Baby steps up

Not much has changed since yesterday, and a few little things have been added--namely I also have a bacterial (strep) infection in my blood which has caused fevers today. But I got so much "good" news today that I wanted to share.

All tests looking for fungal infections other places in my body have shown no sign of fungal infection! That includes:

Sinus CT

Echocardiogram

Chest CT

Abdominal CT

Third (and final) nasal scoping

It doesn't mean that there isn't more Fusarium somewhere, but there doesn't appear to be any obvious hidden site. That means less to clear when and if I get functioning neutrophils, which is good.

But the biggest news is that during rounds I was told that they have secured a donor to do a granulocyte transfusion! I don't know many details, and they are very rarely done, so the nurses and many of the APPs haven't seen one, but theoretically at least (since I haven't heard anything definitive), I will start receiving what is essentially a "neutrophil transplant" tomorrow. As mentioned earlier, they aren't always effective, and there can be icky side effects, but this offers me a chance to fight off the fungal infection and allow my counts to recover. 

This is possible because someone matched me, was contacted by Versiti, and agreed to come in today to receive a neupogen shot and steroids, then to return each of the next three days to donate their granulocytes (similar to a platelet donation or double reds where needles are in both arms and the blood cycles through a machine to separate parts out). Wow. They received a call today with a 4-day commitment and agreed to it. I am blown away.

I'll try to share more details as I know them, and since I haven't actually heard a fully laid-out plan, I guess I'll believe it when I see it, but I am excited. 

And thank you all for your Facebook replies, blog comments, personal messages and texts yesterday. I cried a lot last night, but they were happy tears as I reminisced with so many of you. Thank you for such a wonderful gift. And thanks to those who have driven past and waved to me in the window. Today my visitors were announced by the roar of two Harleys. I told the ID doctor that was my cue and I had to get to the window. So wonderful to see your faces, even from far away. 

I continue to feel so unbelievably surrounded by love. Thank you for the best feeling, as I drift off to sleep, still visualizing my new marrow making neutrophils.

And then it all comes crashing down

I was feeling pretty good mentally after the weekend and making it through all steps in the clinical trial. I was growing tired of my hospital stay--the food, the boring lap-walking, being mostly stuck in a single room. But I did have this strange red spot on my forearm that hadn't been much of anything, but my hospital bracelet poked it constantly and it was getting irritated, so I told my nurse about it. She decided it was worth mentioning to the doctor, and that's how I won myself another punch biopsy from Dermatology. Dr. Carlson didn't think it was necessarily a concern, but it looked different from the earlier lesions I'd had (they were flaky and peely but not painful), and then we started looking elsewhere on my body and found at least half a dozen of them. I remembered that I had actually entered the hospital with a similar spot on my left thumb, which was unique because it had a sort of "head" on it, and I didn't remember bumping it anywhere. I asked Dr. Carlson what it could be and she said it could be another generic "dermatitis," it could be something called Sweet's Syndrome, but what they wanted to rule out, which would be very dangerous, was a fungal infection. I stopped complaining about needing another invasive procedure because my friend Kelly's son Logan died from a fungal infection after his bone marrow transplant. I definitely wanted to rule that out.

Tuesday morning the Dermatologist popped in to say they didn't have news yet, but they were thinking it was Sweet's Syndrome.

Tuesday afternoon two dermatologists came in my room and as they were talking to me, Dr. Carlson came in. Unfortunately, the biopsy showed a fungal infection. They don't know exactly which, but that it is a "septate hyphae" fungi, likely either Aspergillis or Fusarium. They explained that they'd contacted Infectious Disease, who would meet with me to explain some things.

I'm not going to mince words. This is really, really bad. You can try to prevent fungal infections with anti-fungals (I was on many, but had to go off for two weeks to protect my liver), but you cannot CURE a fungal infection with them. The ONLY way to cure this is to have neutrophils to fight it. And my clinical trial has a known prolonged recovery time--meaning at least three weeks and likely more since I'm on the step-up dose. Anti-fungals will probably not be able to hold back the infection that long. The likelihood of my body producing neutrophils in time is slim. 

This is very possibly how my life will end.

Apparently a fungal infection in a severely immunocompromised person is a Big Deal, as very quickly I had numerous specialists in my room, back-to-back.

