Sunday, November 20, 2011

A Way Overdue Update

I apologize for the delay of communication lately. It's not for lack of action around here. In fact, it's quite the opposite. Jacob has been doing well since our last hospitalization in September, but we've had a lot of major decisions to make: whether we want Jacob do go through a second bone marrow transplant, and if so, when, where, and how would we have it done. We have made some progress in some of those areas.

First, after much inner conflict on my part, we have decided that we should try again. It was a very difficult decision to come to seeing Jacob eating well again and watching his counts creep back toward normalcy. I hate to start from square one and watch him suffer and face complication after complication all over again. I feel grateful that he is almost completely recovered from his transplant in April. He even got the okay to join everyone for our Thanksgiving dinner.

The second question we face is when would we want to go through transplant again. My initial decision was to wait a year or so to enjoy having him healthy and at home again. However, part of the complication that presents, is with CGD, there is a window of good health that is ideal for transplant. The patient must be free from infections, namely fungal (e.g. aspergillus) infections, otherwise, he can no longer be a candidate for transplant because of the increase in risk. Once a patient gets a fungal infection, the doctors are never convinced that it is completely gone, even if labs and procedures say it is gone. It is just too sneaky of an infection and could prove fatal if found in an immunosuppressed (BMT) patient.

So, thinking through that logic, we decided the sooner the better, as much as it pains me to say it. Jacob has never had a major fungal infection that has been detected. He's had some abnormalities on his lungs, swollen lymphnodes, that came back benign after a biopsy was performed pre (first) transplant. After Jacob underwent chemotherapy at Children's Hospital Los Angeles, there was a test that indicated that Jacob may have had a nonspecific fungal infection, but it was never determined what it was and was never detected again after that. The other minor issue that pushed us to sooner rather than later on a second transplant was that his doctor wanted to have his central line removed. It might sound silly, but I'd rather have his line removal be a sign of a successful BMT and recovery, not just a postponement of more dreadful things to come. So there you have it.

That brings us to where and how we'd like to have it done. After being in communication with a couple of other CGD moms, I really liked the sound of going to Texas Children's. They have transplanted 15 CGD patients, 10 of which were unrelated donors, with a 100% success rate. Those are amazing numbers! After I brought it up to Jacob's doctor, he suggested we also investigate Seattle Children's, as well as do a followup with the team at Children's L.A.

The team at CHLA admitted that they didn't know why Jacob rejected his graft. They had a few possibilities to explain it, but nothing for certain. They also mentioned that if he went through another reduced intensity transplant, he'd have a 25% chance of rejecting the graft again. However, if we did a full myeloid ablative protocol, which they were recommending, he'd only have a 10% chance of rejecting the graft, but a 25% chance of mortality. Neither option sounded very hopeful to me, and I left not feeling any better than before we consulted with them.

Incidentally, the BMT doctor and CGD specialist doctor we met with at CHLA noticed the rash that Jacob has had on his face recently (see the picture above). The CGD specialist wanted to rule out the possibility of a fungal rash and suggested getting it cultured. The BMT doctor thought it looked like graft versus host disease (GVHD) and got our hopes up slightly about the possibility that the donor cell count might have increased. Neither seems to have been the case. I had just figured it was the same sort of eczema rash common amongst GCD carriers. A blood sample was sent off to check Jacob's chimerism (the percentage of donor cells vs. his old cells), and unfortunately there was no evidence of improvement in donor cell engraftment. A dermatologist assessed Jacob and said the rash didn't look fungal.

A couple of weeks after our CHLA appointment, our doctor called saying he spoke to Seattle Children's and would have them give us a call because they are running a trial up there for which Jacob would qualify. Basically, they replace busulfan, which is an extremely toxic chemotherapy drug used in bone marrow transplantation, with a trial drug called treosulfan. Treosulfan does the same job of aggressively killing the immune system in preparation for transplantation, without the same toxicity to the liver and lungs, and is still a myeloid ablative chemotherapy, which increases the chance for engraftment. It is a preferred drug to high risk patients like Jacob and other children with immune deficiencies, because it does less damage to the body. They are in phase two of the trial and have tranplanted 28 patients in the past two years, 3 of which were CGD patients, who are all doing well. The mortality rate is 10%, versus 25% with busulfan. The one patient that they lost came in for a second transplant and was already suffering from severe GVHD. We are hopeful that Jacob is in good enough health from the start that he would pull through successfully. 100% of their patients engrafted. After speaking directly with the doctor conducting the trial, both Josh and I feel good about traveling there for a consultation and to meet with the transplant and immunology teams. We are waiting to hear about travel arrangements and such.

The other bonus about Seattle (and this may seem trivial), is that Kaiser has a contract with them so we would not have to file appeals to have our insurance cover the transplant, like we'd have to if we ended up going to Texas Children's. It's just one less concern to have to stress over, however unimportant it may sound.

On another note, here are my two super handsome Spideys on Halloween:

We had a fun time doing the trunk-or-treat, minus the face mask and the panic attacks I get any time Jacob's hands touch ANYTHING or anyone outside our house; you just don't know what kinds of germs people and things carry. Josh even sanitized the candy wrappers before we let the kids sort through their stash.