This is part of our House MD Project series.

Click here to read the connection to the episode (spoiler alert!)


On episode 19 of season 7, called “Last Temptation”, a 16 years old patient named Kendall Pierson collapses while embarking on a boat trip. Later her hand turns blue while running on a treadmill and her pineal gland is found to be calcified. Later she collapses due to a hypertensive crisis. An MRI of her arm discovers that she has a tumor called lymphoid sarcoma in the arm. As hard as we tried, we couldn’t really find enough data about lymphoid sarcoma. Seems the writers went a little too rare with the disease, or that a more likely diagnosis is in place here: osteosarcoma.

Photo by NBCUniversal

Danger level: High

What is it?

Osteosarcoma is the most common type of bone cancer is children.

Who gets it?

In the United States, about 400 children  and adolescents (under age 20) are diagnosed with osteosarcoma each year. 

It’s a little more common in black people and in males. It’s also more common as a child ages – quite rare under the age of 5, but becoming more common towards age 20 (it’s more common at the age when a child is growing faster).

What causes it?

The exact reason for the development of osteosarcoma isn’t known. There are, though, some risk factors which increase a child’s risk of developing the tumor:

1. Rapid bone growth: As mentioned above, at times when the child grows faster, their chances of developing an osteosarcoma increase.
2. Exposure to radiation
3. A genetic problem: For example, children with retinoblastoma (more on that in a future post) are more likely to develop osteosarcoma. (other genetic diseases associated with it include Li-Fraumeni syndrome, and Rothmund-Thomson syndrome – more on those in the future).

How does it feel?

Any bone may be involved in the disease, but it’s more common in areas of bone which grow faster, such as the end of the thigh bone, the beginning of the shinbone, or the beginning of the arm bone.

Usually the child will feel pain in the area, and a swelling may also be felt there. Sometimes the child may limp as a result of the pain.

How is it discovered?

Usually an x-ray is performed first on the area. It will show an area of destroyed bone (called in medicine a “lyric lesion”). An example for that can be seen in this x-ray.

Photo by bc the path

In order to diagnose osteosarcoma for sure, a piece of the bone is needed (a process called a biopsy). It is then looked at under a microscope. This is how it looks:

There are many types of cells in this picture, which we can’t explain here. There is also a clear pink area, created by the tumor. Photo by Nephron.

CT and/or MRI are usually also needed, to see if the tumor has spread to other areas in the body (it tends to spread to the lungs and to other bones).

How is it treated?

Osteosarcoma is usually treated with chemotherapy, after which surgery is performed, which either removes the tumor or involves an amputation of the limb in which the tumor exists (like the case on the House episode). After that, more chemotherapy is usually used.

What happens after treatment?

The most important way to answer that depends on whether the tumor has spread to other areas, a fact which worsens the outcome.

About 60-70% of children with a tumor that hasn’t spread are cured thanks to treatment. Those with metastasis have a worse outcome – only 30-35% of them will survive.

There is currently no known way to prevent osteosarcomas.

The following video is about Bianca Bresadola, who died of osteosarcoma. May she rest in peace.

Related posts:

1. Neuroblastoma – The Most Common Cancer in Infants
2. Paget Disease of Bone – Bone Deformity For An Unknown Reason
3. Necrotizing Fasciitis Revisited, Osteosarcoma, and Aneurysms – (As Seen on House MD)

On Thursday’s episode of Grey’s Anatomy, a girl with no cheek bones needed a surgery so that she could start playing sports without the fear of getting her face harmed. The girl had a syndrome called Treacher-Collins syndrome, explained below.

Danger: Medium

What is it?

Treacher-Collins Syndrome (TCS for short), also called mandibulofacial dysostosis, is a rare genetic disease causing deformities in the facial bones of our skull, such as absent cheek bones.

Who gets it?

TCS is rare. It happens in 1 out of 40-70,000 births.

It is genetic, and in 40% of cases runs in the family, meaning that the child inherits the defective gene from one of the parents in 40% of cases. The other 60% don’t depend on the parent, and the defective gene appears for the first time in the child.

What causes it?

When a fetus develops, its organs have many phases along the way to becoming adult organs. An example for that are the pharyngeal arches, grooves, and pouches. These are all structures that exist only in the fetus, while it’s developing in the womb. They develop slowly during pregnancy into adult organs.

For example – there are 6 pharyngeal arches, each developing into different organs or organ parts in our body.

A developing fetus. Three of the pharyngeal arches are labeled below (mandibular, hyoid, third).

