SPOILER ALERT!

Natalie is an unpopular, overweight teenager who concealed a full-term pregnancy, then discarded the products of her unattended delivery in a vacant crackhouse - or so she thought. Weeks later Natalie collapses, develops seizures, and spirals into multi-organ failure.

It was Cuddy, not House, who tumbled across the diagnosis: Natalie has eclampsia! (It is also called toxemia of pregnancy.)

Many of you know about eclampsia. This is a dangerous impairment of brain bloodflow usually associated with high blood pressure (most of the time but not always!) There are no effective preventive measures for eclampsia. If high blood pressure develops it can be treated and perhaps this eliminates many potential cases of eclampsis. Chronic headache and edema-related weight gain are important warning signs.

Eclampsia can be dangerous to both mother and fetus. Up to 5% of affected mothers succumb. Half the time eclampsia occurs prior to labor and another 20% encounter it in the delivery room. That leaves approximately 30% of eclampsia cases emerging postpartum (no harm to the neonate obviously!) Natalie's problems started one month after delivery, longer than the textbook timeline of 14 days. Who cares? When it comes to House I stopped arguing medical facts long ago!

The subject now switches to truth-telling. Episode 511 (Joy to the World) was loaded with lies, half-truths and deceptions. Nearly every character was dishonest at least once during the program: House, Cuddy, Wilson, Taub, Thirteen, Foreman, Natalie, her classmates, Kutner, and many more. For example, had Natalie confided in her doctors at the time of admission that she had recently delivered a baby, the diagnosis of eclampsia would have emerged far sooner - perhaps in time to spare her life. Of course, that is the most egregious example but Natalie and House's team were doomed by many other untruths that amused and entertained the audience.

Here's a bonus observation. Did you notice that House, the embodiment of ethical medical practice, never spoke to Natalie, not even once? That's how I knew she was a goner. I'll look for that behavior in future episodes and see if a trend develops. It's just as well he kept silent. He probably would have lied to her anyway, perhaps by wishing her a Merry Christmas.

Related Topics:

• WebMD Video: What Is Pre-Eclampsia?
• Preeclampsia and High Blood Pressure During Pregnancy

This week's episode of House (#510: Let Them Eat Cake) offered a powerful lesson in human behavior in depicting the lengths an individual will go in order to preserve one's health - consciously and unconsciously.

Emmy is a weight-conscious fitness maven who keeps collapsing. As a result of her workup (and multiple incorrect diagnoses) the team discovers that Emmy had undergone previous gastric bypass surgery. In the past Emmy was obese and she loved sweets. She still does!

Late in Act II House declares that Emmy suffers from Hereditary Coproporphyria. This is a metabolic condition caused by a defective gene involved in blood protein synthesis. These patients can experience severe abdominal pain and such attacks can be reversed with a bolus (large dose) of glucose. Earlier in life Emmy managed her disease by overeating carbohydrate-rich foods.

Believe me, it's not worth nitpicking the rest of this episode. We already have enough with which to work!

Emmy discovered that sweets eliminated her pain. No medical degree was necessary. Intuitive patients learn on their own how to compensate for their symptoms:

• Young toddlers with cyanotic heart disease discover that they breathe easier when they squat


• Folks with acid reflux often swallow a spoonful of sugar after eating tomatoes


• Individuals with lactose intolerance shun dairy products


• Gentle rubbing of the eyes can lower the intraocular pressure during a glaucoma attack

The point to remember is whenever you observe someone exhibiting unusual habits, you have to ask yourself, "Are they trying to compensate for some kind of unsolved problem?"

Here's another great example. There may be 23 million diabetics in America but at least 8 million of them don't know it! All they know is that they are frequently thirsty, love to drink orange juice (quick source of glucose) and tend to urinate more often than others. From a medical perspective the classic symptoms of diabetes include: polydipsia (excess thirst), polyphagia (excess appetite) and polyuria (excess urination). Sure, it all makes sense, but the diabetic patient is unaware of these facts: they drink, they eat, they pee!

Emmy's situation was very similar. She compensated for her symptoms and bought herself some time. Then, when she weighted 300 pounds she again compensated by consenting to undergo gastric bypass surgery.

