兒童EBV感染及相關(guān)疾病的診斷(講)-謝正

1、兒童EBV感染相關(guān)疾病及診斷病毒室 謝正德常用名正式命名所屬亞科生物學(xué)特性單純皰疹V-1型人皰疹V1型在感染N節(jié)中潛伏單純皰疹V-2型人皰疹V2型在感染N節(jié)中潛伏水痘-帶狀皰疹人皰疹V3型在感染N節(jié)中潛伏EBV人皰疹V4型在淋巴細(xì)胞中潛伏CMV人皰疹V5型在淋巴細(xì)胞及分泌腺體中潛伏人皰疹V6型人皰疹V6型同上人皰疹V7型人皰疹V7型同上人皰疹V8型人皰疹V8型同EBVBurkitts lymphoma in KenyaEpstein-Barr virus (EBV)1964, discovered from Burkitts lymphoma tissue by Epstein, Achong

2、, and Barr1968, the etiologic agent for infectious mononucleosis1970, nasopharyngeal carcinoma1980, non-Hodgkins lymphomaEBVn雙鏈DNA病毒，皰疹病毒科，亞科，基因組Genome: 172282 bp，有環(huán)狀和線性兩種形式n人群感染率高，我國(guó)35歲兒童95%已血清轉(zhuǎn)化nEBV原發(fā)感染在嬰幼兒及學(xué)齡前兒童主要為亞臨床感染，在青少年和成人致IM（國(guó)外）nEBV與許多疾病相關(guān)Circular form of the EBV genome (latent infection)Li

3、near form of the EBV genome (lytic infection)EBV 相關(guān)疾病n傳染性單核細(xì)胞增多癥（Infectious mononucleosis，IM）n慢性活動(dòng)性EB病毒感染（Chronic active EBV infection，CAEBV）nEB病毒相關(guān)性嗜血細(xì)胞綜合征（EBV-associated hemophagocytic syndrome, EBVAHS)EBV相關(guān)疾病n伴性淋巴增殖綜合征（X-linked lymphoproliferative syndrom）n鼻咽癌（Nasopharyngeal carcinoma）nBurkitts 淋

4、巴瘤（Burkitts lymphoma）n何奇金淋巴瘤（Hodgkins lymphoma）BCD21gp350MHC-IIEBVAsymptomatic infectionSymptomatic infection（IM)Primary EBV InfectionLatent infectionEBV-related other diseases SalivaOropharynxLymphoid tissue and peripheral bloodResting B cellEpitheliumLytic EBV-infected B cellEBV-infected B-cell bl

5、astReactivated EBV-infected B-cellLytic EBV-infected B cellEBVEBVLatently infected, resting memory B cellsCytotoxic T cell Cytotoxic T cell Natural killer cell LMP-1LMP-1LMP-2LMP-2LMP-2LMP-2Primary infectionPersistent infectionCohen, JI N Engl J Med 343:481-492, 2004傳染性單核細(xì)胞增多癥（Infectious mononucleos

6、is，IM）IMIM嗜異白細(xì)胞陽(yáng)性：EBV 嗜異白細(xì)胞陰性：EBV CMV Rub HHV6 AdvEBV-IM的臨床表現(xiàn)n發(fā)熱： 約1周，嚴(yán)重者2周或更久，幼兒可不明顯n淋巴結(jié)腫大：任何淋巴結(jié)，頸部最易受累n咽炎：50有滲出物，25上腭有瘀點(diǎn)n脾腫大：病程23周，50出現(xiàn)n肝炎：腫大1015，而GPT升高80n皮疹：紅斑、斑丘疹或麻疹樣疹，50可有眼瞼浮腫EBV-IM的臨床表現(xiàn)n其它：1.間質(zhì)性肺炎2.CNS: 腦炎、格林巴利綜合征等3.心肌炎4.血液系統(tǒng)：溶血性貧血、再障、粒細(xì)胞減少5.腎炎6.關(guān)節(jié)炎7.胰腺炎IM的診斷nIM的擬診：臨床表現(xiàn)（發(fā)熱+滲出性咽峽炎+淋巴結(jié)腫大、脾腫大） +異

7、型淋巴細(xì)胞升高（10）EBV-IM的診斷n嗜異白細(xì)胞凝集抗體n特異性EBV抗原的抗體檢測(cè):衣殼抗原（CA）IgMn熒光定量PCR檢測(cè)外周血中EBV-DNA嗜異白細(xì)胞抗體nIgM抗體nIM病人的血清在經(jīng)吸收幾內(nèi)亞豬腎抗原后引起山羊紅細(xì)胞的凝集n第12周出現(xiàn)，持續(xù)約6個(gè)月；小于5歲者，很可能陰性外周血中EBV-DNA檢測(cè)n普通PCRn熒光定量PCR：熒光定量PCR檢測(cè) EBV-DNA（血清、血漿、全血、外周血單核細(xì)胞），急性期（病程10天內(nèi)）敏感性和特異性100衣殼抗原（CA）IgMn一般情況下：一周左右升高，持續(xù)存在48周，類風(fēng)濕因子和IgG抗體可致結(jié)果假陽(yáng)性n臨床要注意以下情況：1、有的病人抗

