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Chapter 8
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Cameron looked at her watch: half past three in the morning. The whole day went by in a blur of checking the scans and trying to find logical reasoning to substantiate her theory. It would be terribly impolite to call at such an hour, but House had never been the one to bother about pleasantries. On second thought, he could be with Cuddy now, and her call could interrupt… Cameron didn't want to go there. Anyway, he had meddled with her personal life with much more disastrous consequences; one call wouldn't do any harm.
"I was kinda busy, you know." He finally picked up. His voice sounded sleepy, so whatever he had been doing, it was over before she called.
"It'll take only a few minutes." Still, she hurried to justify herself, hoping that House wouldn't hang up on her. Then she heard the faint sound of his cane and later a barely discernible "thud" of a closing door, which meant that he had just limped into another room.
"I knew you'd be jealous, but didn't think you'd take it this far."
"Not everything is about you, House."
"Not what you said in my office while quitting." He sounded strangely serious, and Cameron wondered why he still couldn't let it go, he should have forgotten about her words, just like he always did, facing something uneasy. Meanwhile, House continued sarcastically: "It's good you're an atheist, otherwise you'd burn me in the inquisition flames for all my cardinal sins."
And here his deflecting appeared, just like she expected. Cameron composed herself, she had more pressing issues to deal with. Before she could start, he asked, as if reading her thoughts:
"So what are you shooting at: Lupus, antiphospholipid syndrome, Lyme disease, Guillain-Barré? And screw the symptoms, just cross them out."
"I think it's ADEM."
"Come again?" House was clearly surprised.
"Acute disseminated encephalomyelitis."
"I know what it is, Cameron." He sounded irritated, and then muttered. "You think… Sure you would."
"Why?" She gripped her cell, waiting for him to shatter her theory in pieces, which he started doing immediately:
"Because of all other options you had to chose something immune mediated, the least probable one, but with greater chances of recovery."
But maybe she needed this kind of challenge, if she could convince House, there would be a chance that she was right. At least she could try:
"It isn't impossible."
"He's 6o something, not 6."
"It does happen with adults."
"Less than 3% of cases."
"As if statistics ever mattered to you."
"But logic does. For starts, ADEM usually occurs after a viral infection or vaccination."
"The patient had the flu a week before the symptoms appeared."
"How come you're telling me this only now?"
"I've just got the full history."
"Well, it might be related, or might be not."
"Sure, and an increased white cell count is just an increased white cell count." She didn't mean to, but she almost perfectly imitated the sarcastic tone, which House had used asking her about the reason behind Sebastian's cancelled visit to Princeton. "And by the way, I mean it: there were increased lymphocytes in the spinal fluid."
"You must be an immunologist or something." Cameron could clearly imagine him smirking at this point. Meanwhile, House continued: "So it's still not enough. Once again, what was there about the second attack?"
"It happened three weeks after the first one. I think it was a relapse of ADEM, the timing fits."
"It seems to fit, here's the difference." House was silent for a moment and then said: "I know what you think: the first course of steroids wasn't enough, the idiotic docs overlooked it, discharged the guy and the relapse happened. But you still can't prove that it wasn't MS."
"No new attacks, no deterioration."
"Hate to say it about anyone but myself, but he's a lucky bastard. So far."
She suddenly had a feeling that House was disagreeing just to test her, trying to gauge her reaction. She needed him to concentrate on the case, not the puzzle of her obsession here. Cameron asked in frustration:
"You're refusing the diagnosis because it's impossible, or because it's me?"
"Not everything is about you." Cameron briefly wondered whether repeating and twisting each other's words would always be the defensive mechanism they both would use. House mockingly continued: "Astonishing, isn't it?"
"It's naïve and caring me. So I must be looking for something that isn't there, right? Just like with Cindy."
"Who?" House seemed genuinely surprised, small wonder, he hardly remembered the names of his patients. Let alone the name of the terminal cancer patient whose case he had refused to take, since it had been too obvious.
"Doesn't matter." She saw no point in reminding him how he had preferred to teach her a lesson then, in his own, abrasive way. In fact, much later, already working in the ER, Cameron had realized that he had done her a favor. She couldn't change herself and stop empathizing with her patients, but she had come to terms with the fact: there were things which couldn't be changed, sometimes acceptance was the only way. But now, with the threat of a loss affecting her personally, she couldn't come to acceptance, as long as there was still the slightest hope.
"What are you waiting for? My blessing?"
"Your opinion. You're still a diagnostician, remember?"
"You're pushing for autoimmune, seems like you've already made a choice."
"You aren't going to help, are you?" Cameron gripped her cell tightly; maybe it was a mistake to call him in the first place.
"Finally! You get it." He spoke these words with exaggerated relief. "You used to take hints better."