Almost immediately after, Infectious Disease came to see me. They are continuing the Voriconazole which I'd resumed taking when my liver function improved from the Myelotarg, but they also added an IV anti-fungal called Amphotericin-B. I will receive that once daily, and it's side effects are chills and rigors. They pre-medicate with Tylenol and Benedryl.

The optometrist did a full eye exam in the room. My eyes have been very sensitive to light from the cytarabine, plus I have eyelid swelling that started Friday. When he dilated my eyes and then shone the bright light in to look at the back of my eye? That was excruciating! And my eyes stayed dilated and extremely photosensitive until today. Ugh. He said my vision is normal--maybe needing a slightly stronger prescription in the right eye--and the thing on my left eyelid is a stye. (Now I just heard that ophthalmology is coming back to look at my eyes again. I will be again be dilated and not able to write, so I'm just going to hit publish. I don't know that I'll be able to view screens any more today.)

Echo came into the room and did ANOTHER echocardiogram to check for fungal growth on my heart valves.

Ear, Nose & Throat (ENT) were next. They looked in my ears and at my throat and then they stuck a camera in my nasal cavity toward (into?) my sinuses. This, too, was really, really, really awful. The ENT actually wanted to go back in the right side because she "saw something concerning," so I had three of these.

Then Infectious Disease came back in and talked more about Fusarium. He's only had one other patient all year infected with it. He had AML. He died. (I wanted to know.)

Then I went down for another CT scan of my sinuses to see if they have worsened.

I started the Amphotericin, and the pre-meds worked. However, when they wore off, my temp rose to 101, which delayed my receipt of platelets and won me more blood cultures!

This morning I was woken up by ENT to scope my nose again. Still really bad. And I just learned that they're going to do it again tomorrow morning. They're looking for changes indicating fungal growth, and if they find them, I get a trip to the OR so they can scrape it out of my sinuses.

I then had several visits from "the team" (Dr. Carlson and her PAs, med students). A plan of sorts emerged, although everything still depends on so much that we don't know yet.

1. Infectious Disease stopped in to let me know that the culture shows that it is, in fact, Fusarium. 

2. I had a chest and abdomen CT scan today to see if there is any sign of a localized fungal infection in either of those. I am getting daily nasal scoping to look for progression in the sinuses. 

3. I'm using wetting drops for my eyes, plus two ointments.

4. I'm receiving Neupogen (GCSF) shots daily. These boost neutrophils a day or two before they'd naturally appear. Since we don't know when/if my marrow will recover, I guess it's one more layer of possibly speeding up their appearance.

5. Dr. Carlson is looking into the possibility of a granulocyte infusion. I didn't even know that was a possibility. This website explains it really well. Basically the best match is both blood and HLA matched and it's not guaranteed, and it's got icky side effects. The ID doctor seemed to think that unless I took a turn for the worse and it was truly my last option, waiting for count recovery might be better. I'll let them figure it out.

After all that, I'm just going to say that this sucks. I am so very sad about it all and yet I have not completely given up. I'm just afraid I'm a lot closer to that last goodbye than I'd hoped.

And now we wait

 Thank you, everyone, for sending leukemia blasting thoughts, prayers, etc. on Friday. I felt completely surrounded with love. The procedure itself was almost anti-climactic. I was transported down to the nuclear medicine area and set in a very small (tight quarters) bay. Due to the clinical trial, I had to have a nurse with me throughout, and she had a new trainee, so he came, too. Then there was the nuclear med specialist and her assistant. They brought out a capsule that looked somewhat other-worldly and had radiation symbols on it, but the only precautions they took were wearing gloves. It was explained that this antibody emits alpha radiation, which is essentially stopped by almost anything (gloves, plastic, paper). They took out a giant syringe filled with a yellowish liquid and inserted it into a machine that dispensed the contents over 30 minutes. The machine was connected to one of my PICC lumens, and that was it. My vitals stayed great throughout (and for the hours afterward that they had to check). I didn't feel anything or any different (actually, I felt better because one of my pre-meds was Tylenol, but I'll get to that later). And now I spend any downtime visualizing my leukemic cells getting toasted by this amazing antibody.