In TCS, there’s a problem with growth of organs that derive from the 1st and 2nd arches (and grooves, and pouches) which are responsible for growth of structures in our face.

How does it feel?

Most people with TCS have underdeveloped facial bones, especially cheek bones, and a small jaw and chin (this is called micrognathia).

Sometimes an opening in the roof of the mouth can occur, called a cleft palate.

In severe cases, it may impair the baby’s airways and be life threatening.

In terms of appearance, people with TCS have eyes that slant downward, sparse eyelashes, and a coloboma, which is a notch in the lower eyelids. There can be other eye abnormalities, causing loss of vision.

The ears can also be affected and be absent, small, or have an unusual shape. This can also lead to hearing problems.

Here’s an example – this video is from a girl with TCS -

How is it discovered?

The looks of a child with TCS help diagnose the disease. The set of features unique to the condition help the doctor come at the correct diagnosis. Also, genetic testing can be done to see if the child has the defective gene.

If the doctor is in doubt, an facial image using x-ray or a CT scan can be used to help with the diagnosis.

How is it treated?

Plastic surgery can be used to treat certain deformities in the face (on Grey’s Anatomy, a bone graft was used to give the girl cheek bones).

Other things are also done to aid other problems that come with the disease, such as hearing aids for hearing loss, or help with breathing if the disease involves the airways.

What happens after treatment?

Children with this syndrome usually grow to become normally functioning adults. It’s important to address any hearing problems, so that the child can perform normally in school.

If there is a history of TCS in the family, genetic counseling may prevent the birth of a child with the condition.

You can learn more about the condition by reading the Reflections on Treacher-Collins Syndrome blog, written by Amie.

Related posts:

1. As Seen on Grey’s Anatomy – Tethered Spinal Cord Syndrome
2. Superior Canal Dehiscence Syndrome – Hearing Sounds Inside Your Own Body (As Seen on Grey’s Anatomy)
3. Osteoporosis – How Your Bones Can Get Thinner With Age And What You Can Do To Avoid It

This is part of our House MD Project series.

Episode 21 of season 1, named “Three Stories” is not a usual episode. Instead of the usual one patient story (and the occasional clinic patients), this episode tells 3 short stories (as its name implies). Each patient presented with a different disease. Since this episode was presented differently, so will this article digress from the usual presentation. The 3 diseases on that episode will be covered here in brief.

Disease 1 – Necrotizing Fasciitis

This long name means simply an infection by what is known as the “flesh eating bacteria”.

On the House episode, a 40 year-old farmer arrives at the hospital claiming he was bit by a snake. After an anti-venom doesn’t help him and his leg’s muscles begin to rot, it is found out he was actually bitten by a dog, a bite that infected him with a germ called streptococcus.

We already covered necrotizing fasciitis in the past and you can read all about this disease here:

Necrotizing Fasciitis (Flesh Eating Bacteria) – Are You at Risk, and How You Can Avoid It

Disease 2 – Osteosarcoma

update: We now have a complete article about osteosarcoma, if you’re interested to know more details

The 2nd patient is a 16 year-old volleyball player arriving at the hospital after what seems like a strained ankle. After some trial and error it is found she has osteosarcoma, a cancer in the leg of thigh.

Osteosarcomas are the most common malignant bone cancer in children (along with a cancer named Ewing sarcoma). The cause is unknown. In the US, about 400 children and adolescents younger than 20 years old are diagnosed with osteosarcoma each year. It most commonly affects adolescents.

The disease presents with pain in a bony site. A mass may be palpable in the area as well. X-ray image of the area can discover the tumor. A biopsy from the area is needed to make sure it’s osteosarcoma.

An x-ray picture of an osteosarcoma of the arm. Photo by bc the path

Before chemotherapy, osteosarcoma used to be treated with amputation alone. Today chemotherapy is used along with surgery which can cut the tumor. Sometimes amputation is still needed, as was seen on House.

Disease 3 – Aneurysm

The 3rd patient is actually Dr. House himself, telling the story of how he got his leg pain to begin with. Turns out he had an aneurysm in the artery of his leg which wasn’t diagnosed on time, leading to blockage of blood to his leg’s muscles, which led to muscle death.

An aneurysm is a dilatation of an artery. The chances of getting it increase with age (it happens to at least 3% of people older than 50). Most aneurysms don’t cause any symptoms and go unnoticed. As they progressively enlarge, though, they may cause symptoms as a result of compression of the surrounding area, of clogging, sending a blood clot, or rupturing.

