1、兒童EBV感染相關疾病及診斷病毒室 謝正德常用名正式命名所屬亞科生物學特性單純皰疹V-1型人皰疹V1型在感染N節中潛伏單純皰疹V-2型人皰疹V2型在感染N節中潛伏水痘-帶狀皰疹人皰疹V3型在感染N節中潛伏EBV人皰疹V4型在淋巴細胞中潛伏CMV人皰疹V5型在淋巴細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，有環狀和線性兩種形式n人群感染率高，我國35歲兒童95%已血清轉化nEBV原發感染在嬰幼兒及學齡前兒童主要為亞臨床感染，在青少年和成人致IM（國外）nEBV與許多疾病相關Circular form of the EBV genome (latent infection)Li

3、near form of the EBV genome (lytic infection)EBV 相關疾病n傳染性單核細胞增多癥（Infectious mononucleosis，IM）n慢性活動性EB病毒感染（Chronic active EBV infection，CAEBV）nEB病毒相關性嗜血細胞綜合征（EBV-associated hemophagocytic syndrome, EBVAHS)EBV相關疾病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傳染性單核細胞增多癥（Infectious mononucleos

6、is，IM）IMIM嗜異白細胞陽性：EBV 嗜異白細胞陰性：EBV CMV Rub HHV6 AdvEBV-IM的臨床表現n發熱： 約1周，嚴重者2周或更久，幼兒可不明顯n淋巴結腫大：任何淋巴結，頸部最易受累n咽炎：50有滲出物，25上腭有瘀點n脾腫大：病程23周，50出現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n其它：1.間質性肺炎2.CNS: 腦炎、格林巴利綜合征等3.心肌炎4.血液系統：溶血性貧血、再障、粒細胞減少5.腎炎6.關節炎7.胰腺炎IM的診斷nIM的擬診：臨床表現（發熱+滲出性咽峽炎+淋巴結腫大、脾腫大） +異

7、型淋巴細胞升高（10）EBV-IM的診斷n嗜異白細胞凝集抗體n特異性EBV抗原的抗體檢測:衣殼抗原（CA）IgMn熒光定量PCR檢測外周血中EBV-DNA嗜異白細胞抗體nIgM抗體nIM病人的血清在經吸收幾內亞豬腎抗原后引起山羊紅細胞的凝集n第12周出現，持續約6個月；小于5歲者，很可能陰性外周血中EBV-DNA檢測n普通PCRn熒光定量PCR：熒光定量PCR檢測 EBV-DNA（血清、血漿、全血、外周血單核細胞），急性期（病程10天內）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，持續存在48周，類風濕因子和IgG抗體可致結果假陽性n臨床要注意以下情況：1、有的病人抗

8、EB病毒CA-IgM產生延遲2、少部分病人感染EBV后，CA-IgM持續陰性3、也有的病人CA-IgM持續幾個月陽性抗體親合力檢測n機體在受到病原體入侵時首先產生低親合力抗體，隨感染的繼續和進展，抗體親合力升高。因此，低親合力抗體的檢出提示原發性急性感染。n原發EBV感染，100的病人在第一個月內可檢測到抗EB病毒CA-IgG低親合力抗體原發性原發性EBV感染后的免疫抗體反應感染后的免疫抗體反應IMEBV抗體四項nVCA-IgGnVCA-IgMnEA-IgGnNA-IgGnVCA-IgG親合力EBNA-IgG陰性VCA-IgG陽性VCA-IgG陰性未感染VCA-IgM陽性原發感染VCA-IgM

9、陰性EAIgG強陽性原發感染（ VCA-IgG 低親合力）、感染后復發、或感染晚期抗EBNA抗體降低（ VCA-IgG 高親合力）EAIgG陰性感染后復發或感染晚期抗EBNA抗體降低（ VCA-IgG 高親合力）EBNA-IgG陽性僅VCA-IgG陽性晚期感染VCA-IgG陽性和EA-IgG強陽性或VCA-IgA強陽性或VCA-IgM陽性感染后復發Cervical lymphadenopathyCervical lymphadenopathyHepatosplenomegalyEyelid edemaPalatal petechiaeAtypical lymphocytes慢性活動性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) High EBV viral load in peripheral blood2.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 mo

12、derately 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 malai

13、se;(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.發病機制nEBV感染的T細胞或NK細胞克隆性增殖n存在

14、的問題：1.如何感染T細胞或NK細胞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n發熱：間斷性發熱n淋巴結腫大n肝脾腫大n間質性肺炎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 associ

15、ated 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 hepa

16、titis6. 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 p

17、rognosisSCEBV: 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, ne

18、utropenia, 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 explaine

19、d 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 increased

20、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等發現一個家系中，18個男性有6個人出現良性或惡性淋巴細胞增生和組織細胞增加等征候，取名Duncan病n1998年，缺陷基因被確定： Called “Duncans diseas

21、e”after the family nameSH2D1An編碼含128個氨基酸的蛋白質- SAP (signaling lymphocytic activation molecule SLAM-associated protein), n表達于活化的T和NK細胞表面，通過與SLAM及其他免疫球蛋白超家族如2B4等結合，參與信號傳遞，調節CTL的功能，如產生IFN-gamma 的能力臨床表現n家族史，僅見男性n發病年齡從6個月22歲（原發性EBV感染后）nIM樣癥狀：發熱、咽峽炎、淋巴結和肝脾腫大、異型淋巴細胞增加n免疫球蛋白異常：無球蛋白血癥、多克隆性高球蛋白血癥n高IgM的免疫不全癥n患者

22、血清中EBV抗體陰性臨床分型nA型：屬于急性致死性IM,多發病4周后死亡，占55nB型：同時有急性致死性IM和惡性淋巴瘤，占15nC型：EBV感染后免疫機能不全、低球蛋白血癥、骨髓增生低下、EBV抗體能力產生低下，占15nD型：無明顯EBV感染表現而發生的惡性淋巴瘤，占15診斷標準（Hamilton）n6個月至22歲男性有2個以上下述表現型 1. 增殖性改變 （1）有致死性或慢性IM （2）有B免疫母細胞性淋巴肉瘤 （3）有非何杰金氏淋巴瘤 （4）IM繼發高IgM免疫不全癥 2. 非增生性改變 （1）粒細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）

23、心血管系 （2）中樞神經系診斷標準n在母系直系親屬中有2人以上具備上述表現型者，可診斷本征n本征男性的B淋巴細胞體外感染EBV后，能自發的發育增殖；患者的唾液可使臍帶血中的淋巴細胞發生形態改變；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 & F

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