Day + 11: we think we have a culprit

Last night Mina Brigitta laid in one place all night long, which is totally unusual. She occasionally woke up whimpering and shivering, and got meds several times. Her rash was much worse, little angry red dots all over her body, especially her legs. It seems like the nurse was in there all night long. She finally gave some morphine at about 5:45, and that put Mina Brigitta out till about nine. I slept in the chair instead of in the bed because I didn't want to disturb her. She didn't throw up all night, which was good, but she threw up again this morning, and just generally felt miserable.

They decided to try some prednisone at about noon, just in case this was an early manifestation of graft vs. host disease. I wasn't there to witness it, but Keri said you could almost see the transformation right before your eyes. The rash went way down, her fever broke, she stopped feeling nauseous, and generally had a very nice afternoon. The rash had returned by the time I got here about 8:00, and she was so tired she crawled right up in my lap and went to sleep. But her fever is still down and she seems a lot more comfortable than she was last night. She'll get another dose of prednisone at midnight, so maybe we'll actually get some sleep tonight.

Prednisone is a steroid that is used to combat GVHD, and the fact that she improved so rapidly has the doctors thinking that's what this is. GVHD occurs because the donor white blood cells (the "graft") attack the host's cells because they see it as a foreign body. Between 50% and 80% of BMT patients get some form of GVHD, and a little bit is desirable because the graft is also known to kill the host's leukemia cells ("graft vs. leukemia", or GVL). It can cause serious problems, however, and is a major cause of treatment-related mortality. I'm a bit worried that such an early onset might mean that Mina Brigitta is in for a severe case. But Dr. Cowan said that wasn't necessarily so, and a quick search of the literature didn't turn up anything to indicate that early-onset GVHD is more of a problem than a later manifestation.

They did a skin biopsy today which may be able to confirm whether it's GVHD or not, but the results will take 3-7 days. In the meantime, they'll continue to treat her with prednisone as long as it seems to help. There's also the possibility that this is "engraftment syndrome", which is basically described as a reaction that occurs around the time of neutrophil recovery. Engraftment syndrome is sometimes, though not always, associated with a host vs. graft reaction and graft failure, which we're really hoping is not the case.

You may have already figured this out from the preceding paragraphs, but Mina Brigitta's white counts appear to be recovering. Her total WBC went from 100 million cells per liter on Sunday to 200 on Monday and 300 today. Normal is above 5.5 billion, so we're not booking those tickets to India just yet, but we're pretty happy to see any improvement at this point. This fits with the graft vs. host theory, because the rash began to appear right around the time her white counts started to inch up, and it's the donor's white cells themselves that cause the graft vs. host effect.