Chapter 245: Milo (2)
I got off the private jet and got into a vehicle reinforced with bulletproof glass, accompanied by my bodyguard.
Philadelphia.
The destination was the University of Pennsylvania Hospital.
When we arrived at the hospital entrance, David was waiting as always.
But there was an awkward smile on his face.
“You’re here again.”
David paused for a mont and added cautiously.
“I’m really glad to see you, but... with the way things are, it’s hard to say that and an it.”
“I feel the sa way.”
It was always the sa whenever we faced each other.
Whenever a Russian Roulette patient appeared.
We couldn't exactly greet each other with a smile when soone's life was hanging in the balance.
“Shall we... et the patient first?”
At David’s habitual question, I hesitated for a mont.
I briefly wondered what the point of eting this patient in person might be.
Still, not eting them wasn’t an option.
This patient, too, was soone ant to spin the Russian Roulette.
“Of course.”
On the way to the hospital room, my thoughts grew more complicated with every step.
‘I knew another one would show up soon, but...I was hoping for at least a few more months. If I’d had that, I could’ve gathered more tools.
Naturally, the AI tool I was developing wasn’t finished yet. Although I managed to secure access to China’s DNA/geno database with great difficulty, full-scale training hadn’t even begun. If only I’d hurried a little more—No. Even if I had, it would take another year or two for a beta model. And Russian Roulette patients will keep appearing during that ti.’
While I was lost in thought, David broke the silence.
“This patient... is the most difficult type.”
His face looked darker than usual.
“None of the theories or tools we’ve built so far will work. We’ll have to scrap all existing thods.”
Each ti Russian Roulette recurred, we had accumulated data.
From that, we were able to find small patterns and develop a kind of know-how.
But.
In this patient’s case, even our entire system and data were likely useless.
The reason was...
David hesitated, then confessed honestly.
“To be honest, I wasn’t even sure we should call you in. As you know, this case is...”
He suddenly stopped speaking and walking.
We had arrived in front of the hospital room.
Inside, many people had already gathered.
dical staff, and what looked like the patient’s family.
And, as always, Rachel was at the patient’s side.
“Sean, you’re here?”
She noticed and managed a faint smile.
But today, her smile looked especially sad.
Rachel gently stepped aside and gestured to the patient lying in the bed.
“Say hello. This is Milo.”
I couldn’t clearly see the patient behind Rachel.
‘I had a feeling...’
But he was even smaller than I imagined.
Roughly the size of a pillow on the hospital bed.
Yes.
This ti, the Russian Roulette patient...
Was a three-year-old boy.
Milo was unlike any patient I had encountered before.
And it wasn’t just because of his age.
‘No swelling.’
All the Castleman’s patients I had treated so far had bodies puffed up like water balloons.
Their kidneys couldn’t excrete fluids properly, causing the whole body to swell.
But Milo’s body showed none of those signs.
If anything, he was alarmingly thin.
I realized the reason too late.
‘Because he’s a child...’
The water balloon symptom cos from kidney dysfunction.
But that applies to adults.
Adults can endure for a while even with failing kidneys.
In other words, even if they swell up, they’re still strong enough to stay alive.
But children are different.
In children, reduced kidney function can quickly lead to tabolic shock and death.
What adults can endure, children cannot.
If an adult’s body is a water balloon that can hold together, then a child’s body is like bubblegum—ready to burst with the slightest pressure.
‘So that’s what David ant by “scrap everything.”’
The “blank slate” he had referred to.
Now I understood what that truly ant.
All the symptoms, progression, treatnts, and side effects of Castleman’s I knew...
Were based entirely on adult patients.
None of it applied to Milo.
And that wasn’t the only issue.
“No shots...”
His round eyes trembled as he looked up at .
He must have thought I was here to give him an injection.
His frightened little hands clutched a green dinosaur plushie tightly.
“Where’s Mommy? What about Daddy?”
“They’re talking with the doctor. They’ll be back soon.”
“No! Now!”
Rachel gently tried to soothe him, but the child eventually burst into tears.
Relatives nearby ca over to comfort him, but his crying didn’t stop.
Rachel gave an awkward smile, clearly flustered.
“He’s scared of strangers. He should be a little better in a few days.”
All the Russian Roulette patients we’d t until now had opened their hearts to Rachel easily, but Milo was different.
He was still far too young.
Three years old.
An age when stringing together even three words in a sentence was a challenge.
He didn’t even know he was sick.
No, he might not even understand what “being sick” ans.
I asked quietly.
“Where are the child’s parents right now?”
At that mont, Rachel’s expression subtly stiffened.
Hesitation.
That short pause told everything.
“Well... they went to seek a second opinion...”
The parents didn’t trust the dical team.
Which likely ant they hadn’t agreed to the Russian Roulette treatnt either.
‘Well, I guess that’s a natural response.’
Every patient’s family we had encountered so far had responded the sa way.
They were against it, saying it was far too dangerous.
But their objections didn’t matter.
Because the patients themselves wanted it.
And ultimately, the right to decide their own lives belonged to them.
But Milo’s case was different.
He couldn’t understand anything yet.
And the authority to make dical decisions rested entirely with his parents.
‘This just keeps getting harder...’
Then, the hospital room door opened and a young doctor entered.
“You’re here. I’ve co to escort you. The MDT eting is about to begin…”
MDT (multidisciplinary team eting) ant a eting where experts from various fields gathered to discuss a treatnt plan.
But for Milo’s MDT, a total of fifteen dical professionals were present.
“This is Professor Patel, the attending physician and pediatric hemato-oncologist.”
