Transcript Journal Club - NYU Langone Medical Center

Medical Grand Rounds
Clinical Vignette
Avni Shah
PGY-2
January 29, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• Mr. M is a 57-year-old male who presents
requesting treatment for chronic Hepatitis C.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient previously followed at an outside
hospital where he was diagnosed with Hepatitis
C, genotype 1 and found to have a viral load of
> 8 million IU/mL.
• Four months prior to presentation the patient
was started on pegylated interferon alpha 2a
180 mcg weekly and ribavirin 800mg daily.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hypertension
•Chronic low back pain
•Past Surgical History:
•Appendectomy
•Social History:
•Smokes 6 cigarettes daily for the past 8 years. Prior alcohol use.
Prior intravenous drug use.
•Family History: Mother with stroke
•Allergies: NDKA
•Medications:
•Norvasc 5mg daily
•Oxycodone prn
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: alert, obese, no apparent distress
•Vital Signs: T: 98.7, BP: 142/80, HR: 75,
RR: 14
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: within normal limits
•Basic metabolic panel: within normal limits
•Hepatic panel: AST 69, ALT 87
•remainder of hepatic panel was within
normal limits
•PTT, PT, and INR were within normal limits
•HIV negative
•Hepatitis C Ab positive
•HBsAg negative, HBsAb negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Abdominal Ultrasound – mildly
heterogeneous liver parenchyma, normal
contour, no ascites
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• The patient was evaluated in Infectious
Disease clinic and 16 weeks of treatment with
peg-IFN alpha 2a and ribavirin was confirmed
with his pharmacy.
• HCV viral load was found to be > 7.0 x 105
IU/mL (pre-treatment VL was 8.46 x 106
IU/mL). As there was less than 2 log10 IU/mL
reduction in VL after 16 weeks of therapy,
treatment was discontinued.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• One year later the patient was started on pegIFN alpha 2a 180mcg weekly and ribavirin
1200mg, followed four weeks later with the
addition of bocepravir 800mg three times daily.
• Pre-treatment VL was 2.14 x107 IU/mL, and 8
weeks later (4 weeks of triple therapy) the VL
was 2.92 x 103 IU/mL, signifying a viral load
reduction of ~ 4 log10.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• Triple therapy was continued. The 12 week VL
was noted to be 3.38 x 105 IU/mL.
• The 16 week VL was 8.10 x 105 IU/mL
signifying virologic breakthrough.
• The patient was determined to have failed
therapy with bocepravir, and treatment was
discontinued.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Chronic Hepatitis C infection refractory to
treatment with peg-IFN/ribavirin and
protease inhibitors.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS