德州检验会课件

Fare clic per modificare stile,Fare clic per modificare gli stili del testo dello schema,Secondo livello,Terzo livello,Quarto livello,Quinto livello,#,03.01.2020,Sci Dpt:Yang Jiang,北京东方志禾商贸有限公司,李保昌,临床检验项目的合理选择与配伍,0,1,Torch,检测的内容包括,T,oxoplasma,gondii,：,弓形虫,O,thers,：梅毒，,B19,细小病毒,R,ubella virus,：风疹,C,ytomegalo virus,：,CMV,H,erpes Simplex virus,：单纯疱疹病毒,2,ToRCH,检测方法,印迹法：,a.,蛋白印迹，,westernblot,，,b.,将纯化的抗原印迹于膜上,Euroimmune,）,金标法,酶标法（,a.,间接法,b.,捕获法）,化学发光法（,a.,间接法,b.,捕获法）,化学发光法酶标法（捕获法）印迹法、酶标间接法金标法,定量定性,3,CMV,概述,人类感染面最广的病毒之一,传播途径多样,直接接触：唾液，性接触,垂直传播：经胎盘母婴传播,血液传播：输血（白细胞）,移植,潜伏部位常在唾液腺,、,乳腺、肾等,影响因素,-,年龄,-,种族,-,职业,-,社会经济条件,影响后果：,健康人（机会性感染）：无临床症状，单核细胞增多症,免疫系统受损的病人：肺，心，肝和肾的多系统损伤,胎儿：先天性,CMV,感染,核内包涵体呈“猫头鹰眼”状,4,先天性,CMV,感染,-Congenital infection,-,孕妇初次感染,primary infection,(,对胎儿的影响严重,）,孕妇再次感染,re-infection,（,J Clin Virol.2009 Dec;46 Suppl 4:S6-10.Epub 2009 Oct 2.Congenital cytomegalovirus(CMV)epidemiology and awareness.,）,（占先天性,CMV,的,3/4,）,90%,无症状,10%,出生有症状,几个月或几年后有 后遗症（,10-15%,）,无症状,先天性,CMV,感染,（,0.2-2.5%,）,先天性,CMV,感染,来源于孕妇的,CMV,急性感染,感染,感染后果,5,先天性,CMV,感染胎儿不良后果,神经发育方面疾病为主,出生后有症状,出生后无症状但以后发病,：,neurological problems,（,unilateral or bilateral sensory neural hearing loss,单或双侧感觉神经性听力丧失）,Indian J Pediatr.2010 Jan;77(1):77-9.,Neonatal cytomegalovirus infection:diagnostic modalities available for early disease detection.,小头畸形,(70%),智力缺陷,(35%),听力障碍,(60%),肝脾肿大,(70%),黄疸,(68%),血小板减少症,(65%),低体重,(65%),肺炎,(2-5%),先天性心脏病,(5%).,6,1.IgM,阳性就是近期感染吗？！,-,仅有,IgM+,是不能下结论的。,2.,原发感染与复发感染的临床处理不同，如何鉴别,-,亲和力,3.,该如何做：,IgG/IgM/Avidity,合理配伍，灵活选择应用。,伴,IgM,由,-,转,+,则为复发感染,巨细胞病毒,CMV,感染状况的实验检测方案,7,导致孕妇,CMV,IgM,检测阳性结果原因众多,初次急性感染,继发急性感染,交叉反应,(,疱疹病毒家族,),患者体内,IgM,持续阳性,免疫系统的多克隆刺激,单独检测,CMV IgM,导致假阳性，一定加入,IgG,检测,8,多克隆激活,多克隆激活示意图,T,、,B,细胞可通过多克隆激活剂直接被激活,T,或,B,多克隆激活剂,（如,EB,细胞内毒素）,抗体,抗原,T,H,耐受,T,H,Preferential retroviral-mediated transduction of EBV-and CMV-specific T cells after polyclonal T-cell activation.,Sauce D,Mercier P,Battini JL,Ferrand C,Certoux JM,et al,Gene Ther.2004 Jun;11(12):1019-22.,9,CMV IgG avidity,检测：,引入细胞免疫，,确定感染时间,CMV,avidity,检测,B,细胞在淋巴组织生发中心会经历克隆选择，生成高亲合力抗体的浆细胞才会选择性存活，而非高亲合力的则凋亡。,10,卫生部临检中心,CMV,推荐检测方案,11,Liaison CMV panel,CMV IgG:,IU/mL,0.4,NEGATIVE,0.4IU/mL0.6,EQUIVOCAL,IU/mL,0.6,POSITIVE,CMV IgM:,AU/mL 15,NEGATIVE,15,AU/mL 30,EQUIVOCAL,AU/mL,30,POSITIVE,avidity recommended,CMV IgG avidity:,Av 0.200,LOW AVIDITY,0.200,Av 0.300,MODERATE AVIDITY,Av,0.300,HIGH AVIDITY,12,胎儿,CMV,感染的诊断标准（北美）,羊膜腔穿刺检测羊水,CMV,：,CMV,分离培养（金标准）,&PCR,检测,注意：在孕妇,CMV,感染后,7,周和孕,21,周后，检测过早往往导致假阴性,超声检查发现胎儿不良结果,:,J Obstet Gynaecol Can.2010 Apr;32(4):348-54.Cytomegalovirus infection in pregnancy.,13,确认,CMV,感染后的治疗,CMV hyperimmune globulin,新生儿出生不良后果明显减少,抗病毒药物：丙氧鸟苷（,ganciclovir DHPG）,有防止,CMV,扩散作用；耐丙氧鸟苷的,CMV,感染可选用磷甲酸钠，但效果比前者差。