In the case of the House episode, his leg aneurysm clogged with a blood clot. This led to blood not arriving to his leg muscles, causing muscle death.

Related posts:

1. Osteosarcoma–The Most Common Bone Cancer in Children (As Seen on House MD)
2. Necrotizing Fasciitis (Flesh Eating Bacteria) – Are You At Risk, and How Can You Avoid It
3. Acute Intermittent Porphyria Revisited (As Seen on House MD)

This is part of our House MD Project series.

Click here to read the connection to the episode (spoiler alert!)


On episode 20 of season 1 (called “Love Hurts”)  a guy named Harvey Park comes to the clinic and suffers a stroke after House yells at him. His CT scan shows death of brain tissue. Deciding the stroke (which caused the brain death) was due to a blood clot, the team start to make assumptions as to where that clot came from . Turns out it came from an infection in his jaw, called osteomyelitis. Infected tissue from the jaw broke off, clogged an artery, and thereby blocked blood supply to the brain.

Danger level: High

What is it?

Osteomyelitis (OM) is an infection of the bone.

Who gets it?

Osteomyelitis isn’t very common: it happens to about 2 out of every 10,000 people.

It occurs mostly in young children and older adults, but it can affect anyone.

Osteomyelitis is an infection of bone. Photo by an untrained eye.

It’s more likely to occur in these people:

1. People with diabetes, sickle cell disease, HIV or AIDS, Rheumatoid arhritis

2. People who abuse alcohol or IV drugs

3. People who use steroids for a long time

4. People who are after a severe bone fracture or bone surgery

What causes it?

When a bone becomes infected, its inner part (the bone marrow) becomes swollen and presses against the rigid outer wall of the bone. That also presses the blood vessels in the bone, cutting the blood supply to the bone. Without it, bone simply dies.

The dead bone (called sequestra) is difficult for the body to cure, since its protective cells usually use the blood to reach places of infection.

How does it feel?

Acute osteomyelitis (acute because it can also become a long term condition, called chronic osteomyelitis) develops rapidly over a period of 7-10 days. Symptoms include:

• Fever, fatigue, irritability
• Nausea
• Tenderness, swelling, warmth and redness around the area of infection
• Lost range of motion of the involved extremity

If it happens in the vertebrae it can cause back pain.

How is it discovered?

On X-ray changes typical for osteomyelitis may show, but it may take them a few weeks to show up. CT and MRI can also be used, but they can’t make the diagnosis since what you see there may be seen in other types of bone problems.

An image showing osteomyellitis in the vertebral column. Photo by Nuclear Fire

Bone scans (images of bone taken after injecting a radioactive substance into the body) will almost always show a problem.

The doctor may take a sample of blood, pus, joint fluid, or the bone itself to diagnose infection to the bone and the germs causing it.

How is it treated?

Antibiotics are usually used to treat OM. Depending on the severity of the infection, they may be given directly to the vein at first but can be given by mouth later. Usually treatment takes weeks (between 4-8).

Sometimes surgery is needed to clear the infected area.

What happens after treatment?

With early and proper treatment, the condition usually goes away. There can be complications, though, such as an abscess (like the one on the House episode, causing the foul breath in the patient).

In some cases, the disease can spread to a nearby joint, causing an infection in the joint. If OM happens in children, it may impair their growth afterwards. The condition may also lead to skin cancer in the area of the infection.

People with artificial joints or metal components attached to a bone should take preventive antibiotics before surgery since they may be at increased risk of infection from bacteria normally present in the mouth and other parts of the body (In the House episode the patient had an artificial jaw that got infected).

Related posts:

1. Osteoporosis – How Your Bones Can Get Thinner With Age And What You Can Do To Avoid It
2. Treacher-Collins Syndrome – Being Born Without Cheek Bones (As Seen on Grey’s Anatomy)
3. Necrotizing Fasciitis Revisited, Osteosarcoma, and Aneurysms – (As Seen on House MD)

Danger level: Medium

What is it?

Osteoporosis (the word is in Greek: “Osteo” means bone, and “porosis” means holes) is a condition in which bones become thin and weakened, which makes them susceptible to fractures.

Who gets it?

About 10 million people in the US, and 200 million people worldwide have osteoporosis. One in 3 women and one in 5 men over the age of 50 will experience fractures as a result of osteoporosis.

White people (especially of northern European origin) as well as Asians are at an increased risk. The condition is also more common in women – 4 times more common.