8、EB病毒CA-IgM產(chǎn)生延遲2、少部分病人感染EBV后，CA-IgM持續(xù)陰性3、也有的病人CA-IgM持續(xù)幾個(gè)月陽(yáng)性抗體親合力檢測(cè)n機(jī)體在受到病原體入侵時(shí)首先產(chǎn)生低親合力抗體，隨感染的繼續(xù)和進(jìn)展，抗體親合力升高。因此，低親合力抗體的檢出提示原發(fā)性急性感染。n原發(fā)EBV感染，100的病人在第一個(gè)月內(nèi)可檢測(cè)到抗EB病毒CA-IgG低親合力抗體原發(fā)性原發(fā)性EBV感染后的免疫抗體反應(yīng)感染后的免疫抗體反應(yīng)IMEBV抗體四項(xiàng)nVCA-IgGnVCA-IgMnEA-IgGnNA-IgGnVCA-IgG親合力EBNA-IgG陰性VCA-IgG陽(yáng)性VCA-IgG陰性未感染VCA-IgM陽(yáng)性原發(fā)感染VCA-IgM

9、陰性EAIgG強(qiáng)陽(yáng)性原發(fā)感染（ VCA-IgG 低親合力）、感染后復(fù)發(fā)、或感染晚期抗EBNA抗體降低（ VCA-IgG 高親合力）EAIgG陰性感染后復(fù)發(fā)或感染晚期抗EBNA抗體降低（ VCA-IgG 高親合力）EBNA-IgG陽(yáng)性僅VCA-IgG陽(yáng)性晚期感染VCA-IgG陽(yáng)性和EA-IgG強(qiáng)陽(yáng)性或VCA-IgA強(qiáng)陽(yáng)性或VCA-IgM陽(yáng)性感染后復(fù)發(fā)Cervical lymphadenopathyCervical lymphadenopathyHepatosplenomegalyEyelid edemaPalatal petechiaeAtypical lymphocytes慢性活動(dòng)性EBV感染

10、 CAEBV is characterized by severe, chronic or recurrent infectious mononucleosis-like symptoms after a primary EBV infection, and has a high morbidity and mortality from hepatic failure, lymphoma, sepsis, or hemophagocytic syndrome.1. Unusual pattern of anti-EBV antibodies (high levels of IgG anti-V

11、CA and EA, absence of anti-EBNA)2. High EBV viral load in peripheral blood3.Clonal expansion of EBV-infected T cells and NK cellsHistorical milestones of CAEBVn1948, Issacs: prolonged fever, malaise, lymphadenopathy, hepatosplenomegalyn1975, Horwitz et al:such clinical manifestations with mildly or

12、moderately high or positive IgG against VCA and EAn1982, Tobi et al: similar atypical illness associated with serological evidence of persistent EBV infectionHistorical milestones of CAEBVn1984, Dubois et al: criteria for such cases termed chronic mononucleosis syndrome:(1) disabling fatigue and mal

13、aise;(2) low-grade afternoon fever;(3) variable other nonspecific symptoms: myalgias, sore throat, depression,lasting 6 months or longer, with EBV serologies of (1)VCA-IgG160, (2)EA-IgG 5, (3) postive anti-EBNA, (4)absent VCA-IgM, (5) absent Paul-Bunnell heterophil antibody.發(fā)病機(jī)制nEBV感染的T細(xì)胞或NK細(xì)胞克隆性增殖n

14、存在的問題：1.如何感染T細(xì)胞或NK細(xì)胞2.如何引起臨床癥狀unknownB cellsT/NK cellsNK cellsT cells38273212EBV-infected cells in Japanese patients with CAEBV臨床表現(xiàn)n發(fā)熱：間斷性發(fā)熱n淋巴結(jié)腫大n肝脾腫大n間質(zhì)性肺炎n貧血n肝炎n眼葡萄膜炎Diagnostic criteria of CAEBVI. Severe illness of greater than 6 months duration that:1. Began as primary EBV infection OR2. Is asso

15、ciated with grossly abnormal EBV antibody titers(IgG to VCA1:5,120; antibody to EA1:640; or antibodyto EBNA1:2), AND(Straus S.E.)II. Histological evidence of major organ involvement, such as:1. Interstitial pneumonia2. Hypoplasia of some bone marrow elements3. Uveitis4. Lymphadenitis5. Persistent he

