Thursday, November 21, 2013

Days +87 to +90: The Silver Lining

If every cloud has a silver lining, then we found the silver lining of Ezra's GVHD. He now has a very small number of T cells. Although the T cells are causing the GVHD, if we can get it under control, then having T cells is exactly where we want to be. The steroids prevent T cells from growing, so the sooner Ezra is off the steroids, the better. Once he is off the steroids, the expectation is that the T cells will continue to grow and Ezra will be on his way to a functioning immune system. IF he can get off the steroids.

We have thankfully started to wean the steroids. The rash is completely gone. The dose has been cut in half and will remain that way for a week. If there is no sign of GVHD, we will cut the dose again and go from there. If the rash comes back, he will go back on the higher dose. We are anxiously watching and trying not to obsessively check his skin.

The other piece of good news is that the higher level chimerism test showed that all cell lines that Ezra has (not including T cells) are 100% donor. Yes, it is still possible that Ezra's T cells can end up being mixed chimerism, despite the fact that all other cell lines are 100% donor. T cell chimerism will be checked once he has more T cells.

The wean couldn't come soon enough. The steroids are wrecking havoc on Ezra's stomach. We are already seeing improvement in how he feels since cutting the dose. We've been struggling to figure out ways to help Ezra deal with his pain. Fortunately, Ezra has figured out his own way to deal with the pain - with "pain rockets." He pretends that one of his rockets is a pain rocket and he launches it into space where it hits an asteroid and all the pain disappears into space where it can never hurt anyone again. It's working for him, at least for now. 

The super-sized menorah is back on our front lawn ready to light up our Hanukkah! For those of you who have noticed compared to last year's picture, yes, he is most definitely taller! Here's to hoping that the holiday of miracles brings the miracle of no GVHD and a growing immune system.

Sunday, November 17, 2013

Days +83 to +86: GVHD

On Thursday, after looking at a picture of Ezra's rash, the doctor decided that it is indeed what we have feared - Graft Versus Host Disease. The rash had not spread, but the rash on his back was worse. She also decided that it was best to be aggressive with treating it and started Ezra on "systemic" (oral) steroids, rather than waiting and trying different topical creams to see if they would lessen the rash. Steroids are a major problem post-transplant because they suppress the number and replication of T cells, delaying immune reconstitution. This is the last thing Ezra needs at this stage when we are anxiously awaiting the appearance of T cells. Steroids are a game changer. They also can cause very serious side effects. But the doctor explained that they have found that if you wait too long to treat GVHD, it becomes much harder to remedy, and it is best to attack it early.

Since starting the transplant process, GVHD has been our greatest fear, short of Ezra dying. This latest set back is very difficult for us to come to terms with. We were told that a T cell depleted transplant (the type of transplant Ezra had) has a 5-10% risk of GVHD. For his first transplant, we were told there was about a 10% chance of engraftment failure. Why our one-in-a-million son ends up on the wrong side of the statistics so often is a question to which we will never know the answer. And yet, we know we are lucky that he has so far landed on the right side of the most important statistic - he is alive and he is fighting.

The good news is that the rash responded immediately to the steroids - it was much improved after just the first dose. The plan is to stay on the higher dose of steroids for a few more days at least and then start a slow wean. The concern is that the GVHD will flare up once the steroids are weaned and that will require an indefinite course of steroids, and result in continuing impact on his immune system and other organs. We will all be watching closely once he is allowed to start the wean.

The confusing part of this GVHD flare up is that as of a few weeks ago, Ezra had no T cells. T cells are what causes GVHD. The new T cells that form from the stem cells from the donor and "grow up" in Ezra are not supposed to cause GVHD. It is typically T cells that come in with the graft at the time of transplant that cause GVHD. With the T cell depleted transplant that Ezra had, only a very small number of T cells come in with the stem cells. Ezra received even less than the level of T cells that Sloan considers "safe" - so small an amount that T cells have been undetectable since the day of transplant. 

So, how does Ezra have GVHD? Well, first of all, labs were drawn on Friday to check again for T cells. If there are T cells, there is no way of knowing if they are the very small number of donor T cells that have multiplied for some reason or new T cells that aren't behaving as expected and are attacking Ezra's skin. If the test comes back showing no T cells, then the assumption is that there are T cells in his skin and organs, but not in his bloodstream, which is why they have been undetectable. His doctor has described GVHD as a "black box" in many respects, and that has been our impression of so much of the transplant process. It is, and always has been, an enormous leap of faith.