Experts from other fields were also present.
Pediatric intensive care, immunology, nephrology, infectious disease, neurology, pharmacology, molecular pathology…
If the patient had been an adult, three or four specialists would have sufficed.
But pediatric patients were different.
A child’s body is much more fragile and unstable than an adult’s.
One minor change could lead to catastrophic deterioration, and a failure in a single organ could trigger systemic collapse.
That’s why a multi-angle approach was necessary from the start.
The attending physician spoke first.
“The patient was admitted five days ago with fever, difficulty breathing, and severe fatigue.
Initial tests showed CRP at 210mg/L and ferritin at 15,000ng/mL, suggesting a severe cytokine storm.
A lymph node biopsy confird a diagnosis of multicentric Castleman disease, so we administered tocilizumab, an IL-6 inhibitor.”
Tocilizumab.
The primary treatnt for Castleman disease.
If it worked, fever would subside and inflammation markers would drop within 48 hours.
However…
“After 48 hours, CRP and ferritin levels showed no change.
We determined that the patient was unresponsive to IL-6 inhibition and decided to move on to rapamycin, an mTOR inhibitor.”
They tried a second treatnt.
But the results...
“After administration, the patient experienced hyperglycemia, hypertriglyceridemia, and tabolic acidosis. Kidney function deteriorated rapidly, with eGFR dropping to 20mL/min/1.73m2. Urinalysis showed proteinuria and microscopic hematuria, suggesting acute glorular damage.”
The first treatnt had failed.
And so had the second.
According to the system we had built, the next step was clear.
Try a bold new treatnt.
In other words, Russian Roulette.
But...
That kind of decision couldn’t be made so lightly when the patient was a child.
Why not?
Because even the previous failures couldn’t definitively be called failures.
“We need to try the IL-6 inhibitor again.”
The pediatric immunologist stepped forward.
He argued for re-administering the already failed first-line treatnt.
“It’s too early to conclude that IL-6 isn’t the central chanism. It’s more likely the dosage was insufficient than the drug being ineffective.”
Milo hadn’t received the necessary dose.
Why?
Because he’s a child.
“IL-6 inhibitors are usually dosed by weight, but this patient only received 70% of the required amount. In children, IL-6 also plays a crucial role in immune developnt and infection defense. Too much inhibition can sharply increase infection risk. Even with the reduced dose, he still showed signs of sepsis.”
Adults can tolerate IL-6 suppression to so extent.
But for a child, the infection risk skyrockets.
So they couldn’t give him the full dose, and that likely led to its ineffectiveness.
“Statistically, one-third of Castleman cases are IL-6 driven. We must rule out this possibility completely. I propose we administer the full required dose while co-treating with preventive antibiotics and G-CSF to manage infection risk.”
On the other hand, the pediatric nephrologist disagreed.
“There was no inflammatory response after administering the IL-6 inhibitor. It’s hard to see this as a re dosage issue. Rapamycin seems like the more likely option.”
“But rapamycin also failed to reduce inflammation markers, didn’t it?”
“That’s because it takes longer to work. According to clinical data, rapamycin typically requires at least two weeks of treatnt to show efficacy. This ti, it was discontinued after just three days.”
There had been good reason to stop the treatnt that quickly.
“Because the patient experienced sudden tabolic dysfunction and kidney deterioration.”
Once again, the child’s body couldn’t tolerate the dication.
This ti, it was insulin regulation and reduced renal blood flow.
“We need to administer it continuously for two weeks. By combining it with tformin to improve insulin sensitivity, and using ACE inhibitors or ARBs...”
‘This is tough.’
Should we retry the first drug?
Or attempt the second one again?
Either might be what Milo needs.
But nothing was certain.
And then—
There was a third possibility we couldn’t ignore.
Russian Roulette.
The new path Dylan had risked his life to uncover.
We also had to consider the PI3K/AKT pathway and others.
But the doctors didn’t even entertain that option.
“In diagnostics, you start by ruling out the most likely chanisms. It’s premature to attempt experintal treatnt before fully validating IL-6 and rapamycin.”
They weren’t wrong.
By the book, you only consider a third option after options 1 and 2 are definitively exhausted.
So we had to reexamine 1 and 2 first.
However—
“The IL-6 inhibitor already caused sepsis.”
“If you’re talking risk, isn’t rapamycin worse? I’d say kidney damage is the more serious concern.”
Both had high potential for severe side effects.
The doctors were split.
But there was no right answer.
This wasn’t sothing that could be resolved through theory alone.
Ultimately, the treatnt had to be administered, and the results observed.
‘If only I had AI now. If we could simulate side effects in a pediatric body, drug tabolism rates, the ti required for efficacy—If all those variables could be modeled from clinical data...’
But it was pointless to dwell on that.
That kind of technology still didn’t exist.
‘If only there were a way to find so kind of clue...’
Just then, my eyes landed on the watch dial.
It was almost midnight.
The mont the hands struck twelve, as always, a translucent window appeared in my vision.
[Ti of Death: March 11, 2023]
[Ti Remaining: 2,682 days]
[Survival Rate: 24.2%]
The sa death notice as always.
As I stared at it, the doctors’ voices continued in the background.
“Then let’s go with the IL-6 inhibitor first.”
“That seems best.”
A decision had been made.
The dical team had finally chosen a direction.
But at that very mont...
Sothing happened to my death notice that had never happened before.
[Ti of Death: March 11, 2023]
[Ti Remaining: 2,682 days]
[Survival Rate: 24.0% (-0.2%p)]
The number changed.
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