Kikuchi-Fujimoto disease: a sheep in wolf's clothing

INTRODUCTION

Kikuchi-Fujimoto disease (KFD) is a rare, self-limiting disorder that typically affects the cervical lymph nodes. Recognition of this condition is crucial, especially because it can easily be mistaken for tuberculosis, lymphoma, or even adenocarcinoma. Awareness of this disorder will help prevent misdiagnosis and inappropriate treatment.

METHODS

From January 2006 to December 2008, 30 patients who underwent a biopsy of a cervical lymph node and proved histologically to have KFD were enrolled in this study. We studied clinical manifestations, laboratory results, treatment, and recurrence for each patient. Patients were followed up for a mean period of 2 years.

RESULTS

There were 24 women and 6 men, with a mean age of 18 years. Two patients had a past history of tuberculosis. Major clinical symptoms and signs were fever (70%) and lymphadenopathy (100%). The affected cervical lymph nodes were most commonly located in the posterior cervical triangle. Unilateral and bilateral cervical lymph nodes were affected in 25 and 5 patients, respectively. The affected lymph nodes were most commonly less than 3 cm in size. Leukopenia was observed in 46.7%, and a raised erythrocyte sedimentation rate was seen in 56.7% of the cases. Treatment strategies included no medication, nonsteroidal antiinflammatory drugs (NSAIDs) alone, steroids alone, or a combination of NSAIDs and steroids. Ninety percent improved within 3 months, whereas one patient showed improvement only after 9 months of continued treatment. No recurrence has since been noted.

CONCLUSION

KFD is a benign disease that masquerades as other more sinister diseases and can lead to unnecessary treatment-induced physiologic, psychological, and financial morbidity to the patient. Tissue diagnosis is necessary in all cases, and an effective communication between the surgeon and the pathologist is imperative in making an accurate diagnosis.

A rare case of Kikuchi's disease of the cervical lymph node

Kikuchi's disease, or histiocytic necrotising lymphadenitis, is an uncommon and unique form of self-limiting lymphadenitis and typically affects the head and neck regions. The most common clinical manifestation is cervical lymphadenopathy, with or without systemic signs and symptoms. Clinically and histologically, the disease can be mistaken for lymphoma or systemic lupus erythematosus. Pathologically, presence of karyorrhexis, paracortical areas of necrosis and the absence of neutrophils, eosinophils and plasma cells were consistent with Kikuchi's disease. CT scan showed enlarged lymph nodes with hypodense centres and peripheral ring enhancement. As Kikuchi's disease can be cured by steroid, its diagnosis can prevent unnecessary surgery.

[Kikuchi-Fujimoto disease]

Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis is a rare, benign, self-limited condition of unknown etiology. A 16-year-old woman with no relevant clinical history seeks medical attention for fever and cervical adenopathies. In a physical examination the patient is found to be febrile (38.5 C) with multiple bilateral, hard-elastic cervical adenopathies, congestive oropharynx and mild splenomegaly with no other relevant pathological findings. The laboratory examination shows signs of pancytopenia and an increase in the erythrocyte sedimentation rate, Β2-microglobulin, transaminases and lactate dehydrogenase. Several serological tests are carried out with negative results except for immunoglobulin G for parvovirus, which is positive. A computerized axial tomography scan of head, neck, thorax, abdomen and pelvis shows bilateral lateral cervical adenomegalies (the largest with a size of 15 mm) and bilateral axillary adenomega- lies of less than 10 mm in diameter; small basal lung condensations with mild pleural effusion, mild homogeneous splenomegaly, and a small amount of free fluid in the abdominal cavity at the bottom of the Douglas cul-de-sac. Possible respiratory and gynecological infections are treated with ampicillin/sulbactam together with doxycycline. The patient progresses with persistence of the symptoms. A lymph node biopsy is then performed, revealing a morphology compatible with Kikuchi-Fujimoto disease. Treatment with prednisone is initiated with a clinical and laboratory improvement in the patient's condition. Kikuchi-Fujimoto disease is probably under-reported and under-diagnosed due to the low index of suspicion. Greater awareness of this illness would result in clinicians arriving at this diagnosis more often.

