Every ti I walked down the hospital hallway, hushed voices could be heard from all around.
"That person, could it be……."
"The orca? Why is he here……………?"
Perhaps it was because of the recent incident that made even more well-known.
The gazes that recognized pierced my back like daggers.
But no one dared to approach.
And for good reason—David and I were walking briskly, like ergency staff rushing to the ER, with no room for relaxation on our faces.
“Up until 24 hours ago, the situation was dire.”
David explained the situation as we walked quickly.
“Due to systemic inflammatory response, his body temperature spiked to 39.5 degrees Celsius, his blood pressure dropped rapidly, and he went into shock. His kidneys nearly shut down, and his peripheral oxygen saturation fell below 80%. We barely, just barely, managed to get him through the worst with ECMO and dialysis.”
“An inflammatory cytokine storm, then.”
“Yes, that’s right.”
His entire immune system had collapsed, and a storm had raged within his body.
“In the end, that ans the MTOR pathway wasn’t the cause in Dylan’s case.”
Dylan.
That was the na of our current patient.
‘So it was this, after all.’
Dylan was a patient I had t before.
I had even strongly suspected that he was the sa type as .
The patterns of creatinine and IL-10 fluctuations in his chart were remarkably similar to what I had experienced.
‘So I had hoped he’d be the sa type…’
But now that my guess had been confird, I didn’t feel entirely pleased.
To , this was progress in the situation, but for Dylan, it was a devastating revelation.
It ant that he, too, was a patient dood to die with no known treatnt.
“This way.”
When David opened the hospital room door, tired faces turned to us.
Jesse, who must’ve been surviving on naps for days, had dark shadows under his eyes.
“Sean?”
Unexpectedly, Rachel was in the room as well.
It seed she, too, had been keeping vigil by the bedside.
Her usually neat hair was disheveled, and her reddened eyes were wet with tears.
“Thank you for coming.”
The people who approached were Dylan’s family, whom I had once t before.
They tried to smile, but their attempt failed miserably.
Their faces showed an awkward expression—neither a smile nor a cry.
I gave them a silent nod and walked over to the bed.
“Dylan?”
Under the oxygen mask, Dylan’s pale face slowly opened his eyes.
Maybe he recognized —sothing resembling a faint smile passed across his lips.
“The worst may be over for now…”
But even at a glance, Dylan’s condition was critical.
Irregular heartbeat, dangerously low blood pressure, and purplish hemorrhagic spots all over his skin.
His entire body was severely swollen—no need to even ntion that.
Then, the hospital room door opened, and the dical staff entered.
“Ha Si-heon?”
“Why is Ha Si-heon here…?”
Gasps of surprise burst from the residents and interns standing behind the attending physician.
But one sharp look from the attending silenced them imdiately.
In the heavy silence, the attending opened his mouth.
“At this point, we have two options we can consider. One is to try suppressing the inflammatory response with strong immunosuppressants, but…”
That would only address the visible symptoms, not the underlying cause.
It was like trying to patch a revolt of the immune system with a band-aid.
“And the second is… the off-label attempt proposed by your foundation.”
The attending physician knew of our approach.
That is, to take a Russian roulette-style gamble—choosing one of ten suspected immune pathways related to Castleman’s disease.
However, his eyes were filled with deep concern.
“But the ten proposed thods here are purely theoretical. Rapamycin has shown positive results in so patients, but the rest…”
He shook his head.
“They’ve never been tried before.”
This was a completely uncharted territory.
There were no precedents to rely on, no data to refer to.
“This is no different from Russian roulette. And if we take this path, Dylan will be the first to pull the trigger.”
It would be the true beginning of Russian roulette.
The doctor understood the need for our trial, but that didn’t an he supported it fully.
“Of course, soone has to take the first step. But whether that soone has to be Dylan…For now, I suggest we try symptom control and observe the progress.”
When the doctor finished speaking, the sound of sobs from Dylan’s family filled the room.
I spoke slowly, but with conviction.
“It’s true that we’re short on evidence, but that doesn’t an we’re acting without any basis at all. We plan to mobilize every available resource to find the best possible option.”
“But how can we be sure it really is the best option?”
A sharp rebuttal from the dical team followed.
I responded even more firmly.
“My resources are far more extensive. Hospital tests have their limits, but the biotech companies I’m currently investing in have far more sophisticated diagnostics. I plan to fully mobilize them.”
“That’s still just speculation.”
“All dical decisions are based on speculation in the end. But isn’t it better to pull the trigger in search of a cure than to just slap on a band-aid and wait?”
The attending physician clearly felt uneasy but couldn’t argue strongly.
He knew too well that the current prescriptions were nothing more than a temporary patch.
“The decision lies with the patient’s family.”
As heavy silence fell, a clear voice cut through the room.
“No, this decision isn’t for the doctors or the family to make.”
It was Rachel.
While we argued, she had been sitting by Dylan’s side, explaining the situation to him.
“The final decision belongs to Dylan.”
“……”
Both I and the dical staff fell silent at those words.
Rachel then calmly whispered the details into Dylan’s ear.
After a long fifteen-minute explanation, she asked,
“Dylan, which do you choose?”
He couldn’t speak through the oxygen mask, but Dylan’s intention was clear.
He smiled faintly and raised his hand.
With only his thumb and index finger extended, he mimicked pulling a trigger.
‘Bang’
It was as if a silent gunshot rang out in the room.
“Looks like the decision’s been made.”
Dylan chose to pull the trigger.
#
We had narrowed the suspected immune pathways involved in Castleman’s disease down to ten.
In other words, we had ten possible faulty circuits.
But the urgent question was—which one of them was the real problem?
