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 moment and added cautiously.
“I’m really glad to see you, but... with the way things are, it’s hard to say that and mean it.”
“I feel the same way.”
It was always the same whenever we faced each other.
Whenever a Russian Roulette patient appeared.
We couldn't exactly greet each other with a smile when someone's life was hanging in the balance.
“Shall we... meet the patient first?”
At David’s habitual question, I hesitated for a moment.
I briefly wondered what the point of meeting this patient in person might be.
Still, not meeting them wasn’t an option.
This patient, too, was someone meant 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/genome 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 time.’
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 methods.”
Each time 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.
Medical 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 me 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 time, 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 comes 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 metabolic 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 meant by “scrap everything.”’
The “blank slate” he had referred to.
Now I understood what that truly meant.
All the symptoms, progression, treatments, 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 me.
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 came over to comfort him, but his crying didn’t stop.
Rachel gave me 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 met 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” means.
I asked quietly.
“Where are the child’s parents right now?”
At that moment, Rachel’s expression subtly stiffened.
Hesitation.
That short pause told me everything.
“Well... they went to seek a second opinion...”
The parents didn’t trust the medical team.
Which likely meant they hadn’t agreed to the Russian Roulette treatment either.
‘Well, I guess that’s a natural response.’
Every patient’s family we had encountered so far had responded the same 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 medical 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 come to escort you. The MDT meeting is about to begin…”
MDT (multidisciplinary team meeting) meant a meeting where experts from various fields gathered to discuss a treatment plan.
But for Milo’s MDT, a total of fifteen medical 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 confirmed a diagnosis of multicentric Castleman disease, so we administered tocilizumab, an IL-6 inhibitor.”
Tocilizumab.
The primary treatment 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 treatment.
But the results...
“After administration, the patient experienced hyperglycemia, hypertriglyceridemia, and metabolic acidosis. Kidney function deteriorated rapidly, with eGFR dropping to 20mL/min/1.73m2. Urinalysis showed proteinuria and microscopic hematuria, suggesting acute glomerular damage.”
The first treatment had failed.
And so had the second.
According to the system we had built, the next step was clear.
Try a bold new treatment.
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 treatment.
“It’s too early to conclude that IL-6 isn’t the central mechanism. 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 development 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 some 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 mere 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 treatment to show efficacy. This time, it was discontinued after just three days.”
There had been good reason to stop the treatment that quickly.
“Because the patient experienced sudden metabolic dysfunction and kidney deterioration.”
Once again, the child’s body couldn’t tolerate the medication.
This time, it was insulin regulation and reduced renal blood flow.
“We need to administer it continuously for two weeks. By combining it with metformin 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 mechanisms. It’s premature to attempt experimental treatment 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 something that could be resolved through theory alone.
Ultimately, the treatment 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 metabolism rates, the time 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 some kind of clue...’
Just then, my eyes landed on the watch dial.
It was almost midnight.
The moment the hands struck twelve, as always, a translucent window appeared in my vision.
[Time of Death: March 11, 2023]
[Time Remaining: 2,682 days]
[Survival Rate: 24.2%]
The same 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 medical team had finally chosen a direction.
But at that very moment...
Something happened to my death notice that had never happened before.
[Time of Death: March 11, 2023]
[Time Remaining: 2,682 days]
[Survival Rate: 24.0% (-0.2%p)]
The number changed.