A fatal case of Kikuchi-Fujimoto disease

Kikuchi-Fujimoto disease is an extremely rare, benign, auto-immune, clinicopathological condition presenting with fever and lymphadenopathy. It has higher prevalance among Japanese and other Asiatic individuals. It is usually self-limiting with extremely rare mortality. A case of an adolescent girl who presented with fever and cervical lymphadenopathy, found to have Kikuchi's disease on histopathology of cervical lymph node is being reported. She eventually succumbed to the disease.

Kikuchi-Fujimoto disease mimicking tuberculous lymphadenitis

A 28-year-old woman was referred to our hospital for treatment of tuberculous lymphadenitis, after presenting with fever, left cervical lymphadenopathy, and a positive interferon-gamma release assay (QuantiFERON®-TB Gold In-Tube; QFT) result. Surprisingly, biopsy specimens of the cervical lymph nodes showed necrotic lesions with prominent nuclear debris and a proliferation of histiocytes, consistent with Kikuchi-Fujimoto disease (KFD). A diagnosis was made of KFD complicated by latent tuberculosis infection (LTBI), and all symptoms had resolved completely two months post-diagnosis. KFD may be misdiagnosed as tuberculous lymphadenitis, and antibiotics unnecessarily prescribed. Careful attention should therefore be paid when diagnosing cervical lymphadenopathy.

[Loss of pan-T cell antigens CD2, CD3, CD5 and CD7 in Kikuchi's disease]

OBJECTIVE

To study the possible loss of pan-T cell antigens CD2, CD3, CD5 and CD7 in Kikuchi's disease and to evaluate the role of T cell antigen loss in distinguishing benign from malignant T-cell lymphoid lesions.

METHODS

Formalin-fixed and paraffin-embedded tissues of 33 cases of Kikuchi's disease and 15 cases of reactive lymphoid hyperplasia were studied by EliVision immunohistochemical staining for CD2, CD3, CD5 and CD7.

RESULTS

Twenty-four of the 33 (72.7%) cases of Kikuchi's disease lost one or more of the pan-T cell antigens, including the loss of CD5 only (13 cases), CD7 only (1 case), CD2 only (1 case), CD2 and CD7 (2 cases), CD5 and CD7 (4 cases), CD2 and CD5 (2 cases), and CD2, CD7 and CD5 (1 case). Amongst these cases, the commonest antigen loss was CD5 (20 cases, 60.6%), followed by CD7 (8 cases, 24.2%) and CD2 (6 cases, 18.2%). Compared with the xanthomatous subtype of Kikuchi's disease, the loss of antigens was more commonly seen in the proliferative and necrotizing subtypes. Analysis of follow-up data showed that the loss of antigens in Kikuchi's disease was not significantly associated with the prognosis. In reactive lymphoid hyperplasia, the expression of CD2, CD3, CD5 and CD7 was seen in all cases with similar intensity, with no obvious pan-T cell antigen loss.

CONCLUSION

Loss of one or more pan-T cell antigens in Kikuchi's disease is demonstrated in present study, suggesting that the immunophenotypic pattern is not unique in T cell lymphoma.

[Histiocytic necrotizing lymphadenitis: (Kukuchi-Fujimoto disease): a diagnostic challenge]

Kikuchi-Fujimoto disease, also called Histiocytic necrotizing lymphadentis, is a rare, benign and self-limited disease, with unknown etiology, that affects mainly young women, and is characterized by adenopathy (usually localized in the cervical region) and fever. Diagnosis is based on histopathological findings in ganglionar tissue obtained in excisional biopsy, which allows, in most cases, the differential diagnosis with other similar clinical conditions, but which have a completely different clinical evolution and therapeutic needs. We report a case of a twenty four year old woman with persistent cervical lymphadenopathy, in which histopathological examination followed by immunohistochemical analysis of ganglionar tissue revealed to be Kikuchi-Fujimoto disease.

