Weak tonic on ‘House’

“House”

“Living the Dream” episode

Fox, May 5.

The premise: Actor Evan Green (Jason Lewis) plays Dr. Brock Sterling in Dr. Gregory House’s (Hugh Laurie’s) favorite soap opera. While filming, Green collapses, and House rushes to the set, convinced Green may have a brain tumor because his speech has been slowing and he’s been having problems with coordination and vision. An MRI scan turns out to be normal, but Green suddenly develops leg numbness and is unable to walk. House continues performing tests, including an electromyogram and a reflex erection test (Green is impotent), and considers whether Green’s symptoms, including a heart arrhythmia, could be due to a toxin or a thyroid problem.

But tests continue to come back negative, and Green develops kidney failure and slips into a coma. He is transferred to the ICU and treated with antibiotics for possible sepsis (systemic infection). When Green fails to improve, House becomes convinced the actor has a severe allergy to flowers and decides to treat him with steroids, which he says might kill Green if he has an infection but would save him if he is suffering from an allergy. Green wakes and improves, and House, watching the soap opera later, realizes that the cause of the allergy was quinine in the tonic water (used for gin and tonic) Green’s character was drinking on the show.

The medical questions: Would slurred speech and problems with coordination and vision suggest the presence of a brain tumor? Are toxins a likely cause of progressive neurological symptoms? Can severe allergy be confused with severe infection -- and will steroids improve the former and worsen the latter? Can quinine allergy cause numbness and paralysis, followed by coma? What is the difference between quinine hypersensitivity (allergy), which the show considers, and toxicity (which it doesn’t)?

The reality: Slurred speech, poor coordination and a partial loss of vision can all be symptoms of a brain tumor, but they also suggest several other -- more likely -- diagnoses, including stroke, complex migraine, multiple sclerosis attack or inflammation of the brain.

As the show suggests, toxins can cause progressive numbness (peripheral neuropathy), foot drop and even paralysis or coma, but Green’s toxicology screen is negative. Anaphylactic shock (in which the body generally makes a large amount of antibodies to a specific allergen) can be confused with septic shock (caused by an infection) and often responds to steroids, but the use of high-dose steroids isn’t automatically deadly in people with septic shock. Although House considers hypersensitivity to chrysanthemum flowers (containing the toxins pyrethrins) as the cause of the possible allergic reaction, this kind of allergy would much more likely result in skin irritation and eye burning than in paralysis and coma.

In reality, a quinine allergy would be more likely to cause coma. Dr. Bernard Feigenbaum, assistant professor of allergy and immunology at New York University School of Medicine, says that a person can become allergic to any drug at any time even without a typical rash, but he adds that, “anaphylactic shock almost always occurs within the first few hours after an exposure. Frequent exposure without symptoms of allergy would not generally be followed by sudden anaphylaxis.”

Further, he adds, anaphylaxis to quinine “out of the blue,” preceded only by neurological symptoms, would be almost impossible from drinking tonic water daily on the show.

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Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He is also the author of “False Alarm: The Truth About the Epidemic of Fear.” He can be reached at marc@doctorsiegel .com.