兒童EBV感染及相關(guān)疾病的診斷講

兒童EBV感染及相關(guān)疾病的診斷講當(dāng)前第1頁\共有59頁\編于星期五\17點(diǎn)Burkitt’slymphomainKenyaEpstein-Barrvirus(EBV)1964,discoveredfromBurkitt’slymphomatissuebyEpstein,Achong,andBarr1968,theetiologicagentforinfectiousmononucleosis1970,nasopharyngealcarcinoma1980,non-Hodgkin’slymphoma當(dāng)前第2頁\共有59頁\編于星期五\17點(diǎn)EBV雙鏈DNA病毒，皰疹病毒科，亞科，基因組Genome:172282bp，有環(huán)狀和線性兩種形式人群感染率高，我國3~5歲兒童95%已血清轉(zhuǎn)化EBV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（國外）EBV與許多疾病相關(guān)當(dāng)前第3頁\共有59頁\編于星期五\17點(diǎn)CircularformoftheEBVgenome(latentinfection)LinearformoftheEBVgenome(lyticinfection)當(dāng)前第4頁\共有59頁\編于星期五\17點(diǎn)EBV相關(guān)疾病傳染性單核細(xì)胞增多癥（Infectiousmononucleosis，IM）慢性活動(dòng)性EB病毒感染（ChronicactiveEBVinfection，CAEBV）EB病毒相關(guān)性嗜血細(xì)胞綜合征（EBV-associatedhemophagocyticsyndrome,EBVAHS)當(dāng)前第5頁\共有59頁\編于星期五\17點(diǎn)EBV相關(guān)疾病伴性淋巴增殖綜合征

（X-linkedlymphoproliferativesyndrom）鼻咽癌（Nasopharyngealcarcinoma）Burkitt’s淋巴瘤（Burkitt’slymphoma）何奇金淋巴瘤（Hodgkin’slymphoma）當(dāng)前第6頁\共有59頁\編于星期五\17點(diǎn)BCD21gp350MHC-IIEBVAsymptomaticinfectionSymptomaticinfection（IM)PrimaryEBVInfectionLatentinfectionEBV-relatedotherdiseases當(dāng)前第7頁\共有59頁\編于星期五\17點(diǎn)SalivaOropharynxLymphoidtissueandperipheralbloodRestingBcellEpitheliumLyticEBV-infectedBcellEBV-infectedB-cellblastReactivatedEBV-infectedB-cellLyticEBV-infectedBcellEBVEBVLatentlyinfected,restingmemoryBcellsCytotoxicTcellCytotoxicTcellNaturalkillercellLMP-1LMP-1LMP-2LMP-2LMP-2LMP-2PrimaryinfectionPersistentinfectionEBNAsEBNAsEBNA-1Cohen,JINEnglJMed343:481-492,2004ModelofEBVinfectioninhumans當(dāng)前第8頁\共有59頁\編于星期五\17點(diǎn)傳染性單核細(xì)胞增多癥（Infectiousmononucleosis，IM）當(dāng)前第9頁\共有59頁\編于星期五\17點(diǎn)IMIM嗜異白細(xì)胞陽性：EBV嗜異白細(xì)胞陰性：EBVCMVRubHHV6Adv當(dāng)前第10頁\共有59頁\編于星期五\17點(diǎn)EBV-IM的臨床表現(xiàn)發(fā)熱：約1周，嚴(yán)重者2周或更久，幼兒可不明顯淋巴結(jié)腫大：任何淋巴結(jié)，頸部最易受累咽炎：50％有滲出物，25％上腭有瘀點(diǎn)脾腫大：病程2～3周，50％出現(xiàn)肝炎：腫大10％～15％，而GPT升高80％皮疹：紅斑、斑丘疹或麻疹樣疹，50％可有眼瞼浮腫當(dāng)前第11頁\共有59頁\編于星期五\17點(diǎn)EBV-IM的臨床表現(xiàn)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.胰腺炎當(dāng)前第12頁\共有59頁\編于星期五\17點(diǎn)IM的診斷IM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）+異型淋巴細(xì)胞升高（10％）當(dāng)前第13頁\共有59頁\編于星期五\17點(diǎn)EBV-IM的診斷嗜異白細(xì)胞凝集抗體特異性EBV抗原的抗體檢測(cè):衣殼抗原（CA）－IgM熒光定量PCR檢測(cè)外周血中EBV-DNA當(dāng)前第14頁\共有59頁\編于星期五\17點(diǎn)嗜異白細(xì)胞抗體IgM抗體IM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)胞的凝集第1～2周出現(xiàn)，持續(xù)約6個(gè)月；小于5歲者，很可能陰性當(dāng)前第15頁\共有59頁\編于星期五\17點(diǎn)外周血中EBV-DNA檢測(cè)普通PCR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％當(dāng)前第16頁\共有59頁\編于星期五\17點(diǎn)衣殼抗原（CA）－IgM

