by Juraj Koska

Starting week +2, Thomas’ cells were still in the abyss like Arizona’s only professional hockey team. At least the hockey games were entertaining to watch. On Superbowl Sunday, Thomas’ temperature started to climb, his appetite started to sink, and he reached the official fever levels and constant nausea on the next day. He needed more blood transfusions and even more platelets as the fever apparently burned them pretty fast. On Thursday, a seasoned nurse practitioner mentioned that this could reflect some movements in Thomas’ bone marrow and that white blood cells could be seen in the blood in the next 24 to 48 hours. She was right on the spot. On Saturday morning, the numbers on the patient portal changed from <0.1 to 0.1. The fever also abated, bringing back a little bit of appetite. The counts steadily climbed up until Wednesday and brought back the nausea and the fevers that were now higher than in the previous week and were not responding to Tylenol. Thomas also needed more platelets since the high fever was burning them faster again. Though he felt miserable, he was assured that he was still in the lowest percentile of the discomfort scale typically seen in the third week after BMT. Moreover, all symptoms were consistent with the engraftment syndrome of these new cells, making many substances that cause fever, stomach sickness and fatigue.

On Thursday, the fevers and the nausea finally retreated. The neutrophils dropped a little bit too; however, the total white blood cells count went up slightly due to increases in other cell types. To help the neutrophils regain pace, his doctor decided to push it with an infusion of a drug similar to their natural pusher. Instead of a 1st down at the 35, he ended up with an 85-yard touchdown, as the total white cells tripled, and the neutrophils increased 8-fold by the next morning. The neutrophil count increased further on Saturday and then on Sunday, making 3 consecutive days of counts well above 500, and an official call of engraftment on day +22. His red blood cells and platelets are still a little sluggish but over the next week we should see some movement on that front as well. On Day +30, Thomas will have a bone marrow biopsy to make sure the cells from the donor are in and working well. During the next few weeks, he will likely have graft versus host disease with cells from the donor finding his body alien and producing some defense responses. We hope the symptoms will stay mild.

Although Thomas was blessed to be infection free since the relapse of his leukemia in August, despite having no immunity almost the entire time, laboratory tests detected a cytomegalovirus DNA in his blood. In most cases this virus is dormant for years after the infection which typically presents as a mild cold. Once gone, it is kept at bay by memory T-lymphocytes. These cells are effectively destroyed by ATG and the radiation prior to transplant, and the virus could be reactivated and if out of control, it can be life-threatening. For now, Thomas has no signs of an active infection, and the viral load is low. To further reduce the risk, the doctors put him on a drug that will make his stomach sick and affect his kidney function. We hope that the virus will disappear, and the treatment won’t last too long. Thomas is expected to stay in the hospital for about one more week.