Kikuchi-Fujimoto disease. Histiocytic necrotizing lymphadenitis

Kikuchi-Fujimoto disease (KFD), or histiocytic necrotizing lymphadenitis, is a self-limited disease of complex and unclear etiology. Clinically and microscopically, it may mimic malignant lymphoma and other non-malignant diseases. Recognition of this entity is crucial, as mistaking this disease as lymphoma has major clinical consequences. Although KFD is a well-recognized entity in the literature, many clinicians and pathologists are still unaware of its existence. In this article, a review of KFD is provided with special emphasis on the pathogenesis and pathological differential diagnosis of this disease.

Gray scale and power Doppler study of biopsy-proven Kikuchi disease

OBJECTIVES

Kikuchi disease is a benign, self-limiting cause of cervical lymphadenopathy. It can show sonographic features similar to those of other common causes of lymphadenopathy. The purpose of this study was to characterize the sonographic features of Kikuchi disease that can contribute in differentiating between Kikuchi disease and other diseases causing cervical lymphadenopathy.

METHODS

Sonographic findings of 175 patients with biopsy-proven Kikuchi disease were retrospectively reviewed. The mean age of the patients was 27.3 years, and the female to male ratio was 3.5:1. All patients had undergone sonographically guided core biopsy. Pathologic findings were classified into proliferative (n = 57), necrotizing (n = 109), and xanthomatous (n = 9) types. On gray scale sonography, lymph nodes were assessed by their size, shape (shortest/longest axis ratio), location, echogenicity, presence of conglomeration, gross necrosis, calcification, echogenic nodal hilum, and increased perinodal echogenicity. The vascular pattern was assessed on power Doppler imaging.

RESULTS

The mean maximum diameter of the lymph nodes was 1.6 cm. Forty-four percent of them (77 of 175) were oval (shortest/longest axis ratio, 0.5-0.7) and 48% (84 of 175) were elongated (shortest/longest axis ratio, <0.5). Most were located in levels II and V. Seventeen lymph nodes showed gross necrosis, and none showed calcification. One hundred fifty-two lymph nodes (86.8%) had an echogenic hilum, and 76% (133 of 175) showed increased perinodal echogenicity. Increased perinodal echogenicity was seen in 93.5% of the necrotizing type (102 of 109) and 43.8% of the proliferative type (25 of 57); the difference between the two types was statistically significant (P = .001). Normal (n = 161), displaced (n = 13), and absent (n = 1) hilar vascularity was seen on power Doppler studies.

CONCLUSIONS

Sonographic findings of Kikuchi disease can contribute to the differentiation between Kikuchi disease and other causes of cervical lymphadenopathy.

Kikuchi-Fujimoto's disease: a report of five cases

Kikuchi Fujimoto's disease is a rare, self limiting disorder characterized by fever and cervical lymphadenitis. It is often an incidental finding in a patient suspected to have tuberculosis or lymphoproliferative disorder. We diagnosed this disease in a young 23-year-old female who was suffering from prolonged fever, cervical lymphadenopathy, anemia, leucopenia and mild splenomegaly; based on histopathological study of the excised lymphnode. We reviewed the clinical records and histopathologic findings of four more patients of Kikuchi-Fujimoto's disease, who were treated by others at our institute. All five patients improved with NSAIDS (non steroidal anti inflammatory drugs). Histopathological finding of histiocytic necrotizing lymphadenitis or Kikuchi's disease proved invaluable in characterization of these cases.

[Clinical analysis of histiocytic necrotizing lymphadenitis in 68 cases]

OBJECTIVE

To investigate and analyze the clinical features in patients with histiocytic necrotizing lymphadenitis (HNL).

METHODS

A total of 68 HNL patients at our hospital between the years of 1999 to 2009 were enrolled. The clinical data were collected from the hospital records and the relevant literature was reviewed.

