Many patients with chronic hepatitis C (HCV) infection undergoing treatment with pegylated interferon-alpha (PEG-IFN-alpha) and ribavirin develop neutropenia requiring dose reduction or granulocyte colony-stimulating factor (G-CSF) supplement. We analysed the database of patients who completed treatment for chronic HCV infection between 2003 and 2006. Patients with absolute neutrophil counts below 1000 cells/microL were initiated on G-CSF (G-CSF group) while a matching group of patients who received anti-HCV treatment without developing neutropenia were used as a control group (non-G-CSF group). Patients on the G-CSF arm were divided into two subgroups based on the timing of G-CSF administration relative to PEG-IFN-alpha administration. Of the 163 patients with HCV infection, 30 patients received G-CSF, most of who were maintained on 300 microg of G-CSF once a week. Administration of G-CSF 2 days before or after each dose of PEG-IFN-alpha did not make a significant difference in the neutrophil counts. In the G-CSF arm, 23 of 30 patients (77%) had undetectable end-of-treatment viral response which was comparable with 27 of 30 in the control group (90%; P = 0.17). There was no statistically significant difference in the sustained viral response between the two groups (61%vs 76%, P = 0.18). In most patients PEG-IFN-alpha induced neutropenia improved with a once-a-week dose of G-CSF with a comparable virological outcome. Timing of G-CSF administration did not make any significant impact on the patient's neutrophil counts but was better tolerated when given 2 days apart from PEG-IFN-alpha.
Advanced practice nurses are faced with the clinical challenge of recognizing risk factors for chronic hepatitis C, not only in the native-born population, but also in the immigrant populations in the United States. Hispanics/Latinos constitute 13% of the U.S. population and are the fastest growing minority in the United States. A greater understanding of chronic hepatitis C in this populace was accomplished by reviewing current literature in the areas of natural history, epidemiology of risk factors, screening practices, and therapy outcomes. This review serves as a foundation for the creation of a culturally competent assessment tool for the screening of chronic hepatitis C in this population. The information from the literature review suggests that Hispanics/Latinos have an overall prevalence rate for chronic hepatitis C of 2.6%; have faster liver fibrosis progression rates; are infected at an earlier age; are more likely to be HIV coinfected; and show significantly higher alanine transaminase, aspartate transaminase, and bilirubin levels. They also have more portal inflammation than do Caucasians and African Americans and a higher prevalence of cirrhosis than do African Americans--more so in Hispanic women than in Hispanic men. Transfusion, tattoos, and iatrogenic transfer are risk factors that need to be assessed.
Mycobacterium avium complex (MAC) is an uncommon cause of soft tissue infection. There are no standard guidelines for management of localized MAC infections especially when it is refractory to therapy. We describe a 29 year old white male with right wrist tenosynovitis. He was initially treated with local injection of steroids with no improvement. MRI of the hand showed no evidence of osteomyelitis. Tissue obtained at surgical débridement grew MAC. The infection did not show any significant resolution after 4 months of treatment with ethambutol and clarithromycin. Rifabutin and sparfloxacin were added to the regimen and repeat surgical débridement was done. MAC was grown again. Based on in vitro susceptibility results, sparfloxacin was changed to clofazimine with no significant improvement. Repeat surgical débridement showed acid-fast bacilli on staining but no growth on culture. GM-CSF 500 μg SQ three times a week was started. The wrist wound showed complete closure after a week. GM-CSF was stopped at 2 months due to side effects and antimycobacterial drugs were stopped at 18 months. After 6 months, the patient presented with swelling of right 5th MCP joint. Biopsy showed acid-fast bacilli on staining with no growth on culture. Patient was started on ethambutol, rifabutin, clarithromycin and clofazimine again along with IFN gamma 50 μg SQ three times a week. A repeat surgical débridement showed acid-fast bacilli in tenosynovium, necrotizing granulomatous inflammation and caseating granulomas. No organisms were grown. T helper cell count was normal. IFN-gamma was stopped at 3 months. Patient is nearing completion of an 18-onth course of antimycobacterial regimen and is doing well. To our knowledge, this is the first report of successful treatment of recurrent localized MAC infection using IFN-gamma in a patient with no detectable evidence of immunodeficiency.
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