Platelet Multiple Choice Quiz

I haven't written on the blog for two months and Cathy would like a break, so here we go:

Yesterday (Monday, 8/25), Nicole developed a rash, mostly on her elbows, knees, and neck.  We decided since we already had a clinic appointment the next day that we'd just wait and the doctor could look at it then - it didn't seem serious enough to warrant a phone call to PCMC.  24 hours later, the rash had spread to much of her body, and we were glad to be taking her in to have the bone marrow team look at it.

The doctor estimated that about 20% of the total surface area of Nicole's skin is now affected by the rash.  Based on his estimate, I think it was probably 5% or less just the day before, so a big change in 24 hours.  Anyway, they have diagnosed this as a clear indicator that Nicole has Grade 1 Graft Versus Host Disease (GVHD), with Grade 1 being the mildest on the scale.  They are happy about this because, statistically, transplant patients who experience some GVHD are less likely to relapse - essentially the new bone marrow is battling with Nicole's body and hopefully that includes any residual Leukemia that may still be lurking, which is obviously a good thing.  However, if the GVHD becomes too severe, it can be damaging, and potentially life-threatening.  At this point, they don't want to go after it and try to suppress it, so they proscribed some topical steroid cream that needs to be rubbed into her skin twice a day.  This should help alleviate the rash, but will not really impact the GVHD itself.  If the rash doesn't respond to the cream and gets worse, they will have to take a more aggressive approach to try to control the GVHD; hopefully it doesn't come to that - steroids and the associated medicines that go with it are just miserable.

In other news, all of the test results are back from Nicole's bone marrow aspiration: Everything looks excellent, every single parameter is exactly what the doctors want to see, which is super...

Except that the doctors still don't know what is going on with her platelets.  And they were down to 8k today, so they infused her with platelets again.

Just to give some perspective, about a week after Nicole was released from the hospital on July 5th, she received platelets and for a short time her platelet count remained good - her body seemed to be producing its own platelets.  But then they began to drop steadily, with no plateau or up-tick, just downward about 1k per day until she hit 9k on 8/18 and they gave her a second infusion.  3 days after the infusion, on 8/21, her platelets were at around 52k, but just 5 days after that (today), she's back down to 8k.

So, as I said, everything is great, except for the fact that if the doctors were to stop giving her platelets, Nicole would die.  It is dangerous just to have her count below 15k because mild to serious internal bleeding is likely to occur; the lower the count, the greater the risk.

We still don't know why Nicole's body isn't producing platelets, and the doctors are just speculating at this point, which leads to the multiple choice question:

Nicole's body is not producing platelets because...
a)  Her immune system is mistakenly producing a platelet anti-body that is destroying her platelets.
          (The doctors are now running a test to check for this.)
b)  An undetected virus is destroying her platelets.
c)  The GVHD is destroying her platelets.
d)  None of the above.

Unfortunately, the elusive answer to this question is vastly more important than the sum total of all the answers to every quiz I've ever taken in school.  Nicole has another clinic visit this Friday (8/29), and she will probably need more platelets.

Fortunately though, our Heavenly Father does, in fact, know all of the answers, and thus the most important question of all is, what is His will concerning Nicole?  As has often been the case on this journey, the Spirit of God whispers to me, "James, be patient."  And so I shall.