Now I'll go back to a bit before the lintuzimab infusion. Thursday night after Greg left, my nose just started running like crazy! I couldn't even knit because it was dripping that quickly. I also felt like I had some sinus pressure on my left side. That seemed strange because I end up with sinusitis almost every year and it ALWAYS hits my right side. I could still breathe, but I slept with kleenex under my cheek all night. When I woke up on Friday, my left side was even more sensitive across the bridge of my nose and I couldn't stand the sunlight. When I was brushing my teeth, I looked in the mirror and my left eyelid was red and swollen. So I called the nurse, who talked to the doctor, who came to visit me, and (of course) wanted to rule out things, so I got a sinus CT scan (showed low grade sinusitis) and a nasal and throat swab for every virus known to man (all negative). The verdict was that it was likely due to the Cytarabine (the A in CLAG-M), which is the drug that can cross into the nervous system. I'd been getting prophylactic steroidal eye drops, but they stopped on Wednesday. Dr. Carlson said she'd order a stronger steroid eye drop to use until the redness went away and for a few days after. I felt almost immediate relief when using the drops. I had spent most of the day both Friday and Saturday either asleep or with my eyes closed (or keeping the left eye covered if I needed to look at things). It was a rough few days, but I am happy to say that this morning I woke up feeling MUCH better. You know how it is when you feel so cruddy for so long that even a tiny improvement makes you feel like you're on top of the world? That was me today. Chatting with friends, walking the halls, taking a nice long shower....

I know many of you have asked when we know if this regimen is working. We won't know for several weeks, and it won't be until a bone marrow biopsy. I was tracking my blast cell percentage in the peripheral blood, but my WBCs are 0.1, so they can't do subsets of the WBCs and therefore I can't check blast counts. The big thing now is recovery of my marrow ("my" marrow actually being my donor marrow from May--the healthy stuff). I know that those who did this regimen with lower doses of lintuzimab had very delayed cell recovery. My doctor says at least three weeks (not sure when the three weeks counts from). If it doesn't recover after 40 days, I'll need more new marrow. So there's a lot of waiting without knowing anything. I know I don't have to be fully recovered to be discharged, but I do need to be less transfusion dependent (I've gotten blood and/or platelets every other day I've been here). So I wait, and try to be patient.

I have been so lucky to have Greg able to visit me every day. Even on days like yesterday where I laid curled up in a ball, protecting my left eye, and barely interacted with him just knowing he was there was amazing. Friday we made the best of our anniversary that we could. I had all those icky sinusy symptoms and didn't know if it was a cold or something else, but we got permission for him to pick up Vietnamese food. He had a Bahn Mi, and I had a specially-prepared giant bowl of pho (vegetables pre-cooked; no raw ones; extra hot broth). It felt somewhat normal in a strange way. The kids did a Zoom dinner with us, and it was a great way to mark 27 years of marriage. 

Today we played cards and shared a "cheese platter" from the cafeteria. We make our own special times. And we keep hope alive. I've started thinking about the future more than I have since last November. It may well be premature, but I'm rather enjoying it. Here's to 2021 being healthier and less pandemic-y. And really, why not more cheese-y?

Time for the big guns!

When I checked into the hospital last week, I was told that I would likely start to feel the effects of the chemo on Day 7.  They were right!

Last night I just felt generally yucky. My nose was runny and my head was stuffed up. I expected to have a low grade fever (I can usually tell when my temp is in the 99's) and I did--which meant that I had to be monitored more closely all night. They stopped the steroids, so I am having a bit of a steroid dip. My stomach isn't terribly upset, but it's just not right. And I am just exhausted! Today it was difficult to even sit up in bed--I was a puddle. All of this is to be expected, so no concerns. You just forget how cruddy it is until it hits you again.

I didn't need any blood products today (my hemoglobin even ticked up a bit on its own), and my liver function tests continue to drop. Unfortunately my blast percentage inched up a little more again. Dr. Carlson said not to worry--that tomorrow's Lintuzimab is what should knock things out.