Okay, I lied! Here's one diagnostic nit to pick. Remember when House requested a stool sample from Emmy? Had House been thinking of Hereditary Coproporphyria at that point in the story the laboratory could've tested the feces for stool coproporphyrins. In affected individuals stool coproporphyrin levels are markedly elevated, usually 10-200 times greater than control samples.

House decided that the best treatment for Emmy was surgical reversal of her gastric bypass and plenty of carbohydrates. He also could have offered the patient some hematin. The key treatment of porphyria is stopping heme synthesis. Hematin provides negative feedback to the heme synthetic pathway and shuts down production of porphyrins and porphyrin precursors. I don't remember hearing anything about that treatment.

So, how do we compensate for the miserable way this case was managed?

No more House for Emmy and, come next September, no Emmy for House!

Related Topics:

• 5 Big Health Risks
• Interactive Tool: Are You At Risk For A Heart Attack?

One-hour fictional dramas and 30-minute sitcoms are the staple of broadcast television. Granted, every once in a while NBC airs a string of 45-minute 'supersized' programs to lure viewers into staying tuned to their lineup. Following that theory, the viewer is trapped at 8:45pm after a supersized 'The Office' with nowhere else to go! Ever hear of TiVo?

Sometimes TV programmers air a full-hour program without commercial interruption. That requires re-editing when it comes time to repeat an airing of the show (or eternal syndication) so that space is available for commercials.

Another network TV gambit was the 'cold open' at 58 minutes after the hour immediately following the previously concluding program - and I mean immediately! No commercial break, no previews, no promos. Bang! New show begins. The strategy here is that the new show launches so quickly that the paralyzed viewer cannot react quickly enough to escape. Meet my little friend, the remote control!

Fox Television tried something a little different with Episode 509 of 'House' (Last Resort). They programmed the show to run 68 minutes in its entirety. Again, they create an automatic carryover audience but, nevertheless, they will need to trim the story when it comes time for recycling.

I can easily help House's editors chop 8 minutes from this week's extended episode. It all has to do with neurologic problems that affect the eyes, the eyelids, and the face.

A desparate gentleman named Jason takes hospital personnel from Princeton-Plainsboro hostage in order to recruit Dr. House's services. During the assessment House and Thirteen observe a subtle droop to the left corner of Jason's mouth. They suspect Bell's Palsy. This is the eponym for weakness of the seventh cranial nerve, the Facial Nerve. The Facial Nerve is responsible for chewing and facial expression: closing eyelids, raising eyebrows, lip and facial movement. It has nothing to do with facial sensation...that's the job of the fifth cranial nerve, the Trigeminal Nerve.

So, what caused the Facial Nerve weakness? House suggests postherpetic neuralgia (PHN). This is a chronic pain condition following a bout of shingles (Herpes varicella zoster infection). Next, House wants to test his hypothesis by injecting capsasin. I got lost here because capsasin is usually prescribed as a topical pain reliever - you rub it on. It is used to treat PHN by temporarily overriding the pain signals from the PHN-irritated sensory nerves. With capsasin PHN sufferers feel heat instead of pain. Then, to top it all off, when Jason reacts to the pain of the capsasin injection House hastily eliminates "Peripheral nerve paralysis" off his list of possibilities.

I may have missed something, but House appears to have criss-crossed his wires and his nerves. The facial droop and PHN consideration only involved cranial nerves that come directly from the brain. Cranial nerves are very different from peripheral nerves that connect to the spinal cord. (There is nothing 'peripheral' about either the Facial or Trigeminal Nerves). Next, since PHN affects sensory nerves, there is no 'paralysis' involved. Injured sensory nerves experience impaired sensation (too much is hyperesthesia, altered is paresthesia, too little is hypesthesia, none at all is anesthesia.)

Let's summarize. The lid droop reflected a possible problem with the Facial Nerve. House suspected PHN involving the Trigeminal Nerve. Whereas both of these problems involved cranial nerves, House performed a test of peripheral sensation and ruled-out paralysis. Yikes! Get the scissors out and we can get this extended episode back to 60-minutes in no time!

Related Topics:

• Slideshow: Shingles Pictures
• WebMD Symptom Checker

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