儿童EBV感染及相关疾病的诊断(讲)-谢正

1、儿童EBV感染相关疾病及诊断病毒室 谢正德常用名正式命名所属亚科生物学特性单纯疱疹V-1型人疱疹V1型在感染N节中潜伏单纯疱疹V-2型人疱疹V2型在感染N节中潜伏水痘-带状疱疹人疱疹V3型在感染N节中潜伏EBV人疱疹V4型在淋巴细胞中潜伏CMV人疱疹V5型在淋巴细胞及分泌腺体中潜伏人疱疹V6型人疱疹V6型同上人疱疹V7型人疱疹V7型同上人疱疹V8型人疱疹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双链DNA病毒，疱疹病毒科，亚科，基因组Genome: 172282 bp，有环状和线性两种形式n人群感染率高，我国35岁儿童95%已血清转化nEBV原发感染在婴幼儿及学龄前儿童主要为亚临床感染，在青少年和成人致IM（国外）nEBV与许多疾病相关Circular form of the EBV genome (latent infection)Li

3、near form of the EBV genome (lytic infection)EBV 相关疾病n传染性单核细胞增多症（Infectious mononucleosis，IM）n慢性活动性EB病毒感染（Chronic active EBV infection，CAEBV）nEB病毒相关性嗜血细胞综合征（EBV-associated hemophagocytic syndrome, EBVAHS)EBV相关疾病n伴性淋巴增殖综合征（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传染性单核细胞增多症（Infectious mononucleos

6、is，IM）IMIM嗜异白细胞阳性：EBV 嗜异白细胞阴性：EBV CMV Rub HHV6 AdvEBV-IM的临床表现n发热： 约1周，严重者2周或更久，幼儿可不明显n淋巴结肿大：任何淋巴结，颈部最易受累n咽炎：50有渗出物，25上腭有瘀点n脾肿大：病程23周，50出现n肝炎：肿大1015，而GPT升高80n皮疹：红斑、斑丘疹或麻疹样疹，50可有眼睑浮肿EBV-IM的临床表现n其它：1.间质性肺炎2.CNS: 脑炎、格林巴利综合征等3.心肌炎4.血液系统：溶血性贫血、再障、粒细胞减少5.肾炎6.关节炎7.胰腺炎IM的诊断nIM的拟诊：临床表现（发热+渗出性咽峡炎+淋巴结肿大、脾肿大） +异

7、型淋巴细胞升高（10）EBV-IM的诊断n嗜异白细胞凝集抗体n特异性EBV抗原的抗体检测:衣壳抗原（CA）IgMn荧光定量PCR检测外周血中EBV-DNA嗜异白细胞抗体nIgM抗体nIM病人的血清在经吸收几内亚猪肾抗原后引起山羊红细胞的凝集n第12周出现，持续约6个月；小于5岁者，很可能阴性外周血中EBV-DNA检测n普通PCRn荧光定量PCR：荧光定量PCR检测 EBV-DNA（血清、血浆、全血、外周血单核细胞），急性期（病程10天内）敏感性和特异性100衣壳抗原（CA）IgMn一般情况下：一周左右升高，持续存在48周，类风湿因子和IgG抗体可致结果假阳性n临床要注意以下情况：1、有的病人抗

8、EB病毒CA-IgM产生延迟2、少部分病人感染EBV后，CA-IgM持续阴性3、也有的病人CA-IgM持续几个月阳性抗体亲合力检测n机体在受到病原体入侵时首先产生低亲合力抗体，随感染的继续和进展，抗体亲合力升高。因此，低亲合力抗体的检出提示原发性急性感染。n原发EBV感染，100的病人在第一个月内可检测到抗EB病毒CA-IgG低亲合力抗体原发性原发性EBV感染后的免疫抗体反应感染后的免疫抗体反应IMEBV抗体四项nVCA-IgGnVCA-IgMnEA-IgGnNA-IgGnVCA-IgG亲合力EBNA-IgG阴性VCA-IgG阳性VCA-IgG阴性未感染VCA-IgM阳性原发感染VCA-IgM

9、阴性EAIgG强阳性原发感染（ VCA-IgG 低亲合力）、感染后复发、或感染晚期抗EBNA抗体降低（ VCA-IgG 高亲合力）EAIgG阴性感染后复发或感染晚期抗EBNA抗体降低（ VCA-IgG 高亲合力）EBNA-IgG阳性仅VCA-IgG阳性晚期感染VCA-IgG阳性和EA-IgG强阳性或VCA-IgA强阳性或VCA-IgM阳性感染后复发Cervical lymphadenopathyCervical lymphadenopathyHepatosplenomegalyEyelid edemaPalatal petechiaeAtypical lymphocytes慢性活动性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.发病机制nEBV感染的T细胞或NK细胞克隆性增殖n

14、存在的问题：1.如何感染T细胞或NK细胞2.如何引起临床症状unknownB cellsT/NK cellsNK cellsT cells38273212EBV-infected cells in Japanese patients with CAEBV临床表现n发热：间断性发热n淋巴结肿大n肝脾肿大n间质性肺炎n贫血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.伴性淋巴增殖综合征（X-linked lymphoproliferative syndrom）历史n1975年，Purtilo等发现一个家系中，18个男性有6个人出现良性或恶性淋巴细胞增生和组织细胞增加等征候，取名Duncan病n1998年，缺陷基因被确定： Called “Duncans dise

21、ase”after the family nameSH2D1An编码含128个氨基酸的蛋白质- SAP (signaling lymphocytic activation molecule SLAM-associated protein), n表达于活化的T和NK细胞表面，通过与SLAM及其他免疫球蛋白超家族如2B4等结合，参与信号传递，调节CTL的功能，如产生IFN-gamma 的能力临床表现n家族史，仅见男性n发病年龄从6个月22岁（原发性EBV感染后）nIM样症状：发热、咽峡炎、淋巴结和肝脾肿大、异型淋巴细胞增加n免疫球蛋白异常：无球蛋白血症、多克隆性高球蛋白血症n高IgM的免疫不全症n

22、患者血清中EBV抗体阴性临床分型nA型：属于急性致死性IM,多发病4周后死亡，占55nB型：同时有急性致死性IM和恶性淋巴瘤，占15nC型：EBV感染后免疫机能不全、低球蛋白血症、骨髓增生低下、EBV抗体能力产生低下，占15nD型：无明显EBV感染表现而发生的恶性淋巴瘤，占15诊断标准（Hamilton）n6个月至22岁男性有2个以上下述表现型 1. 增殖性改变 （1）有致死性或慢性IM （2）有B免疫母细胞性淋巴肉瘤 （3）有非何杰金氏淋巴瘤 （4）IM继发高IgM免疫不全症 2. 非增生性改变 （1）粒细胞缺乏症或再生障碍性贫血 （2）球蛋白异常：获得性无或低球蛋白血症 3. 先天异常 （

23、1）心血管系 （2）中枢神经系诊断标准n在母系直系亲属中有2人以上具备上述表现型者，可诊断本征n本征男性的B淋巴细胞体外感染EBV后，能自发的发育增殖；患者的唾液可使脐带血中的淋巴细胞发生形态改变；患者血清中缺乏EBV抗体鉴别诊断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