Fever 101.2 and ANC 0

Started 4am, went down on its own then 101 again 11am.  Drew blood culture 4am.  

No mono today and zero ANC.  Plates was 5 so getting platelets transfusion now.   

No appetite but otherwise in good spirits.  Too bad he has to stay in the room because of the fever.  

Let's hope that the culture will be negative and fevers gone.

So warm, can't sleep

Lucas spiked a 100.8 at 12:30am.  He felt warm and was hovering around 100 all day.  Nurse assured me that his other vital signs all look good and she would recheck at 4am.  I woke up 2:30 and again felt he was super warm to my touch all over his body.  I was so scared and shivering when I took his temp.  And it turns out to be 99.8.  I walked out to talk to nurse and she said a lot of the kids on this floor do that -- feels warm but no temp.  I don't think I will be able to fall asleep until he doesn't feel so warm again.

ANC still 0, and all kinds of WBCs

Lucas still has 0 ANC today.  His WBC has been 0.3-0.5, the diff type last three days are:

Tue: 80 Lymph, 20 EOS

Wed: 96 Lymph, 4 EOS

Thur: 87 Lymph, 10 EOS, 3 MONO

I looked back all his CBCs since diagnosis (they are stored in a google doc spreadsheet and the link is at the right hand side of the blog site).  He never had EOS so high before.  I need to ask doctor what that means tomorrow.  Doctor told me today that the appearance of MONO often times means appearance of Neutrophils later.  I looked back to his blood infection in March.  His MONO was in single digits for 5 days, then jumped to 34.  A day later, ANC gets a non-zero number.  During another ANC hospitalization in later part of induction, MONO was 2 and next day neutrophils was 2.  So we still feel hopeful that maybe tomorrow he would have a positive ANC, and if not, the day after next.  We don't mind staying in hospital as long as he doesn't have a fever and eats and drinks okay.

He has been scaring us with his temp hovering around 100 since 3:30am today.  I woke up feeling he was warm and measured his temp -- 100.4.  Got nervous and measured again in 15 minutes and 99.8.  Ever since he has been doing this and we were super nervous whenever he also showed signs of irritation and/or tiredness.   He has very little appetite today and his weight has dropped from 14.4kg five days ago to 13.8kg today.  And I know he looks taller but the reality is that he has grown from 89cm at diagnosis to 90.5cm now.  But surely I worry about his ANC much more than anything else right now.  We are so close to the end of frontline treatment and we really don't need another hurdle.  

We get him fluids at a rate of 46 for 12 hours during night.  We tried to get him to wear pull-ups last night but he insisted that he is no longer a baby and doesn't need diapers.  He did well, woke up 6:30 and went in the potty for roughly 300ml (again shows how flexible his bladder is).   Jianwei took him to the playroom first thing in the morning before any other kid is awake so he can have a clean room by himself.  Later another kid came and they left immediately.  He told me that "the baby with diapers came in and she was full of yucky germs so we had to leave".  And that "baby" just walked by our room and pointed at Lucas -- "Look, baby!".  It's how funny how the 2-3 year olds refer to their peers as babies.  :)

Granulocytes (polynuclear leukocytes)
POLY	POLY, POLYS, PMN, or GRA
POLY, POLYS, and PMN stand for polymorphonucleocytes or polymorphonuclear neutrophils. On some lab reports, they refers to your segmented neutrophils and other times to your total neutrophils (both segmented neutrophils and bands). The Marrowforums ANC Calculator determines which case it is based on which other counts appear on your lab report.
NEUT	Neutrophils or Total neutrophils
Neutrophils are the most plentiful white cells. They move to the sites of injury and infection and break down bacteria by releasing enzymes. There are of two types of neutrophils: segmented neutrophils and bands. Neutrophils may also be called neutrophilic granulocytes.
SEGS	Segmented neutrophils
Segmented neutrophils are fully mature neutrophils.
BANDS	Band neutrophils
Bands are neutrophils that are almost mature. When mature, they become segmented neutrophils. Bands are also called band neutrophils or stabs.
EOS	Eosinophils or MID
Eosinophils proliferate when allergic reactions occur or parasites are present.
BASO	Basophils
Basophils are the least abundant granulocytes. They proliferate when allergic reactions occur and help destroy invading bacteria and viruses.
Non-granulocytes (mononuclear leukocytes)
LYMPH	Lymphocytes
Lymphocytes produce antibodies that fight viruses and bacteria.
MONO	Monocytes
Monocytes ingest foreign particles and dead or worn-out cells.

2nd day with ANC=0

The doctor wouldn't let us go home until that number shows an upward trend.  Considering the chemo he got recently, it will be a few days.  We worry about hospital super bugs a lot.  He is clinically fine -- another proof that ANC zero is asymptomatic.  He is just super bored here as we don't feel comfortable letting him go to the playroom.

Fever again with super low counts

We started the second half of Delayed Intensification on 7/2 with very strong numbers.  We did CBC on 7/1 and Lucas got CPM, AraC, IT MTX, and started Thioguanine on 7/2.  We stayed overnight on 7/2 for the clearance of CPM, just as we did with this chemo twice in Consolidation.  We came to clinic on 7/8 again for physical and CBC and got another IT MTX 7/9.  I have been doing his IV AraC at home for two weeks.  We usually don't turn on the AC unless it's over 85 but we kept the AC at 74 during the days when Lucas was accessed since we realize that his sweating would be problematic for the dressing.  I felt quite stressed for the past two weeks, doing the AraC, and worried that his dressing would come loose.  Luckily it only happened once when his dressing failed us and we had to go back to day hospital to get him reaccessed.  

7/13 Saturday -- the first day after all AraC is done and I felt like celebrating that there would be no more need to keep him accessed at home and administer IV medication for him -- he developed a fever at 10pm.  It was 100.6, then 100.8, then 100.6 -- we didn't rush to the hospital at once since he looked fine and we just thought it might get lower than 100.5.  By the time we got to the ER, it was almost midnight and by the time we got in a room on 12th floor, it was 4am.  Since last time we went to ER at the middle of night and Lucas got woken up on the way from ER to ward, he was very angry and loud and probably woke a lot of people up, I kept him awake until he got to the floor.  Jianwei thought I was cruel but I really didn't want to wake people up again.

His last fever of 101 was 1pm on 7/14 and he shows no sign of sickness other than tired and loss of appetite from chemo.  His ANC was 75, hemoglobin 8.2, platelets 25 at admission.  He was dehydrated that day and after some fluids, his ANC was 36, hemoglobin 7.1, platelets 9 on 7/15.  His heart rate has been above 120 and sometimes 150 so the doctors decided to transfuse him with platelets and blood in the morning of 7/15.   His energy level got a lot better after the blood transfusion.

Today he is due for Vincristine and Peg-ASP.  I didn't argue with doctor about this since I know the protocol says it very clearly that chemo will go on regardless of minor fevers and low counts.  The doctor would like to keep him hospitalized until he shows signs of improving/stabilizing of ANC.   At least he gets to go outside of his room this time.  We don't feel comfortable for him to go to the playroom if there were many other kids there, with is super low ANC.   However, he enjoys his walk in the hallway just as much.

I came home last night to spend some time with Alex and now I'm going back to the hospital so Jianwei can go to work in the morning.  Hope his ANC will rise soon!