‘House’ stretches the truth with fiction writer

“House”

8 p.m. Oct. 4, Fox

Episode: “Unwritten”

The premise

Alice Tanner ( Amy Irving), author of novels for young adults, is admitted to the hospital after suffering a seizure just as she was about to shoot herself. Dr. Gregory House ( Hugh Laurie) places her on 72-hour psychiatric observation. She complains of back and hand pain and excess sweating. House discovers that she eats two to three cans of tuna per day and suspects acute mercury poisoning, but her mercury level is normal. Tanner begins to talk to herself and to imagine things. When she develops a sudden pain in her head and her blood pressure shoots up, House suspects she has an adrenal tumor. He orders an MRI scan, but on the table her leg sparks and burns (screws from a prior injury are ignited). House extends Tanner’s psych hold by offering Tanner a syringe loaded with mock poison; she injects herself, another suicide attempt. A PET scan shows no tumor and an echocardiogram reveals fluid surrounding the heart, which House thinks could be due to a virus or cancer. But in reading Tanner’s manuscript for her new novel, he finds that the female protagonist also suffers from suicidal depression and fatigue, as well as joint pain and sensitivity to light. House now thinks that Tanner must have lupus. But again, tests are negative. House considers hypothyroidism — but then Tanner suffers sudden paralysis, and House finally realizes that all her symptoms are due to a neck injury from an old car accident in which her leg was fractured and her son was killed. She has developed a post-traumatic syringomyelia (fluid-filled cyst in the spinal cord). She blames herself for her son’s death (she’d allowed him to drive with a learner’s permit) and now refuses surgery to her neck. House tells her a lie — that her son really died of a ruptured brain aneurysm that caused the accident in the first place. Tanner agrees to the surgery, which is successful.

The medical questions

Is excessive sweating associated with mercury poisoning? Can adrenal tumors cause seizures, headaches, hallucinations and sudden rises in blood pressure? Would an MRI set metal screws in the body on fire? Are pericardial effusions, depression, seizures, sensitivity to light and joint aches signs of lupus or hypothyroidism? Can an old car accident cause a syringomyelia in the neck leading to this constellation of symptoms and sudden paralysis? Is it ethical for a doctor to tell untruths to manipulate a patient’s behavior?

The reality

Excess sweating may be associated with mercury poisoning, hyperthyroidism, anxiety or adrenal tumors, says Dr. Marc Nuwer, director of clinical neurophysiology at UCLA. The sweating would occur on both sides of the body. A post-traumatic syringomyelia, however, might cause excess sweating on just one side, above the area of injury.

The hormones released by adrenal tumors can cause very high blood pressure, headaches, seizures and vision loss, Nuwer says. More often, though, these tumors cause panic attacks that are mistaken for seizures, says Dr. Jerome Engel, chair of epilepsy at UCLA. Suspicion of an adrenal tumor is first investigated by a 24-hour urine test looking for high levels of metabolites of epinephrine or norepinephrine. The tumor is usually found using a CT, MRI or PET scan of the adrenal gland.

Metal screws from more than 15 years ago could heat up during an MRI scan as a result of the microwave energy, causing a burn, Nuwer says. But, he adds, the heat would diffuse too quickly to set the body on fire or cause a spark.

The patient’s symptoms are consistent with a connective tissue disease like lupus, Nuwer says. But they don’t fit so well for hypothyroidism, which can cause depression and joint pain but does not cause seizures.

Post-traumatic syringomyelia (damage to the spinal cord resulting in a fluid-filled cyst) can occur years after an accident, says Dr. Ulrich Batzdorf, executive director of spinal neurosurgery at UCLA and a world expert on syringomyelia. The neurological symptoms usually come on gradually, not abruptly, he says. Syringomyelia can cause one-sided hand pain, sweating, headache and rise in blood pressure due to damage to the autonomic nervous system, but not seizures, joint aches, sensitivity to light, hallucinations or fluid around the heart, Batzdorf says. Repair “isn’t easy,” he adds: People who are paralyzed would rarely recover fully.

Finally, Arthur Caplan, director of bioethics at the University of Pennsylvania, says it would be “absurd” to tell a patient her son had an aneurysm to help her overcome her guilt over a fatal car accident. As for the fake poison: “I think using a placebo can be defended if you eventually debrief the patient and explain what you did and why,” Caplan says.

Siegel is an associate professor at New York University’s School of Medicine.

marc@doctorsiegel.com