"Okay, sorry for disturbing you." She had a hollow feeling, while what was left of her good memories was shattering in a million of pieces. House had changed irreversibly; she was a fool for still believing otherwise. This case wasn't a puzzle good enough for him, her arguments…. Well, they were hers – too optimistic to be true. Cameron sighed: it was painful, almost like saying goodbye in his office.
A moment later his voice, still skeptical but moderately interested, pulled her out of these thoughts:
"What about demyelination? You wouldn't come up with ADEM if you didn't have other leads."
"That's the point." She felt a sudden relief. House finally started thinking about medical details rather than personal ones, the thrill of catching an elusive diagnosis always attracted him, after all. His question was reassuring, because she already had an answer:
"The scans I got were inconclusive, so I had them enhanced. Seems like it involves the superficial white matter, at the junction with the gray one."
"While MS should've affected the deep or periventricular white matter. Not bad." He seemed slightly impressed, then he paused, thinking over something. "But, ouch, you still have oligoclonal bands."
"They… rarely, but they might be present in ADEM. And the last test was conducted a year ago."
"And you think that they've miraculously resolved. You're a believer, Cameron." He seemed sarcastic, but no more than usual, which could be a good sign. "If you stick to your diagnosis," House sounded uncharacteristically serious, not a hint of mocking this time, and Cameron suspected that there would be either a final blow to her theory, or... She didn't dare to believe until she heard him say:
"Then go for it."
The funny thing was that only after his words Cameron clearly realized that she would have done it anyway, no matter what he would have said. She had matured as a doctor, after all. But this barely distinguishable encouragement was a relief, maybe the greatest one she had in the suffocating nightmare of the last several days. That's what she had been looking for: not his medical advice, but a glimpse of support, because she felt utterly lonely.
"I would've, anyway." She smiled. "No old lesions in the brain, only recent ones."
"An ace up your sleeve. Then why did you call?"
"Old habits, House, old habits."
"You know that a third of patients with ADEM do develop MS, right?" Apparently, House had to bring her back to Earth right now. Maybe it was his way of warning her not to get her hopes up so as not to feel the pain of disappointment later.
"I know." So far it was all she could master. She was aware of the fact, but preferred not to think about it.
"So even if you're right, it'll buy the guy just several years before everything turns ugly. He'll be older, so if MS develops at that time, the progress will be far more rapid."
"But there is a chance that it won't."
"Damn it, you're still the most naïve atheist I've ever met. Just so you know: it's easier to have a definitive answer instead of being stuck in limbo."
"Where did it come from?"
"ADEM will leave things up in the air, while MS gives a clear picture. A shitty one, but clear."
Cameron wondered whether he realized that he had just put into words a fundamental difference in their attitude to life, personal, at least. Taking chances and losing had been painful: her almost something with House and the failed relationship with Chase made it strikingly obvious, but she doubted that not taking a chance at all would have spared her any pain and regrets.
"What's so special about this case?" Apparently, House simply couldn't let it go.
Cameron knew very well that House didn't like being left out of the loop, even about something that was none of his business. Keeping him in the dark, she had managed to fuel his interest and curiosity, and he had listened to her arguments, even accepted some of them in his own way. Had he known that the patient was her father, he probably wouldn't have taken seriously her suggestion about ADEM, ascribing it to her desperation rather than logical reasoning.
"I tend to fall for lost causes, remember?" She could still need his help or advice if it turned out that she was wrong, so she had to keep him hooked somehow.
"Damn, you're good."
She didn't know what to answer, but House made a choice for her, preferring to turn the conversation away from difficult questions. There had been more than enough of them tonight. He said smugly:
"Not bad for the old fella: two threesomes in several days. Though I always pictured it in a different way..."
"What?" For a moment she had forgotten that House must be with Cuddy now, clearly, not in the same room at the moment, but in the same apartment for sure. Yet now even this dirty comment was strangely comforting, not due to its sense, of course, but because it was familiar – old habits do die hard.
"House, spare me the details."
"It's you who has such timing."
"Whatever. Thank you."
Cameron closed her cell. She didn't intend to go home, opting for another night on coffee instead. Anyway, she wouldn't be able to sleep until she found out whether her theory was right, or not. She spent the rest of the night, preparing all necessary materials and printing out research data to talk with Dr. Johnson first thing in the morning.
**
Cameron was hanging the MRI scans on the screen in the Dean of Medicine's office, as Dr. Johnson himself and Dr. Tyler, head of the Neurology department, were standing near her. This part of the office, created and equipped so that the Dean could properly study the details of a case before giving his consent for a procedure, was separated by the adjourning door from "the official space" where he received sponsors and other visitors. Dr. Johnson was looking through the results of the blood work and reports on the reaction to steroids administered to manage the attack.
"Dr. Tyler," Cameron asked the neurologists when she finished. "Could you come closer?"
"Sure."
When he neared the screen, Cameron pointed at the brain lesions on the MRI.