RESULTS

HNL mainly affected young people with an average age of (19 ± 13) years old and a female-to-male ratio of 1:1. All patients had lymphadenectasis. And 95.6% patients (65 cases) were feverish and 36.8% patients (25 cases) had mild hepatosplenomegaly; 25.0% (17 cases) upper respiratory symptoms such as sore throat and cough; 14.7% (10 cases) skin rash in their history; 51.5% (35 cases) leucopenia; 25.0% (17 cases)hepatic dysfunctions; 72.1% (44/61) elevated erythrocyte sedimentation rate (ESR); 11.1% (6/54) positive antinuclear antibody (ANA). The final diagnosis of HNL was confirmed by pathological examination and immunohistochemical staining of biopsy specimens. And 34 (50.0%) patients received glucocorticoid for 2 weeks to 3 months. Seven (10.3%) patients relapsed in which glucocorticoid was effective. Of 6 patients with positive ANA, one case was complicated with systemic lupus erythematosus (SLE) and another case diagnosed with SLE at 2 years after HNL.

CONCLUSIONS

The clinical manifestations of HNL lack specificity so that it can be easily misdiagnosed. While the etiology of HNL remains elusive, the histopathological examination of affected lymph nodes has contributed greatly to the final diagnoses of HNL. Glucocorticoid therapy is recommended for treatment. Generally, HNL has an excellent prognosis but it often relapses. It should be noted that HNL may coexist with SLE or evolve ultimately into SLE.

[Kikuchi-Fujimoto disease: pediatric case presentation]

Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis is a rare, benign condition, usually self-limited to a six-month period. Classic clinical presentation is characterized by cervical lymphadenopathy, leukopenia and prolonged fever. It affects principally young, Asiatic adult women, although a few cases in the pediatric population have been reported. This disease frequently mimics tuberculous lymphadenitis, malign lymphoma, systemic lupus erythematosus and other benign and malignant conditions. The etiology is unknown, although a viral or autoimmune pathogenesis has been suggested. Laboratory investigations are usually unremarkable, and the most frequent findings are leukopenia, elevated erythrocyte sedimentation rate, anemia and positive antinuclear antibodies. To make an accurate diagnosis, histopathological studies are required. To avoid the use of antibiotics (which have no effect), early diagnosis is necessary. Herein the case of a 10 years old girl is described that presented with high, prolonged fever and marked cervical lymphadenopathy secondary to Kikuchi-Fujimoto disease.

Kikuchi-Fujimoto disease: three case reports

CONTEXT

Kikuchi-Fujimoto disease (KFD) manifests in most cases as unilateral cervical lymphadenomegaly, with or without accompanying fever. The disease mainly affects young women and has a self-limited course. It is more common in oriental countries, with few reports of its occurrence in Brazil. KFD should be included in the differential diagnosis of suspected cases of viral infections, tuberculosis, reactive lymphadenitis, systemic lupus erythematosus and metastatic diseases. It can be histologically confused with lymphoma. The disease is benign and self-limiting and an excisional biopsy of an affected lymph node is necessary for diagnosis. There is no specific therapy.

CASE REPORTS

This study reports on three cases of non-Asian female patients with KFD who were attended at our service between 2003 and 2006. A review of the literature was carried out, with a systematic search on this topic, with the aim of informing physicians about this entity that is manifested by cervical masses and fever.

[Kikuchi-Fujimoto syndrome]

This article concerns a 25-year-old woman, with clinical symptoms of Kikuchi-Fujimoto Syndrome (KFS). The patient arrived ten days after symptom onset. She initially discovered lymphadenopathy on the right side of her neck. She had no fever, pruritus or weight loss. Fine needle aspiration biopsy indicated a lympho-proliferative disease, which was confirmed by a lymph node biopsy. KFS is histologically characterized by necrotizing lymphadenitis. The cardinal symptoms are fever, lymphadenopathy and night sweat.