In terms of age, osteoporosis occurs in women after menopause, meaning it’s most common in women in the ages 50-70. Another form of osteoporosis, called senile osteoporosis, isn’t related to menopause and can happen to both men and women, usually after the age of 70.

On top of all of those, there are a few risk factors, which can put you at risk of developing osteoporosis:

1. A family history – Osteoporosis runs in families. If you have a parent or sibling with osteoporosis you are at greater risk of developing it yourself.
2. Your build – Men and women who are very thin or have small body frames are at a greater risk (since they have less bone to begin with).
3. Smoking – Osteoporosis is just one of the many perks you get when you smoke.
4. Excessive drinking – Excessive drinking of alcohol interferes with the body’s ability to build bone.
5. A sedentary lifestyle – Exercise accelerates the process of bone building. Not doing it raises your risk for osteoporosis.

What causes it?

Our bones aren’t stagnant. A process called bone remodeling is always at work, in which new bone (made of minerals like calcium) is formed and old bone is broken down. Early in life (up until our mid 30s or so) this process is even – the amount of bone that is breaking down equals the amount of new bone being formed. At that time, though, the breakdown starts to outpace the building process. This causes the bones to become thinner.

During that time, though, this process isn’t significant.

In women, around age 50-60, menopause occurs. This is the time when the body stops producing the hormone estrogen. As its levels drop, bone loss increases dramatically. This doesn’t mean it doesn’t happen to men, but the process in them is slower, so the disease happens at an older age.

Our bones get thinner and are at a risk of breaking when we reach a certain age. Photo by BillRhodesPhoto.

How does it feel?

In the early stages of the disease usually there are no symptoms, but when fractures start to occur, the symptoms begin. Most of the fractures in osteoporosis occur in the spine, hip or wrist. Symptoms which appear when the fractures occur include:

1. Back pain – Due to fractures in the vertebra.
2. Loss of height, and an accompanying stooped posture
3. The fractures themselves – Which are disabling.

It’s important to note that since the bones are so brittle in this condition, you don’t need a lot to happen in order to have a fracture. Even mild stresses like bending over, lifting a vacuum cleaner or coughing can cause a fracture.

This video explains it:

How is it discovered?

A special x-ray picture called dual energy X-ray absorptiometry (DEXA) is used to detect if you have osteoporosis. It measures the density of bones in the spine, hip and wrist (the areas most involved in the disease). You should consult you doctor about taking this test if you’re a woman and you’re older than 65, post menopausal or have any of the other risk factors mentioned above.

How is it treated?

There are a few ways to treat osteoporosis:

1. Medications – A group of drugs called bisphosphonates are the most common drugs used to treat osteoporosis. They inhibit the process in which bones are broken down, thereby slowing the disease process.
2. Calcium – Since calcium is a mineral used in building bone, supplementing with it is one of the treatments for osteoporosis. In order for calcium to absorb better in the body, you should also take vitamin D.
3. Exercise – Doing aerobics, weight bearing exercises and resistance exercises help in the building of new bone and the slowing down of the disease.

What happens after treatment?

It’s important to not reach a stage when the fractures occur. Hip fractures, for example, can lead to complications (such as deep vein thrombosis and others), and can lead to major disability and even death.

If you do adhere to the treatment, though, you will most probably die with the disease instead of from it.

The bottom line – How do I avoid it?

1. Exercise – It’s recommended that you get at least 30 minutes of exercise each day to strengthen your bones and prevent osteoporosis. Exercise stimulates your bones to create new bone. Examples of exercises you can do include aerobics, climbing stairs, dancing, jogging, running and walking.
2. Get enough calcium and vitamin D in your diet – Not getting enough calcium will cause your body to break down bones (which contain it) when it needs it. Eating low-fat or fat-free dairy products and other calcium-rich foods, or even taking calcium supplements, can help prevent osteoporosis. Since vitamin D helps the body absorb calcium, taking it is also important.
3. Quit smoking
4. Don’t drink too much alcohol
5. Don’t drink too many soft drinks – Especially cola drinks, since the extra phosphorus in them binds with calcium and prevents it from being absorbed in the body.

Know any tips of your own to prevent osteoporosis? Share them in the comments.

Related posts:

1. Osteomyelitis – How Your Bones May Get Infected (As Seen on House MD)
2. Paget Disease of Bone – Bone Deformity For An Unknown Reason
3. Treacher-Collins Syndrome – Being Born Without Cheek Bones (As Seen on Grey’s Anatomy)

Danger level: Medium

What is it?

Paget disease is a condition that affects the growth of bones, causing them to be enlarged and deformed.

Who gets it?

