Harvey Update

I wish I had new stuff to report. Harvey continues to have fevers, some of them alarmingly high and accompanied with shivering and chills – what is affectionately known as “Shake & Bake” by cancer patients. The graft continues to do well. As of today the platelet count is 45K! Long way up from when it used to be 10K with help from platelet infusions and not that far from 50K when he is considered to be officially “platelet engrafted”. The worrisome thing is that the latest CMV viral count has not budged much, it is still hanging tough at ~ 2K. They increased the ganciclovir dose as of today and if that does not work the plans are to switch to Foscarnet on Monday of next week. Local guidelines call for administration of foscarnet only as a hospital in-patient procedure and Harvey would very much prefer not to have to go back into the slammer. Hopefully, the higher ganciclovir dose will have kicked CMV butt by next week and we don’t have to consider Foscarnet.

“Let Them Eat Yogurt”

Since I do not have much news to report on Harvey, I will address some of the issues raised by our reader’s comments on the previous post.

Probiotics are an important part of keeping the gut healthy. These are ‘good bacteria’ that have learned to live in harmony with their human hosts. When their colonies get wiped out for whatever reason, most people get a bad case of diarrhea. One of the major causes of wholesale death of gut bacterial colonies is use of broad spectrum antibiotics. Think back to all the times you had heavy doses of antibiotics, for whatever reason. As the days of antibiotic therapy went on, I am willing to bet most of you got a case of “the runs”.

A simple way of helping your gut maintain a healthy ecosystem of good bacteria is to use foods that are a good source of probiotics such as yogurt. In recent months yogurt companies have come out with a bewildering array of “probiotic” yogurts. Harvey and I have become fans of “Danactive” and “Activia”. (No, I do not own stock in Dannon – and you are welcome to try other brands that you might find better tasting). The trick is to make sure the yogurt you do eat has “live” bacteria. A decade ago almost none of the national brands had live bacteria and you could get the live bacteria variety only in health food stores. If like me you are willing to go the extra step, you can make your own yogurt. It is not at all hard to do and you can get a good yogurt maker and starter for less than the cost of a family meal at the local McDonald. There are also probiotic capsules you can buy, I think the brand name is “Culturelle”.

Keeping your gut well populated with good bacteria is good for another reason. It is a jungle out there. If there are no good guys occupying all the eco niches available, bad guys can get a toe hold and start capturing more of the available real estate. As anyone who has gone through an infection of C. Diff can vouch, this is one nasty stomach bug that you do not want to encourage. Most of us are infected with C. Diff at some point in our lives (it is transmitted by poor hygiene, water contaminated with human waste etc) and our guts retain a sample of the bacteria. Take away the protective effects of good probiotic bacteria and C. Diff may grab the window of opportunity and flourish. C. Diff infection during stem cell transplant carries a still penalty – it is one of the first bugs that they tested Harvey for. I am happy to report Harvey’s gut is well populated with good bacteria and negative for any nasty C. Diff.

Graft-versus-Host-Disease (GVHD) is one of the most important and negative aspects of stem cell transplants. It is the evil twin of much desired Graft-versus-Leukemia (GVL) that is so important in eradicating remaining traces of cancer. GVHD can take place in many different organs: skin, gut, liver, even the eyes. Typically, gut centered GVHD is the most common, along with skin GVHD. There are many theories about what precipitates GVHD – this is an intensely researched area of research as you can imagine. One of the theories goes like this. During the preconditioning chemotherapy / radiation regimen of the transplant, the gut is stripped clean of its protective probiotic bacterial colonies. This in turn leads to inflammation of the lining of the gut.

Step two, the new graft gets settled down and starts making effector cells such as T-cells. These new T-cells look around, sense the massive danger signals coming in from the inflamed lining of the gut and rush to join the “battle” they think is going on. Problem is, these newly minted T-cells from the newly engrafted stem cells do not quite know how to tell friend from foe. Net result, we have a situation similar to the infamous keystone cops, T-cells firing their ammunition all around without necessarily hitting any bad pathogens. This over-the-top and poorly targeted immune response of the newly minted effector cells (T-cells, NK cells, macrophages etc) causes significant damage to the tissues of the gut, killing many of the cells lining the gut and precipitating gut GVHD. The worse the damage to the cellular lining, the more the inflammatory signals getting out and calling even more troops to the “party”. You get the picture, this is one cascade of events you do not want to trigger.

Since there is not a whole lot you can do about avoiding chemo and radiation prior to transplant, the next best thing you can do is soothe down your gut and resolve any inflammation as early as you can, before the ever so efficient (not!) T-cells decide they need to get involved in the process. Probiotics are an excellent solution. Believe it or not, a recent article and editorial in the ever so professional and ‘starchy’ journal “Blood” addressed this very issue in a articles titled “Graft versus Yogurt” and “Let them eat Yogurt”. I believe I reviewed these articles earlier on our website www.clltopics.org , you can look it up by searching for the key word “yogurt” in the search box at the top of the home page.

Making “Raita”

Most Americans are used to eating yogurt that has been sweetened with sugar, fruit or sweeteners. Purists in India would shudder at the concept. Most Indians eat yogurt as a regular part of their diet and kids are fed yogurt even before they become toddlers. I have eaten yogurt all my life, most often just plain. On more special occasions or when I have the time, I make a popular Indian dish called “Raita”. It is very easy to make and I thought I would share the recipe with you.

  • Peel, core, de-seed and dice fine a couple of medium sized cucumbers.
  • Blend in a quart of yogurt (whole milk variety tastes better, but you can use low fat or fat free if you must).
  • Add finely chopped green chili peppers – make it as hot or mild as you wish. I use Jalapeno peppers.
  • A generous dash of lemon juice, salt & coarsely ground black pepper to taste, half-cup of chopped fresh cilantro – and you are done.
  • Serve chilled. If you wish to make it more festive looking, you can also add grated baby carrots, finely minced sweet onion, finely chopped red bell peppers.

Be well,

Chaya