By a strange coincidence, two leading medical journals have published case studies of the same arcane medical mystery. In one, doctors solved the riddle only after the patient got so sick she had to have a heart transplant. But in the other, a physician who teaches at the University of Marburg in Germany found the clues in Season 7, Episode 11, of the Fox television show House.
It turned out that Dr Gregory House, the cantankerous, fictional diagnostician modelled on Sherlock Holmes, had used his powers of deduction to diagnose the very same ailment in a woman played by actress Candice Bergen on an episode that aired in 2011.
In this case of life imitating art — or at least TV — a paper in The Lancet, a London-based medical publication, described how an ailing man in Germany had gone from doctor to doctor, seeking a diagnosis. He had low thyroid hormone levels, inflammation of oesophagus and fever, and he had gone almost blind and deaf. Most perilous of all, his heart had weakened so much it could not pump blood hard enough.
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Finally, in May 2012, the man, then 55, arrived at a University of Marburg clinic run by Dr Juergen R Schaefer, who specialises in puzzling cases and happens to be a major fan of House. In fact, Schaefer uses House in teaching medicine, and he realised his patient’s symptoms were eerily similar to those of Bergen’s character. House’s diagnosis: cobalt poisoning from her artificial metal hip.
Schaefer’s patient had had an artificial ceramic hip that failed, and it was replaced with a metal one in November 2010, shortly before his symptoms began.
Schaefer tested the man’s cobalt level and discovered it was 1,000 times the level considered normal.
A scan showed the metal in his hip was eroded. The reason, Schaefer speculated, was that when the man’s doctor removed the broken ceramic hip, he inadvertently left behind tiny particles of ceramic. Those particles, Schaefer said, acted like sandpaper.
The man had his metal hip replaced with another ceramic one, after which his cobalt level plunged. His heart function improved, but he still needed a defibrillator implanted. His fever and oesophagus problems went away. But his hearing and eyesight barely got any better.
Needless to say, the doctors in the other case, published in The New England Journal of Medicine, had not seen that episode of House.
The patient, a woman in Denver, said she began feeling ill on a vacation in Hawaii a few years ago. “I was tired all the time,” she said. When she returned from her travels, she discovered she had gained 10 pounds on her 4-foot-10, 95-pound frame. Her abdomen was swollen, as were her arms and legs.
Her doctor ordered a CT scan, which showed fluid accumulating around her heart. He drained the fluid, but she still felt ill. Normally, someone with such a condition has an enlarged heart, but hers was a normal size.
By 2011, her heart was failing. She went to the Anschutz Medical Campus of the University of Colorado, Denver, where her doctor, Larry A Allen, a heart failure and transplant specialist, confessed he was baffled.
On September 10, 2011, she underwent a heart transplant.
Sometime later, the orthopaedist who had replaced her hips with metal implants took some routine blood tests and found something curious. Her cobalt level was more than 300 times normal. The cause of her problems was suddenly clear.
About a year after her heart transplant, she had both artificial hips replaced with ones that had a polyethylene liner. Her postoperative course was rocky, but her cobalt level declined.
In their article describing the case, Allen said however rare cobalt poisoning might be, it is something to consider when people with metal-on-metal hip implants have symptoms suggestive of it.
“Unfortunately,” he added, “I have seen about two half-episodes of House.”