一般情況下：一周左右升高，持續(xù)存在4～8周，類風(fēng)濕因子和IgG抗體可致結(jié)果假陽性臨床要注意以下情況：1、有的病人抗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)月陽性當(dāng)前第17頁\共有59頁\編于星期五\17點(diǎn)抗體親合力檢測(cè)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。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低親合力抗體當(dāng)前第18頁\共有59頁\編于星期五\17點(diǎn)原發(fā)性EBV感染后的免疫抗體反應(yīng)IM當(dāng)前第19頁\共有59頁\編于星期五\17點(diǎn)EBV抗體四項(xiàng)VCA-IgGVCA-IgMEA-IgGNA-IgGVCA-IgG親合力當(dāng)前第20頁\共有59頁\編于星期五\17點(diǎn)EBNA-IgG陰性VCA-IgG陽性VCA-IgG陰性未感染VCA-IgM陽性原發(fā)感染VCA-IgM陰性EA－IgG強(qiáng)陽性原發(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）EA－IgG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）當(dāng)前第21頁\共有59頁\編于星期五\17點(diǎn)EBNA-IgG陽性僅VCA-IgG陽性晚期感染VCA-IgG陽性和EA-IgG強(qiáng)陽性或VCA-IgA強(qiáng)陽性或VCA-IgM陽性感染后復(fù)發(fā)當(dāng)前第22頁\共有59頁\編于星期五\17點(diǎn)Cervicallymphadenopathy當(dāng)前第23頁\共有59頁\編于星期五\17點(diǎn)Cervicallymphadenopathy當(dāng)前第24頁\共有59頁\編于星期五\17點(diǎn)Hepatosplenomegaly當(dāng)前第25頁\共有59頁\編于星期五\17點(diǎn)Eyelidedema當(dāng)前第26頁\共有59頁\編于星期五\17點(diǎn)Palatalpetechiae當(dāng)前第27頁\共有59頁\編于星期五\17點(diǎn)Atypicallymphocytes當(dāng)前第28頁\共有59頁\編于星期五\17點(diǎn)慢性活動(dòng)性EBV感染當(dāng)前第29頁\共有59頁\編于星期五\17點(diǎn)CAEBVischaracterizedbysevere,chronicorrecurrentinfectiousmononucleosis-likesymptomsafteraprimaryEBVinfection,andhasahighmorbidityandmortalityfromhepaticfailure,lymphoma,sepsis,orhemophagocyticsyndrome.1.Unusualpatternofanti-EBVantibodies(highlevelsofIgGanti-VCAandEA,absenceofanti-EBNA)HighEBVviralloadinperipheralbloodClonalexpansionofEBV-infectedTcellsandNKcells當(dāng)前第30頁\共有59頁\編于星期五\17點(diǎn)HistoricalmilestonesofCAEBV1948,Issacs:prolongedfever,malaise,lymphadenopathy,hepatosplenomegaly1975,Horwitzetal:suchclinicalmanifestationswithmildlyormoderatelyhighorpositiveIgGagainstVCAandEA1982,Tobietal:similaratypicalillnessassociatedwithserologicalevidenceofpersistentEBVinfection當(dāng)前第31頁\共有59頁\編于星期五\17點(diǎn)HistoricalmilestonesofCAEBV1984,Duboisetal:criteriaforsuchcasestermedchronicmononucleosissyndrome:(1)disablingfatigueandmalaise;(2)low-gradeafternoonfever;(3)variableothernonspecificsymptoms:myalgias,sorethroat,depression,lasting6monthsorlonger,withEBVserologiesof(1)VCA-IgG160,(2)EA-IgG5,(3)postiveanti-EBNA,(4)absentVCA-IgM,(5)absentPaul-Bunnellheterophilantibody.當(dāng)前第32頁\共有59頁\編于星期五\17點(diǎn)發(fā)病機(jī)制EBV感染的T細(xì)胞或NK細(xì)胞克隆性增殖存在的問題：1.如何感染T細(xì)胞或NK細(xì)胞2.如何引起臨床癥狀當(dāng)前第33頁\共有59頁\編于星期五\17點(diǎn)EBV-infectedcellsinJapanesepatientswithCAEBV當(dāng)前第34頁\共有59頁\編于星期五\17點(diǎn)臨床表現(xiàn)發(fā)熱：間斷性發(fā)熱淋巴結(jié)腫大肝脾腫大間質(zhì)性肺炎貧血肝炎眼葡萄膜炎當(dāng)前第35頁\共有59頁\編于星期五\17點(diǎn)當(dāng)前第36頁\共有59頁\編于星期五\17點(diǎn)當(dāng)前第37頁\共有59頁\編于星期五\17點(diǎn)DiagnosticcriteriaofCAEBVI.Severeillnessofgreaterthan6months’durationthat:1.BeganasprimaryEBVinfectionOR2.IsassociatedwithgrosslyabnormalEBVantibodytiters(IgGtoVCA≥1:5,120;antibodytoEA≥1:640;orantibodytoEBNA＜1:2),AND(StrausS.E.)當(dāng)前第38頁\共有59頁\編于星期五\17點(diǎn)II.Histologicalevidenceofmajororganinvolvement,suchas:1.Interstitialpneumonia2.Hypoplasiaofsomebonemarrowelements3.Uveitis4.Lymphadenitis5.Persistenthepatitis6.Splenomegaly,ANDIII.DetectionofincreasedquantitiesofEBVinaffectedtissuesby1.AnticomplementaryimmunofluorescenceforEBNA,or2.Nucleicacidhybridization