[Kikuchi-Fujimoto disease in Gabon. Description of first 2 cases in Gabon]

Kikuchi-Fujimoto disease is a rare disorder sometimes associated with systemic lupus. It has rarely been reported in the black African population. The purpose of this report is to describe the first two cases in Gabon. In patients presenting enlarged cervical lymph nodes, it is first necessary to rule out infectious disease. Histology can allow diagnosis by demonstrating necrotizing histiocyte lymphadenitis.

Severe Kikuchi's disease responsive to immune modulation

Kikuchi's disease, although an uncommon entity, has been increasingly reported since it was first discovered in 1972. The most common manifestation of Kikuchi's disease, cervical lymphadenopathy, has no clinically distinguishable features. Therefore, a diagnosis of Kikuchi's disease has largely been based on clinical suspicion and histopathological confirmation. We present a 15-year-old Chinese girl with severe Kikuchi's disease, whose relapsing course was only responsive to highdose steroid and intravenous immunoglobulin therapy.

Treatment of histiocytic necrotizing lymphadenitis (Kikuchi's disease) with prolonged fever by a single course of methylprednisolone pulse therapy without maintenance therapy: experience with 13 cases

A 26-year-old man was hospitalized with a 1-month history of fever. Cervical lymph node biopsy showed necrosis in the paracortical area with abundant nuclear debris and proliferation of histiocytes. A diagnosis of histiocytic necrotizing lymphadenitis (HNL) (Kikuchi's disease) was made. He received methylprednisolone pulse therapy (MPT) (0.5 g/day for 3 days) without maintenance therapy and experienced dramatic improvement. We also used MPT for another 12 cases of HNL. All patients became afebrile within 1 day without adverse events. Four patients relapsed after the initial MPT, but only 1 patient relapsed during the following year. Our results suggest that MPT is warranted in HNL patients with prolonged fever.

Kikuchi's disease in children: clinical manifestations and imaging features

Previously published studies on Kikuchi disease (KD) have frequently addressed the computed tomography (CT) findings in the adult population, however, only a few studies have been reported for the pediatric age group. The purpose of this study is to analyze the clinical characteristics and imaging features of KD in children. Fifteen children (2-14 yr) who had a neck CT and pathology diagnosis of KD were included in this study. Clinical features, including the duration of lymphadenopathy and fever, prognosis, and laboratory values, were evaluated. We analyzed the sites, size, and lymph node pattern as seen on their CT scans. The median duration of fever was 10 days. Fourteen patients experienced improvement in their condition, although four of these patients experienced recurrent episodes of KD. All patients had affected cervical nodes at level V. Perinodal infiltrates were observed in the affected cervical nodes in 14 cases (93%), and non-enhancing necrosis was also noted within the affected cervical nodes in 10 cases (63%). In conclusion, the combination of imaging findings in conjunction with clinical findings of KD may help to determine whether or not to perform pathology analysis and follow-up studies.

Kikuchi-Fujimoto disease: case report

We present the case of a 27-year-old woman with local cervical lymphadenopathy without other symptoms. Due to a gradual progression of lesions, a biopsy was performed, and a specimen excised from an enlarged lymph node was subjected to histological examination. Kikuchi-Fujimoto disease (KFD), that is histiocytic necrotizing lymhadenitis, was diagnosed. Lymphadenopathy resolved without medical treatment over 6 months. KFD should be considered in the differential diagnosis of lymphadenopathy, even though this disease rarely occurs in Poland.

[The clinical characteristics of histiocytic necrotizing lymphadenitis: analysis of 11 cases]

OBJECTIVE

To study the clinical features of histiocytic necrotizing lymphadenitis.

METHOD

Eleven patients with histiocytic necrotizing lymphadenitis were collected to analyze the clinical features, pathological features of biopsy lymph nodes, diagnosis and treatment.

