CASE 3

• 48 yo man • HIV positive/HEP C positive 12 yrs ago

• Tenofovir/FTC/RTV/Lopinavir x 7 yrs• CD4 310/40% HIV Viral Load <40

CASE 3

• Genotype 1a Hepatitis C

• Liver biopsy in 2009 reveals 4/4 scarring with

ongoing active inflammation

• Compensated Cirrhosis and clinically stable

• OGD negative for varices and U/S negative for hepatoma/Ascites

CASE 3

2010

• HIV meds switched form TDF/FTC/RTV/LPV to TDF/FTC/RGV

• Therapy for Hepatitis C initiated with PEG INF 180mcg/RBV

1200 mg/Boceprevir 2400 mg

CASE 3

• Week 0 HCVRNA 1.67 x 10e7• Week 4 HCVRNA 4.22 x 10 e4• Week 8 HCVRNA 1.90 x 10 e1• Week 10 HCVRNA Not detected

CASE 3

Week WBC Pmns

0 4.3 2.3

4 2.8 1.0

8 1.3 0.3

10 1.0 0.1

CASE 3

• Pegasys dose decreased to 135 mcg

• Ended up with a fever and was hospitalized with febrile neutropenia…hypotensive…no source of infection found

• G-csf initiated and titrated up to daily dosing

CASE 3

Week WBC Pmns

0 4.3 2.3

4 2.8 1.0

8 1.3 0.3

12 1.0 0.1

14 0.9 0.1

16 0.9 0.1

CASE 3

• Pegasys dose decreased to 90 mcg

• Ended up with a fever and was hospitalized once again with febrile neutropenia…

CASE 3

• Therapy abandoned

• Over the ensuing 3 years…Pmns remained below 0.5 despite G-csf daily…antibodies to GCSF not detected

• Bone marrow done and PMN progenitors seen…spleen not huge on U/S

• Trial of IVIG given without benefit in regards to increasing PMNs

CASE 3

Early 2014

• Baseline pmns are 0.4-0.5

• Would you retreat with Sofosbuvir/PEGINF/RBV?

CASE 3

Early 2014

• Fighting with private insurance to get Sofosbuvir/Simeprevir

• Denied

CASE 3

Late 2014

• Pmns 0.4-0.5

• What should we do?

CASE 3

Late 2014

Sofosbuvir/RBV now vs wait for

• Sofosbuvir/Ledipasvir• ABBVIE quad• Other?