Instant Karma (House)

Wealthy businessman Roy Randall ends a meeting partway through and checks on his ill son Jack. Jack's doctor says his diagnosis was wrong, and recommends Jack be taken to the hospital. Roy wants House to work on the case, which Cuddy eventually agrees to, with the patient officially belonging to Foreman but House leading the team. House decides to start off by completely re-analyzing Jack's history and symptoms. Cameron does a physical on Jack; she notices that Jack feels no pain when she presses his belly, and from x-rays, deduces that he's constipated. Foreman diagnoses Hirschsprung's disease. They do a barium enema and a biopsy to confirm.

Over the course of over a week, x-rays show Jack's colon is clear. Cameron checks Jack's belly and says while it feels better, it appears larger. Just then, Jack's right eye fixes (lateral rectus palsy) and he seizes. They give him diazepam for the seizure. Foreman sees Jack's optic disc is swollen, indicating intracranial hypertension. They give him furosemide and phenytoin to relieve the pressure but it does nothing so they rush him to the O.R to relieve the pressure before Jack's brain herniates and he has irreversible brain damage. They paralyze him for the procedure with pancuronium, and manage to relieve the pressure and stop the seizures, but he continues to build up fluid in his abdominal and dural cavities. Foreman notices the shape of the fluid collection is odd, House recommends they do a dural biopsy to confirm brain cancer.

Meanwhile, Cuddy asks House and Chase to present the Dibala case, which unsettles Chase. Foreman and Chase go over the presentation, making sure they're covering all the evidence. Foreman is apprehensive about the situation, and House overhears him as he urges Chase to be careful, although the two deny any wrongdoing. Later, Foreman discovers that Chase neglected to check Dibala's cholesterol, which was off by 20%. Chase is left unsettled, which Cameron notices. Chase admits to her that there is a problem with the figures on Dibala's blood panels.

Meanwhile, House finds Thirteen making travel plans, not intending to return to the hospital. They discuss her relationship with Foreman, and say good-bye to each other. Thirteen later finds he flight reservation got cancelled. She angrily confronts House, accusing him of spying on her and cancelling her reservation to get her back on the team. House claims Foreman is working much better without her, and that he doesn't want her back. House later accuses Foreman of canceling Thirteen's reservations, which he denies. House tells him he will be a good boss.

Chase and Cameron tell Roy that Jack might have early brain cancer. Cameron wants to help with the biopsy but Chase tells her to stay home and rest, and that he will wake her up when he gets back. Chase and Foreman continue going over the Dibala case, not knowing how to solve the cholesterol problem. Cameron arrives and tells them Jack's biopsy results came back negative. House suggests adenocarcinoma of the stomach, which would cause all Jack's symptoms and not show up on the CT. Chase and Cameron scope Jack and get another set of biopsies.

Roy tells Cameron he inherited a business and made major deals until he was very rich. He says everything he touches turns to gold except his family. Having lost his wife, and now presumably his son, he believes it is karma. Just then, Jack starts to seize again, but the readouts show it is not intracranial pressure. There are no signs of masses in Jack's stomach or esophageal lining and he's still accumulating subdural and peritoneal fluid. House notes that Jack seizes every time they try to look at something and rules out cancer. Chase suggests a drug-resistant strain of an infection, but all the tests have been negative. Cameron suggests abdominal epilepsy. The seizures would look like pain and protein malnutrition would cause fevers. It is their best theory, so they start him on gabapentin. However, Jack's EEG shows no interictal spikes, ruling that out, and he has a rash on his chest.

Chase talks with Foreman about Dibala's case. He says he could have 'prescribed' statins and simply forgot to chart it. Foreman figures Chase is going to accuse the pharmacy of bad bookkeeping but Chase suggests they say he just went up and took it out. Foreman walks away and says he'll handle it. He tells Cuddy that he can't do the Dibala presentation, being busy with Jack's case and that House is pawning his responsibilities onto him. Cuddy reminds him they're Foreman's responsibilities, and insists he present the case.

The team reviews the symptoms: fever, stomach pain, seizures, peritoneal and subdural fluid collection and a rash. Cameron notes that if it is not cancer or infection it has to be autoimmune. Chase says polyarteritis nodosa. House tells them to start Jack on prednisone and get a testicular biopsy – if Jack has any real inflammation, it will be down there. Foreman asks Cameron to do it, and orders Chase to over-prep for Dibala's presentation. House asks if the rash is on Jack's penis. It is, meaning it is most likely affecting the small blood vessels which explains why they did not see any inflammation on the biopsies. He says it is Degos disease, and informs Roy that it is incurable. Roy insists House is wrong, but House rechecked all the biopsies. Jack has a day at most.

House sees Chase agitated in the differential room. Chase goes to Cuddy's office and starts to confess the truth, but they are interrupted. Cuddy is called to pediatric ICU by a bunch of lawyers, but urges Chase to come clean. In Jack's room, Roy insists that Jack's disease is the result of karma, and believes if he gets rid of everything he has, it'll help Jack. The lawyers and Cuddy try to dissuade him, but fail. Roy signs the paperwork to divest himself of his business. As Roy's lawyers exit the room, Jack flatlines.

Cuddy tells House Thirteen accused someone of hacking her email and cancelling her reservations, and suspects Foreman. Cuddy wants to know if House believes Foreman should be in charge. House defends Foreman and urges her to keep him in charge. Thirteen later shows up at Wilson's office, claiming she had the techs chase IP addresses to and found that Wilson had entered her account. Wilson admits he did it, claiming House needs someone who keeps his ego in check. He urges her to stay and not throw her job away due to a bad breakup. Thirteen bids Wilson farewell and leaves.

Wilson later confronts House, who admits that it was he who did it, wanting Thirteen to stay. House has an epiphany during the conversation, and goes to Jack's room, telling Foreman that the cardiac arrest was a coronary event, meaning Jack's coronary vessels were obstructed, which can't be from Degos. He says it is primary antiphospholipid syndrome and tells him to start Jack on heparin and IV immunoglobulin. House also says that when Thirteen is not over him.

Chase finds test results sitting on Dibala's file. They show that one of Dibala's doctors prescribed niacin-bound chromium supplements to increase the HDLs. Neither Foreman nor Chase requested the information, which means someone else knows. The next day, House learns that Roy declared bankruptcy. He stops by Jack's room, and Roy tells House, "It worked." House denies that it was karma, and leaves. Chase confronts House, who admits he found out about Dibala and is now covering for them. Chase tells House that he'll always be in charge whether he wants to be or not.

Cameron wakes up alone in her bedroom, and is upset that Chase is gone again without telling her. Foreman presents the Dibala case with Chase in the audience. Meanwhile, Thirteen arrives at the airport and boards the plane to Thailand. Roy and Jack share a pizza. House sits in his office lounge chair.

• "Fire Escape" by Fanfarlo – Plays in the cafe where House meets Thirteen
• "Sarah" by Ray LaMontagne – Plays at the end of the episode.

• Dural tail sign of meningioma

• "Instant Karma" at IMDb