So that brings me to tomorrow. This is it! If you light candles, send positive light, pray, whatever, then I can use all your directed energy tomorrow afternoon. The tentative plan is for me to get pre-meds about 1:00 tomorrow afternoon, then go down to nuclear medicine with a dedicated nurse to monitor my vitals. I'll theoretically start the half hour infusion at 1:30 (depends on exactly when the med is mixed), and will be monitored closely for at least 90 minutes. In preparation for the infusion, they'll start IV fluids at midnight tonight (the lintuzimab is hard on kidneys) and I'll have them throughout the infusion and through tomorrow night. It'll be a long day, and I expect I'll still be feeling pretty icky (much like today). But I am excited to get this part done so I can start my recovery from it. 

Thank you again for all your well wishes. I plan to kick it big time tomorrow afternoon and hopefully get through to the other side. I know it won't be easy even after this infusion, but it's what needs to be done. Let's go!

Quick check-in

 Hi, all.

Just a very quick check-in.

I'm currently getting my last infusion of the CLAG-M (chemo) portion. This is the routine care part. Friday afternoon will be the experimental part (lintuzimab) and the "biggie." I've been heard it will happen sometime in the afternoon. Anywhere from 1:30 - 2:30 has been thrown around. When I hear more, I'll let everyone know in case you want to focus light, healing, prayers, vibes or just powerful Ac-225 radiation at my CD33+ leukemic cells.

The second thing I wanted to say is that apparently people have tried to send me things to the address that the nurse said to use, but it's not working.  I guess it's best just to send cards to my home address. Greg is coming in to see me every day and can make deliveries that way. I'm hoping that my mail sent here eventually makes it to me, but it might well be delayed. I don't want to post my home address on a public blog, so if you don't have it and want it, let me know. I'll post it on Facebook, though, in a "friends only" setting.

Thanks for all your continued thoughts and messages. The meds have kept my side effects to a minimum, other than exhaustion, but I know that tomorrow will likely bring more stuff as I enter that second week. The only way to the other side is through it, so I'm pushing through it!

Goodnight, all.

The steroids are kicking in!

 I'll try to fill in what my past two days have been like.

I slept amazingly well my second night here (Thursday night). I still had the usual hospital interruptions but was awake just long enough to be cooperative and then fell right back asleep. I think I was in bed with the lights out for between 9-10 hours.

Yesterday morning I started the day needing platelets (down to 8K) and blood (HGB at 6.3), but was thrilled to hear that my peripheral blasts had fallen to 63% (they'd been as high as 81%), so doubling the hydroxyurea seemed to help).

I started the chemo portion of the clinical trial yesterday afternoon. About 1:30 I got pre-meds (to prevent nausea and infusion reactions; this includes the steroid that is given with some chemos--my first experience was with the AC chemo during breast cancer). About 2:00 I got the first med--the "M" in CLAG-M (mitoxantrone). This med is bright blue (see photos below). For those that knew Greg and I when we got engaged (or who have heard the story), you might be amused that Cara's response to these photos was, "did you just ask for something blue?"

About 2:30 they started the Cladribine (CL) which ran for two hours. No biggie there. I napped through part of it.

Then I had to take a two hour break. I ate dinner, played around on my phone, took a few walks in the hall.

The Cytarabine (A for Ara-C) is the real deal. It is known to cross the blood-brain barrier and cognitive issues are the first sign that there might need to be a dose decrease or to stop treatment. Cytarabine is actually the first chemo (the "7" in the 7+3 regimen) that I was given at St. Luke's in November to attempt to first achieve remission. But this is a stronger dose and not given 24 hours a day, so more intense. I started protective prednisolone eye drops and take them twice a day to hopefully prevent vision problems. And every night before giving me the Cytarabine, I do a bunch of cognitive function test. I need to write my name on a page that tracks my handwriting. I need to say the current date, approximate time and where I am. I have to do strength tests (squeezing nurse's fingers, pushing and pulling with my feet and arms, rapid back-and-forth motions with my hands, tracing a pen with my eyes, and touching a pen, then my nose, using both hands and as the pen is moved).

I haven't had any terrible side effects from this chemo yet. The "worst" is my reaction to the G (GCSF) injections. I have swollen up terribly at the sites where the injection was given. It's thought that because I lost so much weight (and the injection goes into the fat), it's going more into just skin and that's causing the swelling. We tried my butt cheek tonight (instead of my belly) so maybe that'll help.

