Dr Rossetti stopped by today, and of all the things Beth is suffering from (“one day at a time”), the thing that represents the most danger is the CMV virus, which manifests no symptoms. Nevertheless, here’s why this is dangerous:
Patients who have received marrow transplants undergo ablative chemotherapy and/or radiation. A period of neutropenia and a loss of specific antigen reactivity follow. All transplant recipients have a period of decreased CMV-specific cell-mediated immunity. The next step is unknown; however, patients at greatest risk for CMV disease develop viremia (virus in the blood). The role viremia plays in the pathophysiology of CMV disease is unknown.
Life-threatening CMV pneumonia may develop in immunocompromised patients, with the incidence varying based on the type of transplant received. Patients who receive marrow, lung, heart, heart-lung, liver, pancreas-kidney, and kidney transplants have different levels of immunosuppression. Those most at risk include bone-marrow transplant recipients and recipients of lung transplants. In patients who have received marrow transplants, CMV disease is most likely 30-60 days after transplant. Fatal CMV pneumonia is much less common in patients who have received solid organ transplants than in those who have received marrow transplants. Patients may initially present with an asymptomatic infiltrate on chest radiograph.
Beth’s numbers on this viral infection are going up and down. She is receiving Ganciclovir (“Cytovene”), an antiviral, for this. We should be getting more “titer” numbers on this tomorrow.
I had a chance to talk at length with one of the “practice” doctors (in Dr Rossetti’s practice) about all of this stuff that’s going wrong with Beth. The symptoms she is experiencing are loosely related (because they are typical for some transplant patients). But even when you add them all up, they’re not too serious. She is experiencing some pain, but a we’re just seeing a bunch of loosely related nasty things.
Here’s a breakdown of some of the symptoms and what’s causing them (as best as I can tell):
- BK Virus: I had thought this was going to be the biggest threat, but the doctor said it’s not. It’s definitely the most annoying and painful, and there is a chance for it to head up to the kidneys and cause some damage there, but it is minimal. This is what causes the frequent and painful urination. They’re continuing to give a lot of IV fluids to flush the virus out. Her urination is still painful, but an ultrasound just revealed that her bladder is emptying – urine is not backing up, which is good.
- CMV Virus: This is the more serious of the two viruses; it is being treated with Ganciclovir, and the numbers appear to be going down.
- The swollen legs: This is partly from the fluids, but partly because she isn’t eating enough protein. It’s the same kind of effect that we used to see in the big bellies of the starving kids in the World Vision commercials, except that it’s happening in her legs and feet.
- MRSA: This is probably the least of her problems. She has some degree of ability to fight infections, and it doesn’t really come up as a problem.
- The clot in the arm: There are two places where a clot could form: at the end, which is more serious (because the end reaches into the large artery that enters the heart), or somewhere nearer where the catheter enters the vein (the plastic is causing irritation). It is also incredibly swelled and very painful. They are giving her a mild treatment to dissolve the clot.
That’s a summary of what she’s facing. It’s all very painful and annoying, but no real danger to her health at this point.