Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Alexander Jow, PGY-3
February 21, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
48 year-old man with a history of chronic
hepatitis C infection, genotype 1a with prior
treatment failure in 2010 referred to Bellevue
clinic for evaluation of retreatment.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Diagnosed with hepatitis C, genotype 1a in 2004
• Evaluated at Beth Israel for treatment
• HCV Viral Load: 14 x 106 (IU/mL)
• Liver biopsy with evidence of significant fibrosis
• Initiated on Peginterferon alfa-2a and ribavirin in
June 2010 at Beth Israel
• Developed shortness of breath thought to be side
effect of treatment
• Treatment stopped after 4 months due to lack of
virologic response
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
• Hypertension
• Urolithiasis
•Past Surgical History:
• Laser ablation of kidney stones
• Open reduction internal fixation of L elbow
•Social History:
• Active tobacco use for 35 years.
• Prior EtOH abuse for 35 years, 1 quart vodka/day, clean for 2 years
• Prior intranasal heroin x 30 years, last use 2009
• Multiple Incarcerations
•Family History:
• Father: Urolithiasis, Stroke
• No known family history of liver disease or malignancy
•Allergies:
•No Known Drug Allergies
•Medications:
• Hydrochlorothiazide 12.5 mg daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Well appearing, in no apparent
distress
•Vital Signs: T: Afebrile BP: 118/80 HR: 72
RR: 14 and O2 sat: 100%
• sclera anicteric
• abdomen soft, non-tender, non-distended,
no ascites, no hepatomegaly
• Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC:
•WBC 4.6, Hemoglobin 16.2, Platelets 103
•Basic metabolic panel:
•Sodium 141 (mmol/L), Creatinine 0.9 (mg/dL)
•Remainder of basic was within normal limits
•Hepatic panel:
• AST 121 (U/L), ALT 236 (U/L), Total bilirubin 0.4 (mg/dL) , Total
protein 7.7 (g/dL), Albumin 4.8 (g/dL)
•Hepatitis C genotype: 1a
•Hepatitis C Viral RNA PCR: >6.90 x 107 (IU/mL)
•Hepatitis B Surface Ab: reactive
•Hepatitis B Surface Ag: non-reactive
•Hepatitis A Total Ab: reactive
•HIV 1 and 2 Ab: non-reactive
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•ECG: normal sinus rhythm
•Chest X-Ray: normal
•Abdominal Ultrasound: Liver normal size
with subtle contour nodularity suggestive of
early morphologic changes of cirrhosis. No
ascites.
• Liver biopsy: Records at outside hospital
• Esophagogastroduodenoscopy: No varices
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Chronic hepatitis C virus infection,
genotype 1a, prior null responder with
Peginterferon alfa-2a and ribavirin.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Treatment Course
• Initiated on Peginterferon alfa-2a, ribavirin (1200 mg) and
telaprevir August 12, 2011
• Hepatitis C Viral RNA PCR at week 4: <4.30 x 101 (IU/mL)
• Developed generalized pruritis and mild rash on elbows with
relief using moisturizer
• Completed 12 weeks of telaprevir
• Resolution of rash after several weeks of telaprevir
• Hepatitis C Viral RNA PCR at week 12: undetectable
• Hepatitis C Viral RNA PCR at week 24: undetectable
• Mild anemia with hemoglobin 10.1 (g/dL)
• Completing 48 weeks of Peginterferon alfa-2a and ribavirin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Chronic Hepatitis C, genotype 1 a,
cirrhosis on imaging, prior null responder
on Peginteferon and ribavirin now with
rapid viral virologic response (RVR) and
early virologic response (EVR) after
protease inhibitor-based triple therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS