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The fight of his life
Noah received 73 doses of the "poison," and his mother, Danielle Rheinlander, has no regrets. In fact, she would do it again if it meant saving her young son's life.
The Imperial tot, who will turn 4 years old in June, has acute promyelocytic leukemia and is the first child with APL to be treated with arsenic trioxide at Children's Hospital of Pittsburgh.
Arsenic trioxide is designed to interfere with the growth of cancer cells and is administered through a temporary intravenous line implanted in the chest. Doctors hoped the treatment would help decrease Noah's chances of rejecting a bone marrow transplant.
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But, Krishnamurti said, arsenic trioxide has less toxicity than conventional chemotherapy and has shown to be well-tolerated.
"This is still a relatively new therapy for children with APL," Krishnamurti said. "APL is unique because you can use different agents to try to convert the cancer cells. You can actually force them to mature. In some ways, that's a simpler way to treat cancer."
Compared to other medical treatments, the Food and Drug Administration wasted little time approving arsenic trioxide, also known as Trisenox. In 2000, just three years after the study of the drug was started in the United States, Trisenox was approved for the treatment of patients with APL who either failed to respond or relapsed following the use of first-line therapies. According to the FDA, an estimated 400 of the 1,500 newly diagnosed patients each year fall into those categories.
Arsenic-based therapy was used in the United States and Europe more than 100 years ago to treat leukemia and infections, but was abandoned in favor of chemotherapy and antibiotics. It enjoyed a revival, so to speak, when a physician in China encountered a native practitioner who appeared to be curing all types of cancer using arsenic-based therapy.
Now, it's a front-line treatment in the United States.
"It's quite a great story of medical discovery," Krishnamurti said.
And that's good news for Noah, who was diagnosed with APL on Sept. 15, 2005, just a few weeks after his mother noticed the first symptoms.
APL is a cancer of the white blood cells in which there is a rapid accumulation of the cells in the bone marrow and blood. It can result in anemia, susceptibility to infections, bleeding and hemorrhage.
Danielle became concerned when her rambunctious, fair-skinned son began to experience widespread bruising. One day, he awoke with blood crusted in his nose; two days later, Danielle was pulling clots from his nose.
"This was a heartbreaker," said Danielle, explaining that when Noah was 3 days old, he had surgery to remove four inches of his small intestine that contained a blockage and received an ileostomy.
When the ileostomy was reversed, "He was as healthy as he could be until he got the leukemia," Danielle said.
Noah's grandmother, Gretchen Rheinlander of Hanover Township, who drives a bus for the Burgettstown Area School District, is glad her daughter refused to listen to others and dismiss the bruises as typical boyhood injuries.
"If your kids get sick, we're so fortunate to live in this area," Gretchen said. "Everyone here is wonderful."
When Noah was diagnosed with APL, he underwent three types of chemotherapy. He remained in remission until July 2006, when he started the arsenic therapy. He was admitted to the pediatric Intensive Care Unit for the first 72 hours so he could be monitored; he received the remainder of the doses as an outpatient.
"I'm so glad we did it," she said. "He went into remission and was as close to normal as he could be."
Noah's transplant saga
On Oct. 17, Noah returned to Children's Hospital - and he has remained there ever since.
When he arrived, he was given high doses of chemotherapy for 10 days before undergoing the bone marrow transplant. The bone marrow came from umbilical cord blood, which contains cells from a newborn with an underdeveloped immune system that theoretically, doctors say, should reduce complications of a transplant.
"Cord blood works best on a small target because it may be overwhelmed by the path it has to take," Krishnamurti said. "There's a distinct advantage with a new immune system. It's more likely to attack your cancer cells. Not only will it attack viruses, it will attack any cell that looks out of place."
Noah was recovering just fine until the Epstein-Barr Virus destroyed his bone marrow. EBV is a common herpes virus that normally lies dormant. It can be activated, Krishnamurti said, when the immune system is suppressed.
"We were doing quite well. Then he had fevers," Krishnamurti said.
Noah received low-dose radiation and chemotherapy until Dec. 22, when he underwent what Krishnamurti called a "life-saving" second bone marrow transplant.
Only this time, Noah's recovery was more dubious. Since his immune system was even more vulnerable, Noah developed painful mouth sores, and the lining of his airways became so swollen he required a tracheotomy.
"There was more immune suppression after the second transplant, and we wanted to make sure he didn't lose this graft," Krishnamurti said. "You can transfuse red blood cells and platelets, but if you have no white blood cells, over the course of time you will get an overwhelming infection.
"There wasn't a good way of immediately controlling the herpes. He had fevers for a long time ... he was in danger."
During the tracheotomy, a plastic tracheostomy was inserted into his neck. It bypassed the worst part of the affected airway.
"That's significant in somebody with no white cells," Krishnamurti said. "His herpes was really very bad. His mouth and lips were extremely badly affected. The only thing that saved his life was doing the tracheostomy."
Noah was aggressively treated with antiviral medications, and on Feb. 5, he was moved from pediatric ICU to the eighth-floor cancer ward.
"Noah has a great fighting spirit," Krishnamurti said. "We're very encouraged by how he's doing. In transplants, you take it one day at a time. Today, we are happy."
And so is Noah. One of the first things he did upon returning to the eighth floor was man the controls of his Playstation.
"Anytime he's here, he's a social butterfly. He's got an ornery reputation around here when he's feeling well," Danielle said.
Noah : 6/1/2008
My daughter too was diagnosed with APL at two years. She did not have to undergo bone marrow transplant. We wish Noah the very best in his recovery. Kids are such great examples of fighters! We should all be as tough in spirit as they are!
