolism.
3. Trauma : including surgery
4. Autoimmune : antiphospholipid syndrome (APS), thrombotic thrombocytopenic pupura (TTP)
5. Metabolic : diabetes, obesity, pregnancy
6. Idiopathic : our last resort when we have no clue
7. Neoplastic : malignancy (esp. adenocarcinoma, multiple myeloma)
8. Alcohol or substance use
9. Behavioral : compressing body parts, immobilization for prolonged period of time
10. Congenital : in Western countries, familial thrombophilia causes would be mostly due to Factor V Leiden. However in East Asia (esp. Taiwan), Protein S deficiency, Protein C deficiency, and Antithrombin III deficiency would be the top 3 causes.
11. Drugs : e.g., Hormone Replacement Therapy (HRT), oral contraceptives, thalidomide, lenalidomide, dexamethasone, EPO, ICI, anti-VGFR inhibitors…
12. Environment
13. Food
14. Geriatric : Advanced age might also be a risk

The weird thing is, the patient developed thromboembolism and had coagulopathy at the same time. A possible explanation of that was her thromboembolism was caused by cancer (“cancer-associated thromboembolism”) and her coagulopathy was caused by liver failure.

Lessons Learned

DON’Ts

• Dr. House’s poured his fixation on vaginal fumigation to Dr. Wilson might raise a suspicion of sexual harassment.
• Take a schizophrenic patient completely off her meds. In a single step. This act may make psychiatrist go mad.
• Break into the patient’s house, again.
• Inform patient that she had cancer without biopsy. On the echogram screen, the needle went through liver and directly puncture into her kidney.

DOs

Dr. House picked up extraordinaries out of ordinaries (DVT) based on a patient demography (relatively young age woman) and underlying disease (schizophrenia) and proceed on rigorous investigations. Her schizophrenia developed in rather late stage, when the most common age range was around early 20s.

Personal Reflection

I like how Dr. House use “on my own stethoscope” to imply that he’s practicing. However, he still missed out medical basics when he decided to take over the patient. If the team were to investigate the root cause according to our modern day practice, they should perform comprehensive survey on “thrombophilia” in the first place. Survey on thrombophilia would discover her hepatic tumor under cirrhotic background, and survey on cirrhosis would help them reach the final diagnosis “Wilson’s disease” correctly.