ReproducedfromStrausS.E.(1988,J.Infect.Dis.157:405_/412)

當(dāng)前第39頁\共有59頁\編于星期五\17點(diǎn)CAEBVCEBV:persistentIM-likeillnesswithrelativelygoodprognosisSCEBV:ratherseveremanifestationwithgenerallypoorprognosis當(dāng)前第40頁\共有59頁\編于星期五\17點(diǎn)DiagnosticcriteriaofacasedefinitionforSCAEBV

CategoryCriteriaClinical

Hematologic

Virological

OtherIntermittentfever,lymphadenopathy,andhepatosplenomegaly

Anemia,thrombocytopenia,lymphocytopeniaorlymphocytosis,neutropenia,andpolyclonalgammopathy

ElevatedantibodytitersandpositivityforantibodiestoEBV-relatedantigens(VCAIgG≥5,120;VCAIgA,positive;EA[D]IgG≥640;EA[D]IgA,positive;andEA[D]andEA[R]IgG≥640)and/ordetectionofEBVgenomesinaffectedtissuesChronicillnesswhichcannotbeexplainedbyotherknowndiseaseprocessesbReproducedfromOkanoM.,etal.(1991,Clin.Microbiol.Rev.4:129_/135)

(OkanoM)當(dāng)前第41頁\共有59頁\編于星期五\17點(diǎn)ReviseofCriteriaofCAEBV2001,Kimuraetal.extremelyhighantibodytitersagainstEBV-replicativeantigensarenotabsolutelynecessary,butdemonstratedsignificantlyincreasedcirculatingEBV-DNARevisedvirologicalcriteria:eitherorbothextrmelyagainstEBV-repicativeantigensand/orincreasedgenomecopiesintissues.當(dāng)前第42頁\共有59頁\編于星期五\17點(diǎn)伴性淋巴增殖綜合征

（X-linkedlymphoproliferativesyndrom）當(dāng)前第43頁\共有59頁\編于星期五\17點(diǎn)歷史1975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1998年，缺陷基因被確定：SH2D1A/DHSPorSAP(SLAM-associatedprotein）當(dāng)前第44頁\共有59頁\編于星期五\17點(diǎn)Called“Duncan'sdisease”afterthefamilyname當(dāng)前第45頁\共有59頁\編于星期五\17點(diǎn)SH2D1A編碼含128個(gè)氨基酸的蛋白質(zhì)-SAP(signalinglymphocyticactivationmolecule[SLAM]-associatedprotein),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的能力當(dāng)前第46頁\共有59頁\編于星期五\17點(diǎn)當(dāng)前第47頁\共有59頁\編于星期五\17點(diǎn)臨床表現(xiàn)家族史，僅見男性發(fā)病年齡從6個(gè)月～22歲（原發(fā)性EBV感染后）IM樣癥狀：發(fā)熱、咽峽炎、淋巴結(jié)和肝脾腫大、異型淋巴細(xì)胞增加免疫球蛋白異常：無－球蛋白血癥、多克隆性高－球蛋白血癥高IgM的免疫不全癥患者血清中EBV抗體陰性當(dāng)前第48頁\共有59頁\編于星期五\17點(diǎn)臨床分型A型：屬于急性致死性IM,多發(fā)病4周后死亡，占55％B型：同時(shí)有急性致死性IM和惡性淋巴瘤，占15％C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15％D型：無明顯EBV感染表現(xiàn)而發(fā)生的惡性淋巴瘤，占15％當(dāng)前第49頁\共有59頁\編于星期五\17點(diǎn)診斷標(biāo)準(zhǔn)（Hamilton）6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：獲得性無或低－球蛋白血癥

3.先天異常（1）心血管系（2）中樞神經(jīng)系當(dāng)前第50頁\共有59頁\編于星期五\17點(diǎn)診斷標(biāo)準(zhǔn)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·當(dāng)前第51頁\共有59頁\編于星期五\17點(diǎn)鑒別診斷CAEBV:chronicactiveEBVinfectionGLPD:granularlymphoproliferativedisorderALPS:autoimmunelymphoproliferativesyndrome當(dāng)前第52頁\共有59頁\編于星期五\17點(diǎn)

CAEBVGLPDXLPALPSHeredity??X-linkedAD(AR)SexM&FM&FMM&FGenelocalization??Xq2510q23Responsiblegene??SH2D1A/SAPFas/FasL/caspase10ClinicalmanifestationLPDLPDFIM/LPD/AGLLPDVAHS+++++Lymphadenopathy+/maligbenign+/maligbenign+/malig++/benignmaligImmunoglobulinHighHighLowHighAutoimmunedisease+--++EBV-antibodiesHighHighLowNormal-highEBV-genomeHighHighHighNormal-high當(dāng)前第53頁\共有59頁\編于星期五\17點(diǎn)基因診斷amonoclonalantibody,termedKST-3,