210.3 🩺 內科專科考前版

210.3.0.1 1⃣ Renal Transplant BKVAN Surveillance

  • Urine BK PCR q3 mo first year, q6 mo year 2-3
  • Plasma BK PCR > 10,000 copies/mL = clinically significant
  • Renal biopsy + SV40 IHC for definitive diagnosis
  • Immunosuppression reduction algorithm — calcineurin inhibitor + antimetabolite minimization

210.3.0.2 2⃣ Natalizumab PML Risk Stratification (MS Patients)

  • JC virus serology pre-treatment
  • JC+ + treatment > 2 yr + prior immunosuppression = highest risk
  • Stratification protocols (annual JC serology + index)
  • Switch to alternative DMT if risk high
  • MRI surveillance routine

210.3.0.3 3⃣ Adenovirus in HSCT

  • Quantitative PCR surveillance early post-HSCT

  • 1000 copies/mL plasma — consider treatment

  • Cidofovir or brincidofovir
  • Adoptive T cell therapy (donor-derived) — emerging

210.3.0.4 4⃣ EKC Outbreak Management

  • Strict isolation + hand hygiene
  • Dedicated ophthalmology room if outbreak
  • Disinfect equipment + furniture
  • Healthcare worker exclusion until 14d post-infection
  • Patient educate, return to work 14d

210.3.0.5 5⃣ JC Antibody Test

  • ELISA-based commercial test (Stratify JCV)
  • Used in MS for natalizumab risk stratification
  • Cost + sensitivity / specificity considerations
  • Annual repeat

210.3.0.6 6⃣ Pembrolizumab for PML

  • Emerging therapy
  • 3-6 doses typical
  • Case reports + small series with neurological improvement
  • IRIS risk
  • Not standard yet — clinical trial preferred

210.3.0.7 7⃣ Merkel Cell Carcinoma + Immunotherapy

  • Avelumab (anti-PD-L1) FDA 2017 — first approval
  • Pembrolizumab (anti-PD-1) FDA 2018 for advanced
  • 40-50%+ response rates
  • Adjuvant immunotherapy under study

210.3.0.8 8⃣ Childhood Severe Hepatitis 2021-2022 Cluster

  • Unprecedented cluster (UK, USA, Europe, Asia)
  • Adenovirus type 41 frequently detected
  • AAV2 (adeno-associated virus) co-infection implicated
  • Some required liver transplantation
  • Resolved 2023; mechanism debated

210.3.0.9 9⃣ 健保 / Taiwan

  • 健保 cidofovir for indications (HSCT severe)
  • 健保 immune reconstitution
  • 健保 pembrolizumab for Merkel cell CA
  • BK urine PCR — renal transplant surveillance
  • JC PCR — limited clinical use

210.3.0.10 10. Future Directions

  • Adenovirus-specific T cells (Atara Bio + others)
  • BK virus T cell therapy
  • Brincidofovir expanded access
  • mRNA vaccines for polyomavirus (research)
  • Anti-PD-1 / PD-L1 for PML expanding