Hannah Ward lies in bed, unable to sleep, next to her girlfriend, Max. Hannah has had many sleepless nights. In the morning, Max finds Hannah in the bathroom next to an empty bottle of sleeping pills. Her eyes are wide open and she's banging her head against the wall.
Cuddy wakes House from a nap to inform him of Hannah's case. He is disinterested until he learns that Hannah hasn't slept in ten days. The brain shuts down without REM sleep. Five sleepless nights would bring on insanity with ten causing death. Cuddy points out that the longest anybody has ever survived without sleep is eleven days. On top of that, Hannah downed an entire bottle of sleeping pills with no effect. House is intrigued.
The team dismisses infection, schizophrenia and drugs as a root cause for Hannah's sleeplessness. House wants them to consider optic nerve disease because sleep is initially controlled by external light cues. Hannah's brain might not be able to interpret or receive those clues due to an optic problem.
In a soundproof sleep lab, Cameron photographs Hannah's retina and optic nerve. Foreman notices that Hannah has fallen asleep. Her EEG shows normal, stage one brain waves. Then Hannah quickly wakes up.
Foreman reports to House that the tests for optic nerve disease and ocular pressure proved negative. Hannah slept, but only for up to one minute. A CT showed no tumors, clots or seizure disorder. Hannah sleeps but cannot remain asleep. House figures that Hannah is sick but not sick enough to present symptoms. He orders the team to keep her awake at all times. Depriving her of the few minutes she does sleep will stress her body. This will help them determine what's afflicting her.
Cameron and Foreman take the first shift, waking up Hannah when she drifts off. Each time, she denies falling asleep. Then they notice a pool of blood on the bed sheets. House thinks the rectal bleeding is either a clotting disorder or colon tumor, so Chase heads off to perform a colonoscopy. House makes it clear that Hannah needs to be kept awake through the procedure. She will not be given sedatives unless a tumor is found.
Hannah screams and strains as Chase performs the colonoscopy. Blood begins to drain from her nostrils as she struggles to breathe. Cameron reports that the rectal exam showed traces of nasal matters. Was a massive sinus hemorrhage draining down her throat and out the back? House thinks about the poison ivy that was noted in Hannah's recent history. The rash developed around the same time as the insomnia. A rash plus sleep disturbances equals Wegener's Granulomatosis. House orders a large dose of corticosteroid treatment and an upper airway biopsy to confirm Wegener's.
Chase performs the biopsy when Hannah's eyes start to dart about. She is experiencing REM with her eyes wide open. She then quickly snaps out of it. House rules out REM, dismissing it as a movement. This also rules out Wegener's. Chase throws out the notion of allergies because Max got Hannah a dog about a month ago but sent it back when Hannah was allergic. House seriously doubts it because the poison ivy treatment should have suppressed any allergic reaction. He thinks Hannah was lying about being allergic. A dog is a commitment and she intended to break up with Max. He agrees to check for allergies.
During the test, Cameron inquires about Hannah's relationship status. While Max is out of the room, Hannah admits that she was going to end their long-term relationship. Hannah then complains of a pain. Cameron rolls her over and is shocked to discover the woman's entire abdomen covered with dark bruises. The team struggles to come up with new explanations for Hannah's massive internal bleeding. Foreman reports that Hannah's liver is dead. She needs a transplant and they only have six hours to determine what's affecting her. House points out that Max donated blood to Hannah, so they must be a match. Cameron can't imagine asking somebody who's about to be dumped for half of her liver.
House tells Hannah that she's in acute liver failure and will lapse into a coma in a few hours. Max can't believe they're just giving up, but House says even with a new liver, toxins will continue to build. Max, however, realizes that a new liver will allow the doctors more time to make a diagnosis. She pushes House to go forward with the transplant. House successfully manipulated the situation.
They now have another 36 hours to diagnose the patient. House, however, did not tell Max that Hannah is planning to dump her. As the team searches for causes, Cameron frets that they are ignoring an ethical dilemma. House quickly tires of her questions and shouts that if they tell Max and she changes her mind, then Hannah will die. Foreman and Chase continue throwing out possible explanations. House tells the team to put Hannah through a battery of tests that. He threatens to fire anyone who tells Max about Hannah's intentions.
Without sharing too many details, House consults Cuddy about the conflicting interests between Hannah and Max. She wants to know what he is hiding. He explains that the two options are for her to satisfy her curiosity or remain ignorant and help keep Hannah alive. Cuddy begins taking Max through the detailed steps of a transplant. Max is vigilant about going through with the procedure.
Cameron begins performing an endoscopy on Hannah, which entails a long tube inserted down her throat to swab her stomach for mushroom spores. While sliding the tube, Cameron begins to lay the guilt on Hannah. Max is undergoing painful procedures and will risk her life with the transplant. If Hannah truly loved her, she would tell her the truth. Hannah knows that if she tells Max, she dies.
Max gets clearance for surgery. Foreman and Chase report that tests were negative for Wilson's Disease. House realizes that if those are two are here with him, then Cameron is alone with Hannah and Max. Cameron rolls Hannah's gurney next to Max and leaves them alone for a moment. As Hannah is about to confess to Max, House interrupts. He orders the surgeons to get started.
Max's heart stops during the transplant operation. House pulls Cameron away from observation to focus on Hannah, who is in recovery. The surgeons shock Max back to life. Wilson joins the team to discuss Hannah's situation. Wilson points out that the immunosuppressants they have Hannah on would hide any possible cancer diagnoses. House is aware that they need to retreat. They will stop the immunosuppressant drugs in order to retest Hannah.
Hannah starts to reject her new liver. House is not surprised, but her normal white count is odd because it should be very low. Foreman suggests an infection. The team rapidly fires out a long list of infections, shooting each one down for various reasons. Typhoid fever seems to fit, but Hannah hasn't been abroad. House begins to think about the dog that Max brought home. He asks Cameron where the breeder is located.
House takes his team to Hannah's room. He immediately goes for her upper arm, where he finds a grotesque growth. Using a syringe, he withdraws a thick, black ooze and hands the syringe to Chase. House tells Chase to inform the CDC that they have a patient with the plague. He then explains to his confused team that the Blue Barrel Kennel, where the dog came from, is located in the Southwest. Fleas in that area occasionally carry the plague. A small percentage of plague cases present with severe sleep disturbance. House orders Hannah started on large doses of streptomycin sulfate, gentamicin and tetracycline.
After a few days, Cameron finds Max in the hallway and stops for a chat. Max admits to Cameron that she knew that Hannah was going to leave her. Hannah told a friend and the friend let it slip. Cameron is shocked that Max knew the truth and still went through with the transplant. Max smiles and says there's no way that Hannah can leave her now.