16、patitis6. Splenomegaly, ANDIII. Detection of increased quantities of EBV in affected tissues by1. Anticomplementary immunofluorescence for EBNA, or2. Nucleic acid hybridization Reproduced from Straus S.E. (1988, J. Infect. Dis. 157:405_/412) CAEBVCEBV: persistent IM-like illness with relatively good

17、 prognosisSCEBV: rather severe manifestation with generally poor prognosisDiagnostic criteria of a case definition for SCAEBV CategoryCriteriaClinical Hematologic Virological OtherIntermittent fever, lymphadenopathy, and hepatosplenomegaly Anemia, thrombocytopenia, lymphocytopenia or lymphocytosis,

18、neutropenia, and polyclonal gammopathy Elevated antibody titers and positivity for antibodies to EBV-related antigens (VCA IgG5,120; VCA IgA, positive; EA D IgG640; EA D IgA, positive; and EA D and EA R IgG640) and/or detection of EBV genomes in affected tissuesChronic illness which cannot be explai

19、ned by other known disease processesbReproduced from Okano M., et al. (1991, Clin. Microbiol. Rev. 4:129_/135) (Okano M)Revise of Criteria of CAEBVn2001,Kimura et al. extremely high antibody titers against EBV-replicative antigens are not absolutely necessary, but demonstrated significantly increase

20、d circulating EBV-DNAnRevised virological criteria: either or both extrmely against EBV-repicative antigens and/or increased genome copies in tissues.伴性淋巴增殖綜合征（X-linked lymphoproliferative syndrom）歷史n1975年，Purtilo等發(fā)現(xiàn)一個(gè)家系中，18個(gè)男性有6個(gè)人出現(xiàn)良性或惡性淋巴細(xì)胞增生和組織細(xì)胞增加等征候，取名Duncan病n1998年，缺陷基因被確定： Called “Duncans dise

21、ase”after the family nameSH2D1An編碼含128個(gè)氨基酸的蛋白質(zhì)- SAP (signaling lymphocytic activation molecule SLAM-associated protein), n表達(dá)于活化的T和NK細(xì)胞表面，通過與SLAM及其他免疫球蛋白超家族如2B4等結(jié)合，參與信號(hào)傳遞，調(diào)節(jié)CTL的功能，如產(chǎn)生IFN-gamma 的能力臨床表現(xiàn)n家族史，僅見男性n發(fā)病年齡從6個(gè)月22歲（原發(fā)性EBV感染后）nIM樣癥狀：發(fā)熱、咽峽炎、淋巴結(jié)和肝脾腫大、異型淋巴細(xì)胞增加n免疫球蛋白異常：無(wú)球蛋白血癥、多克隆性高球蛋白血癥n高IgM的免疫不全癥n

22、患者血清中EBV抗體陰性臨床分型nA型：屬于急性致死性IM,多發(fā)病4周后死亡，占55nB型：同時(shí)有急性致死性IM和惡性淋巴瘤，占15nC型：EBV感染后免疫機(jī)能不全、低球蛋白血癥、骨髓增生低下、EBV抗體能力產(chǎn)生低下，占15nD型：無(wú)明顯EBV感染表現(xiàn)而發(fā)生的惡性淋巴瘤，占15診斷標(biāo)準(zhǔn)（Hamilton）n6個(gè)月至22歲男性有2個(gè)以上下述表現(xiàn)型 1. 增殖性改變 （1）有致死性或慢性IM （2）有B免疫母細(xì)胞性淋巴肉瘤 （3）有非何杰金氏淋巴瘤 （4）IM繼發(fā)高IgM免疫不全癥 2. 非增生性改變 （1）粒細(xì)胞缺乏癥或再生障礙性貧血 （2）球蛋白異常：獲得性無(wú)或低球蛋白血癥 3. 先天異常 （

23、1）心血管系 （2）中樞神經(jīng)系診斷標(biāo)準(zhǔn)n在母系直系親屬中有2人以上具備上述表現(xiàn)型者，可診斷本征n本征男性的B淋巴細(xì)胞體外感染EBV后，能自發(fā)的發(fā)育增殖；患者的唾液可使臍帶血中的淋巴細(xì)胞發(fā)生形態(tài)改變；患者血清中缺乏EBV抗體鑒別診斷nCAEBV: chronic active EBV infectionnGLPD: granular lymphoproliferative disordernALPS: autoimmune lymphoproliferative syndrome CAEBVGLPDXLPALPSHeredity?X-linkedAD(AR)SexM & FM & FMM & F

24、Gene localization?Xq2510q23Responsible gene?SH2D1A/SAPFas/FasL/caspase 10Clinical manifestationLPDLPDFIM/LPD/AGLLPDVAHS+Lymphadenopathy+/malig benign+/malig benign+/malig+/ benign maligImmunoglobulinHighHighLowHighAutoimmune disease+-+EBV-antibodiesHighHighLowNormal-highEBV-genomeHighHighHighNormal-hi