Melanie was 43 years old and determined. A 104-degree temperature did not keep her from going to her editing job at Blue Cross, but the mass on her left upper arm kept getting bigger and more painful, persuading her to go see Dr. Munjack, her primary care physician. He diagnosed an abscess and started her on oral antibiotics. After a brief initial improvement, her symptoms worsened again, so Dr. Munjack admitted her to Northridge Medical Center for more aggressive treatment with intravenous antibiotics.
To my mind, this wasn’t a big deal. For over 20 years, Melanie had battled bipolar affective (manic depressive) disorder, obesity, and acne, so an abscess in her arm seemed an annoyance and little else.
It got a little more complicated when we got the results of her routine hospital-admission blood tests; her white blood cell count was 800. The low end of normal is 4000. There are several white blood cell (or leukocyte) types normally present in blood, and most white cells are either granulocytes (more commonly called neutrophils), the cells that give pus its green color, or lymphocytes, the cells that HIV destroys. Melanie had almost no neutrophils, a condition called agranulocytosis, and that’s why her body was losing the battle with the bacteria in her upper left arm. Something had switched off her bone marrow’s granulocyte-production process. Leukemia can cause this, but more often nonlymphocytic leukemia presents with a normal or elevated white blood cell count. Agranulocytosis is an unusual but well-recognized side effect of some medications, and Melanie was still using several prescription drugs to maintain mental stability.
So this was now a life-threatening situation, but with aggressive treatment of the abscess, using surgical drainage and powerful antibiotics, and discontinuation of the offending psychiatric medicine, one would expect a complete recovery. An avid reader, Melanie had a much easier time staying in the hospital than most and could use the time to catch up on the graduate-school courses she was taking at Pepperdine University to get her master’s degree in marriage and family counseling. Her mental illness had, from the time she was forced to drop out of Stanford Law School in 1981 until she began counseling clients in 1998, prevented her from working at jobs commensurate with her intelligence. For the first time in her life she was entering a career that she found rewarding.
Early in her hospital stay, her hematologist, Dr. Davidson, did a bone-marrow biopsy, an often painful procedure that requires the doctor to twist a thick needle into the patient’s pelvic bone just above the buttocks. The preliminary results confirmed the lack of granulocyte precursor cells, so he gave Melanie GMCSF (granulocyte- and macrophage-colony stimulating factor) to try to get production started again, and her cell counts did improve slightly while the antibiotics prevented the infection from spreading. Because the antibiotics kept her in stable condition, the surgeon decided to wait for her bone marrow to recover a bit before making the necessary deep cut into her arm to drain the abscess so that she would have a better chance of healing quickly afterward.
Once they made the decision not to do surgery, her doctors sent her home to get her antibiotics there, something the HMOs make us do now to save money, even though Melanie’s immune system was so compromised that there was debate among her doctors about whether she should stay in isolation and whether she could be in the same room as Nelly, her cat.
Late in the afternoon about 16 days after Melanie had entered the hospital, I got a call from Dr. David- son with the news that he had received the final results of her bone-marrow chro- mosomal studies, and she did not have drug-induced agranulocytosis. She was developing acute myelocytic leukemia (AML). Of the four leukemia classes, AML is the worst. Fate had invited Melanie to play a real-life game of Jumanji; in this version, only 10 percent of the players survive two years. Her mother would leave her home and life in south Laguna to take a ringside seat and look after Nelly.
After letting the news sink in for a few minutes, I went upstairs into my bedroom and cried, because Melanie isn’t my patient. Melanie is my sister.
For as long as I can remember, perhaps as long as I have been alive, Melanie has had an insatiable appetite for books. She was the oldest of four kids, and three of us were lucky enough to have Jack Chap- man as our sixth-grade teacher. Clad in his black leather jacket and helmet, he rode his motorcycle to school every day and used to lead our class in after- noon jogs around the playground. He used humor to maintain interest in a way I never had seen before nor encountered since. For example, when a student neglected to pay attention, Chapman would close one eye and straighten his left arm with the thumb extended upward and wavering slightly as he took aim at his target. The intended recipient of this message usually heard our chuckling and responded by stopping the offending behavior, but if not, Chap- man would lob a small chalkboard eraser in the victim’s direction.
Melanie presented Chapman with a dilemma. She would sit in her chair and read, ignoring assignments. Not wanting to send too disapproving a message but needing to get her attention, Chapman didn’t think the eraser treatment appropriate for her. Instead, when he gave a signal, the entire class would cease all other activity and stare at my sister until she put down her book.
Chapman dropped dead in front of his medicine cabinet of a heart attack at age 51, four days after I graduated from his class. As I wept at his funeral, I couldn’t help but feel that once he had finished with the Eichel children, someone had decided his work was done.
If a patient with AML has any idea what it means, he or she approaches treatment with the same enthusiasm as a sailor of a ten-foot boat approaching a level-five hurricane. Because the dysfunctional leukemia cells displace the normal immune system, infectious agents bombard the unsuspecting host, which is why many leukemics like Melanie have a severe infection at the time of diag- nosis. So what do we doctors do? We infuse poisons designed to destroy the immune system three times. It’s a bizarre notion that something good should come out of that, but these days the only chance that AML patients have of surviving the disease is to obliterate all of the defective cancer cells and replace them with cells that behave normally.