RESULT

Lymph node swelling of neck and persistent fever were detected in all patients. The leukocyte reduction and swiftness of ESR in serum were detected in most patients. The final diagnosis of histiocytic necrotizing lymphadenitis was confirmed by biopsy investigation of the pathology. The pathological features included distinctive necrosis, loss of lymph node structure, infiltration with histiocytes and lymphocytes, absence of neutrophils. All patients were treated with glucocorticoid for 2 to 4 months. The patients improved significantly and were not recurrence during follow up visit.

CONCLUSION

There was no specific clinical manifestation of histiocytic necrotizing lymphadenitis and which easy to misdiagnoses. Diagnosis of histiocytic necrotizing lymphadenitis relies on the pathological examination of enlarged lymph nodes.

[Spontaneous remission of Kikuchi-Fujimoto disease (lymphadenopathy) with focal skin parakeratosis]

Kikuchi-Fujimoto disease is subacute, necrotizing lymphadenopathy affecting mainly young women, and manifested by cervical lymphadenopathy. It is often observed, and described in Asia, but in other world regions sporadically too. Etiology is unknown, but it has been postulated that this condition is induced by infectious factor. We described a case of 20-year-old Caucasian woman with diagnosis of Kikuchi-Fujimoto lymphadenopathy. First symptoms as a cervical lymph nodes enlargement 2 cm in diameter was associated with elevated body temperature, without associated symptoms of infection appeared about one year ago (data from history). Lymphadenopathy and general symptoms receded after empiric therapy with amoxicilin. Relapse of cervical lymphadenopathy alongshore sternocleidomastoid muscles bilateral to about 2 cm in diameter with pseudo-flu symptoms like fever and joints and muscles pains. Focal hiperpigmentation of abdomen, arms and legs skin appeared. In histopathology of collected lymph node histiocytic necrotizing lymphadenopathy without neutrophils infiltration Kikuchi type was diagnosed. In peripheral blood morphology transitional leucopenia 2.58 x 10(9)/l with granulocytopenia 0.64 x 10(9)/l was noted. Anemia and thrombocytopenia did not be observed. In serology active CMV, EBV or toxoplasmosis were excluded. In immunology presence of eleveted levels of anti-Jo, anti-nuclear and anticardiolipin antibodies was excluded too. Serum protein electrophoresis and additional biochemical parameters was normal. In chest X-ray and abdomen ultrasonography abnormalities was not found. In skin and muscles biopsy specimens focal parakeratosis was found. Despite no empiric antiinfectious therapy after 3-4 weeks remission of general symptoms and lymphadenopathy was noted.

Necrotizing lymphadenitis of the neck

Necrotizing lymphadenitis of the neck. Histiocytic necrotizing lymphadenitis is a rare cause of cervical lymphadenopathy. It is a benign, self-limiting disease whose etiology is unknown. Cervical lymphadenopathy and fever are the most important signs. Here we report a 25-year-old female presenting with complaints of fever and a painless swelling in the neck for three months. An excisional biopsy of a posterior cervical lymph node was performed, and histological evaluation revealed histiocytic necrotizing lymphadenitis. This article discusses our case of histiocytic necrotizing lymphadenitis of the neck as well as the relevant literature.

[Systemic lupus erythematosus and Kikuchi-Fujimoto disease mimicking tuberculosis]

Kikuchi-Fujimoto's disease (KFD) or histiocytic narcotising lymphadenitis is a febrile benign lymphadenopathy of unknown etiology, involving more frequently cervical lymph nodes and diagnosed on biopsy of an affected node. It is sometimes associated with auto-immune diseases such as systemic lupus erythematosus (SLE). However less frequent symptoms including involvement of extracervical nodes, hepatosplenomegaly and systemic symptoms (weight loss, night sweats) are possible and suggest an infectious disease. We report the case of a Senegalese patient with positive Ag HBs who developed SLE and KFD mimicking tuberculosis. Atypical pseudo-infectious appearance of an inflammatory systemic disease is a rare occurrence and the diagnosis can be difficult.