September 5, 2011

differential diagnosis part II

  • 3 eyes of newt
  • 3 hairs of a border collie
  • 3 dashes of powdered bone
  • 3 eggs from a robin
  • 3 berries from a holly
Under the light of a full moon, boil the ingredients and stir clockwise precisely 30 times.  Take 3 draughts of the brew and stare into your crystal ball.  Ask the spirits in a slow and steady voice, "wwwhhhaaattt ttthhheee hhheeelll iiisss gggoooiiinnnggg ooonnn???"

     That might as well be what we do for my dad at this point.  Seriously.  To recap.  He finished 5 rounds of chemo, had improved substantially, and right before his six round, his counts plummeted inexplicably.  His neutrophils went to zero.  His total white blood cell count also dropped.  His red cells and platelets dipped ever so slightly.  But a week later both his platelet and red blood cells looked good.  So whatever was happening was specifically hitting the white blood cell population, especially his neutrophils.  His bone marrow confirmed that he did NOT have a new leukemia, a recurrence of his CLL, or myelodysplastic disease.  Besides, in those diseases, his blood counts would've looked differently.  But hey, everyone is different and you're never certain how a patient is going to present.  So to be sure, you look at the bone marrow and that confirmed it.  So that left the possibility of an autoimmune reaction where his body attacked his white blood cells for some reason or a virus.  They just posted his virus results online and they were negative.  And there's no real definitive test for an autoimmune reaction of this nature.  There's one suggestive test and my dad's results weren't even close to suggesting that it was that. 
     So for everything on his differential diagnosis, we came up with nothing.  It's possible it was a virus that we are unaware of having this effect.  It's still possible it was some sort of acute autoimmune reaction.  It's possible that it was the phase of the moon.  But we're certain of nothing.  Medicine is like that a lot of the times.  At our current level of ignorance, the disease processes are just too complex and too numerous for us to be able to understand it all.  So, you take a step back and ask, "how is the patient doing?"  Well, he's a bit more fatigued than usual and in a bit more pain.  But who knows why.  We have a match and there's no point sitting around hoping his neutrophil counts return.  The cancer will come back and some point.  It's only a matter of time.  And besides, the goal of stem cell transplant is to first obliterate the patient's bone marrow anyway.  File this little episode under "$*#($%)*" and put it behind you.  So you move forward.  There's not the luxury to sit and ponder what might be happening.  The donor, my dad's brother will be down here in a few days to begin his part of the process of donating his stem cells.  We're not sure when my dad begins.  He has a visit with his leukemia doc on Wednesday and then the stem cell doctor in three weeks.  I suspect things will start to happen pretty quickly after that.

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