1. NYU Medical Grand Rounds Clinical Vignette Alexander Jow, PGY-3 February 21, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 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. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. Diagnosed with hepatitis C, genotype 1a in 2004 Evaluated at Beth Israel for treatment HCV Viral Load: 14 x 10 6 (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 History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. 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 10 7 (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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Chronic hepatitis C virus infection, genotype 1a, prior null responder with Peginterferon alfa-2a and ribavirin. Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Initiated on Peginterferon alfa-2a, ribavirin (1200 mg) and telaprevir August 12, 2011 Hepatitis C Viral RNA PCR at week 4: <4.30 x 10 1 (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 Treatment Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 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. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS