201.3 🩺 內科專科考前版

201.3.0.1 1⃣ DRESS / DIHS + HHV-6

  • Drug rash with eosinophilia + systemic symptoms
  • Allopurinol, anticonvulsants (carbamazepine, phenytoin), sulfasalazine common precipitants
  • HHV-6 reactivation in 50%+ of cases — supports clinical course
  • Treatment: stop offending drug + steroid + supportive
  • HHV-6 antiviral controversial (not routine)
  • Long follow for relapse, autoimmune sequelae

201.3.0.2 2⃣ ciHHV-6 Clinical Implications

  • 1% of population — incidental detection during PCR screening
  • Don’t treat as active infection
  • Tissue or CSF PCR distinguishes (active vs integrated)
  • Family screening may identify (autosomal Mendelian inheritance pattern of high viral load)
  • Most carriers asymptomatic

201.3.0.3 3⃣ KS Staging + Treatment Algorithm (AIDS Clinical Trials Group)

  • T (tumor): T0 limited cutaneous; T1 visceral / pulmonary
  • I (immune): I0 CD4 ≥ 150; I1 CD4 < 150
  • S (systemic): S0 no symptoms; S1 systemic illness
  • Treatment:
    • T0I0: ART alone often suffices
    • T1 or visceral: ART + chemotherapy
    • PEG-liposomal doxorubicin first-line
    • Paclitaxel alternative

201.3.0.4 4⃣ Castleman Disease — Forms

  • Unicentric: localized, surgical resection curative; idiopathic
  • Multicentric, idiopathic (iMCD): IL-6 driven; siltuximab (anti-IL-6)
  • Multicentric, HHV-8 associated: HIV common; rituximab primary
  • TAFRO syndrome: subtype with thrombocytopenia + anasarca + reticulin fibrosis + organomegaly + multicentric LAP

201.3.0.5 5⃣ Immune Checkpoint Inhibitor in KS

  • Pembrolizumab + nivolumab — some response in advanced KS
  • Less effective than HIV virologic suppression with ART
  • Used in refractory / progressing despite ART + chemotherapy

201.3.0.6 6⃣ mTOR Inhibitor for Transplant KS

  • Sirolimus or everolimus — anti-KS effect via mTOR pathway inhibition
  • Switch from CNI (cyclosporine, tacrolimus) to mTOR-based regimen
  • Documented regression of KS in solid organ transplant
  • mTOR also has anti-CMV activity

201.3.0.7 7⃣ 健保 / Taiwan

  • 健保 valganciclovir, foscarnet, rituximab for indications
  • KS — 眕芋 Taiwan; HIV / 移怍 / 老幎 ID consult
  • HHV-8 PCR — specialty labs
  • HHV-6 PCR — research / transplant centers

201.3.0.8 8⃣ Newer Therapies

  • Pomalidomide (immunomodulator) — KS in HIV
  • Iberdomide — emerging
  • CAR-T for PEL — case reports
  • IL-1β inhibitor for KICS — trials