"They aren't old, I may be wrong, but they seem to be more or less of the same age."
"True. Though typically MS causes brain lesions before symptoms become obvious, so what we see here is unusual. But… other options that could fit were ruled out. There were oligoclonal bands in the spinal fluid, steroids worked, which proves the diagnosis. When was the second attack?"
"In three weeks, less severe, steroids once again." Dr. Johnson answered, checking the file.
"The timing between episodes can vary, there are no definitive intervals." Dr. Tyler shook his head. "Though most of my patients, especially at the first stages of MS, usually have larger intervals between the attacks."
"Or it could've been one attack, insufficiently managed and relapsed." Cameron tried to suppress her anxiety. "Then we don't have the required two episodes, and thus the red flag in diagnosing is out."
"Dr. Cameron, you know that all criteria are relative." Dr. Johnson seemed contemplative. "They chose a diagnosis, based on other symptoms as well, though I would've waited for a new attack to make sure."
"It's been a year and a half," Dr. Tyler was looking through the history, "almost complete recovery: sensory, motor functions, vision. No new episodes. But the patient experiences difficulties with the drugs: switched them several times. So, as for flu-like symptoms and headaches - the former can be a side-effect and the latter… in this case it can well mean a MS symptom. Yet still drugs work – no relapse and no deterioration so far. I would've expected MS to progress sooner."
"That's what doesn't fit. I know it seems unlikely, but…" Cameron took a deep breath and continued: "The patient had the flu two weeks prior to the attack, was put on steroids to manage the episode, a rather short course, as you see," she pointed at the line in the history. "Then, three weeks later, there was another attack, once again, managed with steroids. Since then- gradual recovery, almost no residual damage. Though the side-effects of drugs seem more prominent than usual."
Cameron nervously brushed away a strand of hair that fell from her ponytail.
"I think it's ADEM." She hurried to finish, before she would be interrupted. "Prior viral infection can cause an attack. ADEM is an immune reaction to the infection with the immune system causing inflammation in the central nervous system."
"And then the inflammation in the brain or spinal cord damages myelin." Dr. Johnson seemed to read her mind.
"MS exhibits demyelination of the deep or periventricular white matter. ADEM involves the superficial white matter, often at the junction with the gray one – that's what we see here." Cameron pointed at scans once again. "It's just more evident on the enhanced scans. As for oligoclonal bands, they're common in MS, sure, but in rare cases they might be present in ADEM. However, they usually resolve when ADEM resolves."
Cameron took a deep breath recalling her scattered cups of coffee and the lump of sugar, which had not dissolved in the lukewarm liquid. "Dissolve-disappear- resolve" - that was a strange, unexplainable association, but that's what had set her thinking. She went on:
"The patient hasn't had any tests after he was discharged. A lumbar puncture might show that they had resolved. As for the second attack, I guess that the first course of steroids wasn't enough, so they dealt with a relapse of ADEM. And… you've seen that there are only recent lesions."
"ADEM lesions tend to gradually improve over months." Dr Tyler was scrutinizing the MRI brain scan once again.
"But no new MRI has been done so far, thus it's possible that they have improved."
"If we do new MRI scans and see that lesions have improved," Dr. Tyler said, "then we will need new lumbar puncture to check oligoclonal bands. If the results are inconclusive, well, then a brain biopsy might also be necessary to make absolutely sure that we're dealing with ADEM."
"ADEM is more common with children, and very rare with the patients of this age group, you know it that, right?" Dr. Johnson asked, looking at her sympathetically.
Cameron crossed her arms over her chest as she answered:
"Yes."
"You remember that ADEM can well progress into MS?"
"Yes."
"And you also know that most cases of misdiagnosing ADEM for MS happen with adolescent patients. So, for a patient over 60, it's nearly impossible."
"Yes." She could be proud of herself: her voice didn't even falter, although she felt the tightening in her throat.
Dr. Johnson nodded.
"I needed to make sure you know the odds. Refer the patient here for a checkup, we'll run the tests."
"Thank you."
**
I once again sincerely apologize for any medical inconsistencies you can find in this chapter.
ADEM usually occurs following a viralinfection but may appear following vaccination, bacterial or parasitic infection, or even appear spontaneously. ADEM is a diagnosis that falls, along with MS, under the category of inflammatory autoimmune disease of the CNS. Therefore, its signs and symptoms may appear very similar to, if not indistinguishable from, MS. What is important about distinguishing ADEM from MS is not so much the immediate medical management, since ADEM is also treated using intravenous steroids, but in the prognosis. ADEM is only a single neurologic event without progressive and recurrent symptoms and, therefore, can have a much more favorable long-term prognosis. Approximately 25% of the ADEM cases, however, are actually the beginning of MS.
Thanks to all my readers for following the story and reviewing it. Reading your comments makes my day. I sincerely hope you will further enjoy the story.
