NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Alexander Jow, PGY-3 February 21, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

7. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

8. 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.

9. 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

10. 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.