199.3 🩺 內科專科考前版

199.3.0.1 1⃣ EBV Serology Patterns

Stage VCA IgM VCA IgG EA IgG EBNA IgG
Never - - - -
Acute IM + + + -
Recent (3-6 mo) - + ± +
Past distant - + - +
Reactivation ± + + +

199.3.0.2 2⃣ Nasopharyngeal Carcinoma (NPC) — Taiwan Endemic

  • ~ 1500-2000 new cases/yr Taiwan
  • 男 > 女 3:1
  • High incidence Taiwan, S China, SE Asia
  • Risk: EBV + smoking + salted fish + genetic susceptibility (HLA-A2)
  • Sx: cervical mass (most common presenting), nasal obstruction, hearing loss
  • Plasma EBV DNA = sensitive screening marker; titer correlates with stage + prognosis
  • Treatment: cisplatin chemoradiation; 5-yr survival 70-90% depending stage

199.3.0.3 3⃣ PTLD Risk Stratification

  • High risk:
    • EBV-naive recipient + EBV-positive donor (D+/R-)
    • Pediatric transplant
    • Intestinal, lung transplant
    • Anti-thymocyte globulin / OKT3 induction
  • Surveillance: weekly EBV PCR first 3-6 mo, monthly to 1 yr
  • Pre-emptive rituximab if rising titer

199.3.0.4 4⃣ EBV-Specific T Cells

  • Adoptive transfer of donor-derived or autologous EBV-specific CTLs
  • Effective in refractory PTLD
  • Atara Bio (tabelecleucel) — FDA approval pending

199.3.0.5 5⃣ HIV + EBV-Associated Lymphoma

  • Risk: CD4 < 200 (especially < 50)
  • Histologies: DLBCL, Burkitt-like, primary CNS lymphoma, primary effusion lymphoma
  • Treatment: ART + chemotherapy (R-CHOP, R-EPOCH); CNS — methotrexate or radiation
  • Prognosis improved with ART

199.3.0.6 6⃣ EBV + MS — Therapeutic Implications

  • Active development:
    • EBV vaccine (Moderna mRNA-1189, Phase 1)
    • EBV-specific T cells for MS (Phase 2)
    • EBV antivirals for MS (under study)
  • Not yet standard of care
  • Watch this space

199.3.0.7 7⃣ Steroid in IM

  • Indicated:
    • Airway obstruction (massive tonsillar swelling)
    • Severe cytopenia (AIHA, ITP)
    • HLH
    • Severe hepatitis (rare)
  • Not for uncomplicated IM (no benefit)
  • Prednisone 40-60 mg PO × 7-10d typical

199.3.0.8 8⃣ 健保 / Taiwan

  • 通報 NPC + EBV-associated cancers
  • 健保 rituximab for confirmed indications
  • EBV PCR in 公費 transplant surveillance
  • NPC screening in high-risk family / geography

199.3.0.9 9⃣ Differential — IM Mimickers

  • Acute HIV — similar; check HIV viral load
  • CMV mononucleosis — older patients, less LAP, more hepatitis; monospot negative
  • Toxoplasmosis — LAP + fever, cats, severe in immunocompromise
  • Acute viral hepatitis (A, B, C) — more hepatitis-dominant
  • Drug rxn — DRESS, severe rash
  • Lymphoma — biopsy if persistent LAP
  • All have similar LAP + fever patterns