Last night I fell asleep pretty well after my 9:00 meds. My nurse said the Cytarabine would be done about 11:30 and she'd sneak in, turn it off, do my midnight vitals and labs and let me sleep a bigger chunk. I woke up with a start at 10:30 and couldn't fall back asleep. I felt clammy but not necessarily cold or chilled. Even after the midnight vitals (no fever, despite the clamminess) and labs, I just tossed and turned, and heard all the sirens coming, and got chilled and then overheated, and let my mind race where I talked myself into every symptom being a sign that this regimen was not working and it was my last chance. My heart was pounding and when I tried to pick up my phone to play mindless games, my vision wouldn't focus and I just KNEW that meant that I'd have to stop this treatment. And then from some depths of my brain, I remembered that I'd had steroids earlier in the day. When the nurse rounded for 4:00 am vitals, I asked if my symptoms were possibly from the steroids and she said, "oh, yeah--you developed the ‘roid rage!" Just hearing that made me relax and I was able to sleep for about three hours before getting up for 8:00 am vitals.

The doctors rounded pretty early today. 

Dr. Murthy came and said that my total bilirubin levels have been increasing and they wanted to run some additional labs. The total bili level can be broken down into direct bili and indirect bili. If indirect, it's likely caused by red blood cells breaking down (chemo trashes blood cells and we'd upped the hydroxyurea). But if direct, it indicates an issue with the liver--potentially a blockage of some sort, which can indicate veno-occlusive disease (VOD)--a much bigger deal. VOD is a known risk after taking Myelotarg, and also after having a stem cell transplant. Rates of this happening are still only about 20%, and I don't have any of the other risk factors (history of alcoholism, prior hepatitis infection, prior liver radiation), but it's still a concern. They ran labs on the breakdown of direct/indirect bili. If direct is elevated, the next step would be a liver ultrasound. More waiting and more potential tests... 

Before he left, I asked if I could get a prescription for something, if needed, to allow me to sleep at night with the steroids kicking in. I asked for Ativan, since that had worked at St. Luke's. Best of all, it's as-needed, and fast-acting, so I don't have to take it unless I need it.

I was surprised when Dr. Hamadani popped his head in the room. I didn't even know that he did hospital visits! He said he was excited about this clinical trial and he'd hoped I'd gotten into it the last round when they were accepting patients. He said if I go into complete remission with no MRD, and count recovery, the plan is to just watch and wait. He said he'd preferably give me a donor lymphocyte infusion (DLI), but since my donor isn't available, that's not an option. If I get into remission, but counts don't recover, the plan would be another bone marrow transplant from a different donor. He said it takes awhile to get a Be The Match search launched, so he would start it now "just in case" and not to be surprised if paperwork came in from my insurance to approve the second transplant. I asked about the haplo donor that Dr. Murthy had mentioned and he said his preference would be another perfectly matched unrelated donor from the registry. I said something about there being other matched donors internationally when I had my transplant, but with COVID they went with the domestic donor, so I wondered if they'd opened it up to international again. He said that they had and that he preferred European donors (I think because culturally it's so much more normal there!).

The hem/onc fellow came in about 10:45  to tell me that my direct bilirubin IS elevated and that they wanted to repeat the test to see if by chance it's on its way down. If not, they'll want an ultrasound. She said it's possible that I had a gallstone briefly blocking things and it may have already passed, or maybe if they find one, they can scope it out. 

Two hours later she came back to tell me that the latest test showed that my bili numbers went down. They don't see the need for an ultrasound yet, but they'll keep watching my numbers and if they tick up again, I'll get that ultrasound! (C'mon bilirubin!)

And then I started round two of CLAG-M. That's where I am now--with about three hours left in the A part.

I'd mentioned that I was struggling drinking enough as water didn't taste great and that very few of the beverages on the hospital menu that were appealing. My nurse asked if I wanted a little fridge in my room to bring stuff from home. Heck, yeah! So here's my fridge.

I then got greedy and asked if I could bring a little microwave in (a friend offered one). But I can't have "heat-producing items" in the room (so I assume that means no crockpots or electric kettles or hot plates, either). But I now have good Gatorade flavors and string cheese in my room!

And I was able to take pictures out of my window for those who asked how to visit and wave to me. I'm not sure if you can see anything in my window from the road, but if you text me and I'm in my room, I can stand in the window and others have been able to see me. :) I'm on the fifth floor. I'm on the south side of Froedtert (where the ponds are) off of Doyne Ave.

