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Medical Grand Rounds Clinical Vignette

Medical Grand Rounds Clinical Vignette. Avni Shah PGY-2 January 29, 2013. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Mr. M is a 57-year-old male who presents requesting treatment for chronic Hepatitis C.

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Medical Grand Rounds Clinical Vignette

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  1. Medical Grand RoundsClinical Vignette Avni Shah PGY-2 January 29, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Mr. M is a 57-year-old male who presents requesting treatment for chronic Hepatitis C.

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

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: alert, obese, no apparent distress • Vital Signs: T: 98.7, BP: 142/80, HR: 75, RR: 14 • Remainder of Physical Exam was normal

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  7. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Abdominal Ultrasound – mildly heterogeneous liver parenchyma, normal contour, no ascites

  8. 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.

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Clinical Course • One year later the patient was started on peg-IFN 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.

  10. 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.

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Chronic Hepatitis C infection refractory to treatment with peg-IFN/ribavirin and protease inhibitors.

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