Just as we had finally gotten the real Ezra back, we now have yet another version of Ezra - steroid Ezra. Steroids can cause stomach upset and Ezra's weakened stomach is already causing him more pain.  It is so frustrating to go backwards after he had made great strides. 

Please send prayers and positive thoughts that the T cells chill out and leave Ezra's skin alone ASAP (Ezra Aviel ben Hertzelia Shandel). And please wish us all courage as we confront one of our greatest fears.

Wednesday, November 13, 2013

Days +74 to +82: It's Always Something

Just as Ezra has been starting to do better and his pain lessening, another issue has cropped up. On Sunday morning, Ezra woke up with a rash on his back and stomach. Any type of rash post-transplant is cause for concern. We headed over to Sloan on Monday to get the rash checked. It doesn't look like anything in particular, so the conclusion is that it could be anything. The rash could be a virus, graft versus host disease, a reaction to medication, an irritation, or a food allergy. The tests for common viruses that can cause rashes have come back negative. We are very concerned about the rash being graft versus host disease ("GVHD"). The good news is that the rash is mild and not itchy. However, the doctors think it may be necessary to do a skin biopsy. We are praying that it starts to clear up so that we can avoid the biopsy. The thought of Ezra going through more pain and trauma is devastating. We are applying a steroidal cream and will wait and see what happens. 

On the cell front, we got back one of the chimerism tests and he is 99.8% donor! There is no concern about the .2% - the test has an error rate of 2%. So this is considered to still be 100% donor. This month another higher level chimerism test was sent, which will look at the different cell lines, rather than whole blood. Now that he has B cells and NK cells, they can look at the specific types of cells to see if they are donor or Ezra. Those results are not yet back. 

The other exciting news around here is that Ezra graduated to a "big, big boy bed," as he calls it. He is super proud of his new bed, which is covered in space bedding (of course), although he isn't excited enough to actually make it through the night in his new bed. 

We continue on the roller coaster ride of transplant. A journey of ups and downs with the hope that ultimately in the end Ezra will finish up. The rash is yet another reminder that we never know what tomorrow will bring and to just focus on on the present. We remain thankful for how far Ezra has come, and remind ourselves how quickly everything can change.

Monday, November 4, 2013

Days +67 to +73: He's Back!

After the past week, we can finally say that the real Ezra is back, albeit not 100%, but most definitely back! Since we started the transplant process and in particular the past month at home, Ezra has been totally consumed by the fog of pain and dulled by pain medications. He was shut down and not interested in anything except sitting on the couch and watching movies or reading books. We sat by him with broken hearts feeling helpless and unable to alleviate his pain. But over the past two weeks, we've watched the real Ezra breaking through the fog and returning to us. It is as if he is rediscovering himself - what it feels like to laugh, to be silly, to be mischievous. His inquisitive mind is back to cranking away, mostly about all things space. It is a blessing to see and we are rejoicing with both laughter and tears.

All this being said, Ezra is still struggling with pain. The pain is slowly lessening, and now it is the real Ezra working through it and not the miserable post-transplant Ezra. He is still taking pain medication, but it is basically on an as needed basis and the need is less frequent. We know there may be setbacks, and we also know this is a very long journey. As long as the path is towards improvement, then that is what matters.

Last week, we were sad because Ezra's hair was not yet growing back and his old hair was falling out. This week, we are happy to say that new little hairs have started to pop out. We can't wait for that curly mop head to be back (although we know that hair sometimes grows back differently post-transplant)!

Ezra's counts have been steadily improving. His platelets have actually been in the normal range for the past few weeks. This is incredible because after the first transplant, Ezra's platelets remained low and never returned to normal. His neutrophils have been solid and B and NK cells have been increasing.

So what's missing? Just the most important type of cell - T cells. With the type of transplant that Ezra had (T  Cell Depleted), it takes on average 4 to 6 months for T cells to appear. We may start seeing some T cells around 3 months post-transplant. He's not quite there yet, but those T cells can't show up soon enough for us. Without T cells, Ezra remains highly susceptible to serious 
infection and will not survive in the long run without them. In a non T Cell Depleted transplant, the recipient receives some T cells with the graft at the time of transplant. These T cells give some protection while the new immune system grows and starts to make new T cells. Ezra does not have the benefit of the protection of those donor T cells in this interim period. So grow T cells, grow, and fast.

Another round of chimerism tests will be sent out this week. And another round of extra anxiety for us waiting for word that those donor cells are still hopefully ruling Ezra's immune system.