Thank you all for your continued well-wishes. I'm going to ride the steroid high (energy and increased food intake!) for at least a few days. I'm sure I'll do quite a crash by mid-week next week, just in time for the experimental part of the treatment on Friday. Love to you all!

First full day

 I barely slept last night and had a tough time napping today, so I'm exhausted and will go to sleep as soon as they bring my night time meds. So this post is more of bullet point list than a blog post. :)

6:30 am: I was woken up to head down for my echocardiogram. Luckily since they already had a baseline from April, it only took 15 minutes (not 45) this time.

7:30: Back to the room for vitals, ordering breakfast, discussion of meds, including whether I can take Claritin (and stop the Zyrtec) to help with bone pain from the G-CSF (Neupogen) injections. I can.

9:30: PT came in to do her initial evaluation, show me the floor and set goals.

10:30: Dr. Abedin and his team did rounds to have me sign the paperwork for the clinical trial. Still waiting on screening results before it's official. He discussed lots of things about the clinical trial, but the main things included

• The CLAG-M is the main part of this therapy. It is a salvage chemo, which is used when people either fall out of remission or have refractory leukemia (have never truly gone into remission, which might actually better describe me) and it alone has about a 50% success rate. This trial is adding the lintuzimab to attempt to get any cells that make it through the CLAG-M, thus hopefully increasing the success rate.
• He explained how Myelotarg is a monoclonal antibody that works by connecting to a CD33-expressing cell, injecting calcheamicin (essentially a DNA interruptor), which must make its way into the cell's DNA and reprogram it to commit suicide (apoptosis). However the lintuzimab (actually lintuzimab-Ac223) is also an antibody, but it is connected to the radioactive isotope of Actinium and once it attaches, it destroys the cell in fewer steps.
• I am the first receiving this higher dose of lintuzimab  and so they would not be surprised if I take even longer for my blood cell counts to recover, or if they don't recover at all.
• He defined "too long" as no recover after 40 days. Up to this point most people achieved count recovery in about four weeks.
• I should expect fevers of unknown origin in week two.
• If my counts are starting to recover, but not fully recovered, I might be able to go home before full recovery and complete my treatment outpatient.
• Dr. Abedin asked if Dr. Atallah and Dr. Hamadani told me what would happen if my counts didn't recover. I said that they'd just said they "had things to do." Dr. Abedin explained that no recovery of counts means that I have no remaining donor bone marrow and so they'd need to get healthy bone marrow working. I told him that my donor was not available anymore and he said that if I didn't have any of her bone marrow left, I'd be able to accept another, different bone marrow. That could be another matched unrelated donor, or it could be a haplo-donor (sibling, parent or child).
• Other very real risks from this procedure include kidney damage, as the lintuzimab is eliminated through the kidneys and can do damage on the way out. I've already started taking protective meds, and as I'd said earlier, on lintuzimab day (10/2), they will pump me full of IV fluids, make me drink like crazy, infuse me, and continue pumping me full of IV fluids after.
• The last thing Dr. Abedin said is that for the study they'd be drawing an additional tube of blood to test for single nucleotide polymorphisms (SNPs) in the CD33 gene which might explain why meds like the lintuzimab-AC223 or Myelotarg, which target CD33, aren't effective in some people.

After lunch, I took a nap and then OT paid me a visit. She gave me some exercises and did some baseline screenings on cognition. I was able to take the Montreal Cognitive Assessment (that test that President Trump bragged about acing—person, woman, man, camera, TV). I was horrified that I didn't score perfectly (at the end of the test I could only remember four of my own list of five words). But I passed and the other motor skills tests went better. :)

I got an in-room EKG.

4:30: My nurse came in to give me three meds--one to protect my kidneys, steroidal eye drops, and a neupogen shot. I asked if that meant I was in the trial and she said yes--Dr. Abedin had just received all my screening tests and signed off.

And now it is 10:00 pm and I have to crash. Forgive me for any typos. I'll try to fix them tomorrow.

I will finish with the address to send me cards (NOT needed, but lots have asked):

My name

Room 5

7CFAC

9200 W. Wisconsin Ave.

Milwaukee, WI 53226

Thank you, dear friends, and goodnight!