00:00Induction chemo did a number on me.
00:03Well, you're almost through the first dose.
00:05But we found an invasive fungal infection, presumptive candida.
00:08We're treating it with antifungals.
00:12Candida must have seeded in my liver.
00:15No, well, not the liver.
00:17It's likely diffuse endothelial, given the high beta-D-glucan level.
00:21Did you finish your homework?
00:24Is your father, is your father home yet?
00:27Mom?
00:27Joan, look at me.
00:28Hey, what's wrong with her?
00:29Ethan, step back.
00:33What's happening?
00:34She sees him.
00:35Oxygen to 10 meters.
00:37Alternative mental status?
00:38It's got to be neurological.
00:40Increased ICP, her brain is slow.
00:42If she had leukemia, this wouldn't be happening.
00:44Not this fast.
00:44You're right.
00:46We're missing something.
00:49The prednisone must have dropped her immune surveillance,
00:52which means that we're looking for something that's been there,
00:55possibly for years, like you said,
00:57but that's been hiding in plain sight.
00:59When Joan woke up and I told her about the candidate, she asked if it's seeded in her liver.
01:03Well, that wouldn't be uncommon, but the beta-D-glucan is so high that the fungal load would be too
01:08large to be isolated to her liver.
01:09Okay, we've been assuming that the elevated liver enzymes are caused by the MDS and the prednisone, but look at
01:16her blood work going back to 2016.
01:20Higher range of normal.
01:22But low enough that nobody would flag it.
01:252016.
01:26That's a long time for her to be carrying something.
01:30Wait a minute.
01:31One of my last memories of her.
01:342016, she was in Ecuador.
01:35And she got sick, and I told her that she should come back.
01:39And she self-diagnosed.
01:42She thought it was dysentery.
01:44Which means that she was drinking unfiltered water.
01:46So, if it was a parasite, she could have been sick while she was digesting it, but by the time
01:52it migrated to her liver, she was fine.
01:54And she could have been fighting this quietly for years.
01:56And then the prednisone weakened her immune system and unleashed it on her.
02:02I think we have a path now.
02:06I'm thinking 400 milligrams of bendazole.
02:09I'd go 300, giving the ALT-AST, and 20 of AMFO-B to balance it out.
02:16And 100 milligrams of cimididine to cut the renal toxicity.
02:20It's a tightrope.
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