HOUSE: Half the facts delay diagnosis

This week's episode of 'House' has a mysterious, anonymous patient being admitted with bronchospasm after surviving a late night robbery.

This new patient behaves oddly, mimicking the expressions and behaviors of others in the room. Next, the patient begins to parrot symptoms of other patients on the ward.

Right away the team suspects some type of factitious illness, meaning the patient is healthy but is claiming to be ill. Factitious illnesses come in many varieties:

• Hypochondriasis: patient suspects every physical finding signals an undiagnosed condition


• Hysteria: patient reports false symptoms but is unaware of the reason for the behavior


• Conversion disorder: faked neurologic deficit (limb weakness, blindness) masks genuine anxiety (can be used interchangeably with hysteria)


• Malingering: patient feigns illness and has a good reason to do so (evade work, arrest, etc.)


• Munchausen's: self-inflicted genuine illness with unresolved deep behavioral issues


• Munchausen syndrome by Proxy: make someone else genuinely ill, more behavioral issues

The doctors at Princeton-Hillsboro Hospital believed this squirrelly patient had a unique kind of conversion disorder they labeled Giovannini's Syndrome, wherein the troubled soul behaved like a chameleon and adapted to whatever he experienced. I couldn't find Giovannini's Syndrome under Index Medicus. I believe House also mentioned "Mirror Syndrome", but that same diagnosis was used last season in an episode involving maternal-fetal medicine. Other bloggers are sticking by Mirror Syndrome but, again, my treasured Index Medicus, only refers to it as a prenatal health concern.

Whatever it's called, the TV doctors violated one of the cardinal rules of medicine: Don't call the patient a crock [read phony baloney] until all possible organic (real) illnesses are excluded. Chase the real diseases first and then consider a psych consult. Wasting valuable time trying to untangle a factitious illness can lead to a fatal outcome. Most fakers (whether sound or crazy) will usually still be around tomorrow, but the genuinely septic patient with bizarre neurologic symptoms could expire quickly without aggressive antibiotic therapy.

Good news for this patient, he rapidly crashed and developed the usual House-worthy constellation of near-death crises that convinced House and posse to expand the search for a legitimate cause.

Did you check out that liver biopsy? They're not really performed that way unless the physician also practices voodoo. I'm not going anywhere near that hot tub upright spinal tap!

Here's the second cardinal rule about factitious illness: Eventually, even crocks die from real illnesses.

Lo and behold, a little reverse psychology tricked the patient into divulging critical missing portions of his past history. It appears that the gentleman sold farm implements and all of his problems were blamed on an infection caused by a blood parasite - a soil bacterium called Eperythrozoon.

It is incumbent on the treating physician to consider all reasonable causes for the patient's physical signs and symptoms. When the pieces don't add-up (as happens often on House) it is appropriate to consider a functional problem. Oftentimes nonconfrontational psychotherapeutic intervention will expose the underlying conflict that is the true cause for the patient's misery.

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