,孕 妇,伐昔洛韦,新生儿,更昔洛韦、缬更昔洛韦,终止妊娠,慎重，确诊胎儿,CMV,感染，同时与患者及家庭充分交流，不得已而为之的最后选择,CMV,疫苗处于研发中？疫苗对,CMV,再次感染有效性等问题尚待评估？,14,弓形虫,Toxoplasma,15,怀孕期间弓形虫诊断,临床上,常无明显症状,：轻度发热，酸痛，淋巴结肿大，无力，皮疹，眼部感染等症状,对成人危害不大，但是，在孕妇可引起流产，早产和死胎。,对于未出生的胎儿，它可以侵袭大脑和眼睛，导致严重疾病。,主要的传染源是猫的排泄物，进食生的或半生的肉类也有可能感染。,实验室诊断方法,:,血清学检测及其他,16,弓形虫感染来源,生食感染的肉类,食入污染的蔬菜,肉类加工,食入生鲜海产品,猫等动物,等等,Clin Infect Dis.2009 Sep 15;49(6):878-84.,Risk factors for Toxoplasma gondii infection in the United States.,tachyzote,ftus,soil,cysts,cysts,Cat litter,oocyst,17,怀孕各阶段弓型虫的垂直感染率不同,在孕期的前三个月为约,15%,，进行治疗后，只有,7%,的新生儿发生了感染。,孕中期三个月的传染率为,24-30%,孕期的后三个月，感染的发生率高达,59%,。,早期检测和治疗具有重要意义。,Mem Inst Oswaldo Cruz.2009 Mar;104(2):389-92.Diagnosis of congenital toxoplasmosis:prenatal and neonatal evaluation of methods used in Toulouse University Hospital and incidence of congenital toxoplasmosis.,Montoya J,Remington J.Management of Toxoplasma gondii infection during pregnancy.Clin Infect Dis 2008;47:55466.,垂直感染率随孕周越来越高,孕早期的感染导致的胎儿先天性不良后果较中后期更严重,早期检测和治疗具有重要意义。,弓形虫感染筛查流程,18,19,Liaison Toxoplasma,Liaison Toxo IgG II:,Curve range 0-400 IU/mL,IU/mL 7.2,NEGATIVE,7.2IU/mL 8.8,EQUIVOCAL,IU/mL,8.8,POSITIVE,Liaison Toxo IgM,:,AU/mL 6.0,NEGATIVE,6.0,AU/mL 8.0,EQUIVOCAL,AU/mL,8.0,POSITIVE,Liaison Toxo IgG Avidity II,Av 3,LOW AVIDITY,3,Av 34 WG,Acyclovir 200 mg five times daily,Acyclovir 400 mg three times daily from 36 weeks to delivery,Caesarean Delivery,Accidental Vaginal Delivery,Virus isolation in the mother and newborn,Follow up,Virus isolation in the mother and newborn,To consider,neonatal therapy,Virus isolation in the mother and newborn,To consider,neonatal therapy,孕期初次,HSV,临床方案,WG:weeks gestation,33,Recurrent infection,Acyclovir 200 mg five times daily,at 36 weeks gestation,Positive cultures&negative genital lesions,at the time of delivery,Caesarean,Section,caesarean section with intact membranes or within 4-6 hours from membranes rupture,孕期,HSV,复发的临床方案,WG:weeks gestation,Vaginal,Delivery,Negative cultures&negative genital lesions,at the time of delivery,Positive genital lesions,at the time of delivery,Maternal antivital therapy,+,Neonatl antiviral treatment,(if neonate develops signs of infection),Lazzarotto Tiziana,UO di Microbiologia,Policlinico S.Orsola Malpighi,Bologna,34,HSV,的,IgG,和,IgM,检测试剂盒,HSV-1/2 IgG,HSV-1 IgG,HSV-2 IgG,HSV-1/2 IgM,我该选择哪个品牌的,Torch,试剂，它们真的有区别吗？,