In the US, Paget disease affects 3-4% of people older than 40 (it’s uncommon before age 45). It’s more common in African Americans (and rare in Asians).

Paget disease is almost twice as common in men than in women.

What causes it?

Even though we all know bones as hard, rigid and unliving things, they are actually a living tissue like any other tissue in our body. They constantly grow and break down. Cells in the bones named osteoblasts are responsible for growing the bone, while cells called osteoclasts are responsible for breaking it down, so that in the end the result is an even bone.

In Paget disease, this breakdown of bones is faster than normal, and to keep up with it, the body builds bone much faster. The problem is that the new bone which was built in such a hurry is weaker and more brittle, which causes it to break more often. The bones which are most involved in the disease are those in the pelvis, the spine, the skull, the arms and the legs.

The cause for this phenomenon is unknown. It might be related to a genetic cause or to viruses.

Paget disease affects the bones. Photo by D’arcy Norman

How does it feel?

Most people don’t feel anything. When they do, the symptoms have something to do with the defective process in the bones:

1. Pain – It can develop from a bone that’s affected by the disease or from complications such as inflammation of the joints (arthritis).
2. Fractures – Since the new bone that develops in the disease process is weaker, fractures are more common.
3. Deformities in the bones – When the bone breaks down and builds up properly, the new bone that forms is even. In Paget disease, the new bone doesn’t grow naturally, and so it’s distorted or deformed. For example, the legs may get a bow shape or the skull may be bigger.
4. Related problems – The growth of bone in the skull can cause things related to its location – such as problems with hearing, since the new bone presses on a nerve. When it’s near the spine, it can cause weakness. And so on, depending on the area where the disease is.

How is it discovered?

Usually, since most people have no symptoms of the disease, it’s discovered by chance when you go to a doctor for a different reason. There are two ways to discover it:

1. By an X-ray image – The thickening or deformity of the bones will be seen. You can see an example of such a deformity here.
2. By a blood test – The cells responsible for bone creation (osteoblasts) produce an enzyme (a molecule that’s responsible for reactions in the body) called ALP. Since these cells work overtime, the level of this enzyme will be high.

How is it treated?

The main treatment is with drugs called bisphosphonates – they inhibit the osteoclast cells, which in turn inhibits the breakdown of the bone. Another treatment are pain killers.

If a joint was affected by a nearby disease, a surgery might also be needed to replace the joint.

What happens after treatment?

If treatment is started before any bone deformities occur, the outlook is usually good.

In less than 1% of people with Paget disease, tumors of the bone might develop with time (both cancerous and noncancerous).

The bottom line: How do I avoid it?

There is no known way to avoid it. You can, however, avoid the complications by taking the treatment.

Related posts:

1. Multiple Myeloma – Bone Marrow Cells Taking Over
2. Graves Disease – Why Some People Are Hyperactive For A Reason
3. Osteosarcoma–The Most Common Bone Cancer in Children (As Seen on House MD)

Danger Level: Low

What is it?

Osgood-Schlatter is a disease that causes inflammation and pain in the knee.

Who gets it?

Children who are physically active, around the ages of 10-15 (especially in sports). It used to be more common in boys for that reason, but as girls are more active in sports, they also get the disease.

It usually happens at a period when the child has a growth spurt – the time when bones are lengthening fast.

What causes it?

The muscles in the front of our thighs are called the quadriceps. They are attached to the bones in our knees by a tendon called the patellar tendon. When there is a growth spurt, the repeated pulling that happens on the tendon when doing sports causes stress on the knee bones.

This causes tiny fractures in the bone and an inflammation, which causes the bone to swell.

How does it feel?

The knee hurts during activities, and is swollen and sensitive to touch. The pain eases when you rest and gets worse during activities.

How is it discovered?

Usually the story and looks of the knee are enough. Sometimes, when not certain, the doctor will take an x-ray picture of the knee, which will show that the knee bone is enlarged or has broken into fragments. Here’s an example:

The arrow in red shows the consequence of the disease (Photo by Lucien Monfils)

How is it treated?

The treatment consists of rest and things that lessen the pain, such as ice packs or drugs that relieve pain or inflammation.

What happens after treatment?

Usually within a few months the disease goes away.

Obviously, if you don’t participate in sports your chances of getting Osgood-Schlatter are much lower. But, as you can see in the danger level above, and in the fact that this condition usually goes away by itself, it is not recommended to refrain from sports.

Related posts:

1. Kawasaki Disease – A Childhood Disease That Can Endanger The Heart