That was the first thing we needed to find out.
Fortunately, a significant number of possibilities could be ruled out with just the hospital's tests.
“Looking at the ELISA and angiogenesis markers, as well as the vascular imaging results, it doesn’t seem to be an abnormal expression of VEGF-A.”
“Given the IL-2 receptor and CRP levels, MAS seems unlikely too. The complent activation levels are also within the normal range.”
We were able to eliminate half.
But five potential pathways still remained.
“T-cell exhaustion and regulatory dysfunction, overactivation of the NF-kB pathway, PI3K/AKT signaling issues, problems with the JAK-STAT pathway, or possibly the TLR pathway……………”
The hospital’s tests could not narrow it down any further.
However,
“Let’s request additional testing.”
I had the weapons of money and connections.
That made all the difference.
For instance, in relation to T-cells, the hospital could only perform basic immune profiling, but I knew companies capable of cutting-edge immune diagnostics.
With such technology, we could identify exhaustion markers like PD-1 and TIM-3, and more accurately pinpoint the problem area.
“With an electrophoretic mobility shift assay, though not yet comrcialized, we can directly confirm NF-kB’s DNA binding activity.”
2015 was the year the biotech boom exploded.
There was an abundance of advanced experintal testing thods still not introduced to hospitals.
Pathway-centric proteomics, advanced signal analysis, Phospho-STAT testing, TLR-specific assays.
I contacted companies equipped with such technologies, offering large sums in Ha Si-heon’s na in exchange for their help.
Normally, that wouldn’t be easy.
“Our fund sees high potential in your firm, and we’re currently reviewing an investnt of at least $200 million.”
Ha Si-heon was one of the most prominent investors in healthcare.
Moreover, my preparations for a large-scale private equity investnt were already an open secret in the industry.
Companies desperate for funding created special exceptions for and prioritized my test requests.
Thanks to that, we were able to save a great deal of ti…
But no matter how fast we moved, it would still take a minimum of two weeks—and up to four weeks—for results to co back.
‘Can Dylan even hold out that long…………?’
Dylan was barely suppressing further attacks with powerful immunosuppressants.
But this was like trying to cover a volcanic crater with a manhole cover.
There was still a ticking ti bomb inside his body.
And so, for over ten days, his survival relied solely on his willpower.
Yet still……………..
Dylan held on.
Until the test results ca back.
Barely—but persistently.
However, even after receiving the results, a great mountain still stood before us.
“We were able to eliminate the TLR pathway…………… but the remaining four pathways are still possible.”
In the end, only one pathway could be ruled out through testing.
That was expected.
The immune system is an intricate network.
A problem in one area triggers a chain reaction across all other pathways.
With all four pathways screaming, it was impossible to determine which had malfunctioned first.
“It must be one of the four…………….”
Science had taken us as far as it could.
Now, once again, we had to enter the unknown.
We had to make a choice without knowing what the real problem was.
“Targeting the JAK-STAT and NF-kB pathways first would be the fastest and safest approach. With ruxolitinib, dortezomib, and dexathasone, we could check for progress within 2 to 4 weeks……………”
So we pulled the first trigger.
We decided to calm the two most likely problematic pathways.
If one of those two was the true cause, the attacks would stop.
But if neither was?
“Patient condition deteriorating! Crash! Code blue!”
It wasn’t them.
Though Dylan had regained so stability, he was soon caught in another storm.
He barely survived, but his body had reached its limit.
“He probably won’t survive another round.”
The attending physician’s words fell heavily.
This ant even experintal treatnts might no longer be possible.
Two suspect pathways remained.
But within each were countless potential ‘broken switches.’
And we couldn’t rule out the possibility that even these two were wrong.
The road ahead was still long.
But only one chance remained.
That’s where David and I disagreed.
“I believe we need to try pembrolizumab. In Dylan’s case, PD-1 and PD-L1 expression is abnormally high. Targeting the exhausted T-cells with a checkpoint inhibitor could be the way……”
“But that’s too dangerous. For Castleman patients, it could trigger fatal seizures. I think we should go with idelalisib instead, which has fewer side effects……”
We both presented our logic, but no one truly knew the answer.
They were just elaborate guesses.
Ultimately, we wouldn’t know until we pulled the trigger.
With David joining the disagreent, even the attending physician weighed in, making the situation even more complex.
“Right now, the priority should be calming the cytokines with ruxolitinib and helping the patient regain so strength.”
“But he’s already shown no response to similar drugs. What guarantee do we have this one will work?”
I argued for taking the risk in pursuit of personalized treatnt.
David insisted on a step-by-step verification along the safer path.
The attending physician proposed suspending the trigger pull altogether until Dylan recovered.
No one could say who was right.
Everyone presented their reasoning, but no one had solid evidence to back it up.
As the confusion deepened, it was Rachel who brought clarity.
“The choice belongs to Dylan.”
She carefully unraveled the complex matter, explaining it in a way Dylan could understand.
All the options were laid out.
And Dylan made his decision.
“Are you… absolutely sure?”
But upon hearing his choice, everyone’s face turned grim.
Dylan had chosen the option I proposed.
“This is… the riskiest option among all those presented. As the doctor said, even if we were to attempt it, it should be after regaining so strength……”
However, Dylan shook his head gently.
He probably knew it too.
That ergency asures alone would never restore his strength.
This truly was his last chance.
So instead, he chose the path with the greatest reward, even if it carried the greatest risk.
‘Bang’
Dylan once again mid pulling the trigger with his hand.
And thus, he chose to undergo the treatnt I proposed.
Three days later,
“Ti of death, 10:49 a.m.”
He died.
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