Saturday, October 17, 2009

The Fall of a Sparrow

The history of humanity is awash with laughter and tears and speaks of the collective through the singular. Our dreams and aspirations, displayed in our daily life, are full and bright with the sweet touch of that elusive whim of hope. Yet sometimes in the midst of that dream of life a nightmare insinuates itself shattering the sharp reflections of a smooth glassy desire. The best-laid plans go awry. The marginalized fears collectively take center stage and a spiral of inconceivable torture of the soul is borne to its depths. Just as a singular event, like an untimely frost, imprisoning a beauteous rose in its frozen clutches, can force a withered decline, so can the growth and longevity of life be cut short by unimaginable suddenness of precocious sadness.

Sunday afternoons as they usually are, are full of reflections over the days gone by, the hope of what is to come and hurried attempts to get in the last bit of fun before the sun slips below the horizon. But on this day there is an approaching storm. The outflow is barely visible but the harsh wind is blowing within, and the walls, windows and doors of this house can barely keep the painful stinging out. The family of four sits around the dining room table at the afternoon lunch hour. A proud father rejoicing in his bounty helps his five-year-old with the meal as his wife looks on with a loving smile.

Meanwhile in his bloodstream the scene of chaotic impulse flows in rhythmic waves overwhelming the defenses. A battle rages within these vessels and not a single piercing bullet of pain or anguish has been fired. The population of these white blood cells is different in their demeanor and functionless in form as they continue to ripple through, their numbers geometrically increasing. The waves keep rising higher and higher heralding the oncoming Tsunami of disaster.

Fig 1: Acute Promyelocytic Leukemia Cells

It all started three or so months ago. There was this large onslaught of viral infection. It created an initial flu like syndrome, replete with cough, fever, muscle aches and pains and then as quickly as it erupted, it abated as colds and flu are wont to. Then four weeks ago the first impulse of the riot in the bone marrow occurred. The aches in the joint were minimal at first as the virus had deftly in its cruel but self sustaining mode inserted itself in the DNA of this human. It was an innocent piggyback ride for self-propagation. It was the virus’ means to grow and survive. A simple plant really. Just plug itself into the genomic material within the cell so that as the cell multiplies so would the virus also. And what better ride than the mother (stem) white cell that needs to multiply and divide to create many more white cells to keep the body safe from infection and harm. Surreptitiously in quiet stealth and design for means more innocent than devious the virus did it for its own survival. No wonder the viral population is in the trillions and far outweighs any other living or half-living species. The act of survival is paramount for a species to exist for millions of years.

Once inserted into the DNA as the mother white cell undergoes the division process, the DNA now with added material copies a variant of the original. The virus may not directly issue the edict but may jumble the DNA enough to make the “jumping genes” jump farther and a piece of one chromosome flips and translocates on another chromosome, as happens in Acute Promyelocytic Leukemia (APML) between Chromosome 15 and 17 stimulating the (Retinoic Acid Receptor) RAR alpha which deregulates growth behavior bringing chaos.

 Fig 2: Chromosomal Translocation

The (RARa) receiving chromosome #17 site of attachment carrying the cell regulatory function works like a thermostat, too hot and the heater stops till it gets cold again and the heater kicks in. The attached material disarms this “thermostat” function and the regulatory function being lost creates anarchy of production without demand. The result is a mutiny by the dysfunctional many against the armed few.
As waves upon waves of these mutinous cells hit the shore, the defenses slowly crumble against the unending might of a self-replicating armada of wayward cells. They choke the supply of goods delivered by the blood vessels to the organs that digest, produce hormones collect fresh oxygen and remove waste products. The fight is waged and the duration of the fight is dependent on the age of the individual. The young ones override the signs and symptoms until they are overwhelmed; the elderly deteriorate slowly and progressively due to lack of reserves a bit faster.

The father reaches for salt to sprinkle on his soup and his hand never reaches the saltshaker. The shudder of the table and the dishes fly off crashing in a heap on the floor. The young children cry out in unison with alarm and surprise. The wife grabs her children and runs for the telephone. A decision that has to be made takes moments longer because of the suddenness and the implied gravity of the event, but it is made and the ambulance is on its way.

“How are you feeling today?”
“Better.” He replies looking at the figurine perched next to his bed given to him by his child to watch over him. The blue paint chipped off at the bottom. The figurine is just slightly less than beautiful but for the skin of the paint.
“Any shortness of breath?”
“No.” His face is pale with concern and his shock of black hair is disheveled. The stubble of beard has grown in the twenty-four hours since the event. “So what do I have?”

This question has faced many a person and will continue to haunt many more. The jeopardy in life is the wanting to know but staying in the comfort of not knowing. Something inconsequential is just that where knowing or not knowing is the same – immaterial. But where life hangs in the balance the question gets harder and harder to ask and receiving the answer even harder.

It is difficult whether the answer is what makes some people lift up and fight the fight while others slump down and crawl into a cave of insecurity. The impact of the unexpected hits different people differently. He seemed to take it in stride for the moment. But in the ensuing moments of nothing said the wave of future expectations came crashing down and the beachheads of expectation gradually caved. There in that “worst of times” was no glimmer of “the best of times.”  The “Lots to live for,” seemed a distant memory now with the little to fight with. He could not perceive his future. He could not see his children grow up and give him grandchildren. He could not even see his son’s first bike ride. The vagueness of the cloudy blur overwhelmed the clarity beyond. As the evening approached darkening the afternoon, his wife took the children home. Drowning inside the four walls of this bleached environment he was devoid of the air of family support briefly. He was alone, not hearing the words of optimism, nor the potential option of cure. All he saw through the tunnel of darkness was more darkness. The recent advance in therapy with ATRA combined with Chemotherapy and the potential cure was never brought to bear. Life could have gone on. It could have. But it didn't.

They would call this a case of Acute Promyelocytic Leukemia with an Acute Disseminated Intravascular Coagulation as the catastrophic bleeding event that caused his death but maybe it was the sudden shattering of a dream, the irreplaceable joy, the lucid harmony, his life till then that was suddenly lost to him and his family.

There is special providence in the fall of a sparrow. If it be now, tis not to come, if it be not to come, it will be now; if it be not now, yet it will come- the readiness is all.

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