Cervical lymphadenopathy secondary to Kikuchi-Fujimoto disease in a child: case report

While most cases of cervical lymphadenopathy resolve with conservative management, persistent adenopathy can lead to costly investigations and invasive treatments. One cause of persistent adenopathy, as well as a variety of other associated systemic symptoms, is Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenitis). This rare entity can be diagnosed only by excisional biopsy on the basis of its characteristic histologic appearance. We describe a case of persistent cervical lymphadenopathy secondary to Kikuchi-Fujimoto disease in an 11-year-old girl.

Enthesitis-related arthritis in Kikuchi-Fujimoto disease

Histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease (KFD) is a rare, benign and self-limiting disorder that characteristically presents with fever and cervical lymphadenopathy. Articular manifestations in the form of arthralgias are common but frank arthritis is distinctly rare and dactylitis has not been reported yet. Herein, we describe a young boy who presented with arthritis and dactylitis as the initial manifestation of KFD. A 14-year-old boy presented with a two-week history of fever, generalized lymphadenopathy and asymmetric polyarthritis, enthesitis and dactylitis of the toes. Two years earlier he presented with arthritis of the knee and ankle joints, which lasted for 12 months. However, he had been asymptomatic for one year. Investigations revealed anemia, leukopenia and raised acute phase reactants. Work-up for infectious etiology, systemic lupus erythematosus and leukemia and lymphoma was negative. Excision biopsy of the cervical lymph node confirmed KFD. Fever, lymphadenopathy and leukopenia dissipated with nonsteroidal anti inflammatory drug therapy, but the arthritis persisted. A trial of methotrexate led to the resolution of the arthritis.

Fatal Kikuchi-Fujimoto disease associated with SLE and hemophagocytic syndrome: a case report

Kikuchi-Fujimoto disease (KFD) or histiocytic necrotizing lymphadenitis is a rare, benign, autoimmune condition characterized by lymphadenopathy, fever, and neutropenia. KFD can frequently mimic various diseases including infection, malignancy, and autoimmune disease. KFD has also been infrequently reported in association with SLE, which can be diagnosed previously, simultaneously, or after the diagnosis of SLE. The author presents here the first case of fatal KFD simultaneously occurred with SLE complicated with hemophagocytic syndrome and severe infection. The recognition of this association is of significance for management of affected patients with early intensive immunosuppressive therapy for favorable outcome.

[Histiocytic necrotizing lymphadenitis: report of three cases]

Histiocytic necrotizing lymphadenitis (HNL), also known as Kikuchi 5 disease is a rare condition of unknown etiology. Patients present with cervical lymph node enlargement, fever and malaise. The diagnosis is made by excision biopsy. However, this entity must be distinguished from both reactive processes and malignant tumors such as lymphoma. The clinical course is self limited with spontaneous resolution within a few months. We report three patients with the disease. A 37 year-old woman with a 4 months history of a painless submaxillary mass of 2.5 cm diameter, attached to the deep tissues of the neck. The mass was excised and the biopsy report was HNL. After 26 months of follow up, the patient is asymptomatic. A 30 year-old woman with a history of 2 months of a painless lateral cervical mass and aspiration biopsy was reported as suspicious for lymphoma. An excision biopsy was performed, that was reported as HNL. In both patients, lymphoma was ruled out by immunohistochemistry. A 33 year-old woman with a 3 weeks history of an asymptomatic lateral cervical mass. Biopsy was reported as HNL. This condition must be included in the differential diagnosis of cervical asymptomatic masses. The clinician must be aware of it to avoid long-term, costly treatments.

Paediatric Kikuchi-Fujimoto disease: a benign cause of fever and lymphadenopathy

Kikuchi-Fujimoto disease (KFD) is a rare and benign disease that typically affects the cervical lymph nodes. Its aetiology is unknown and a role of the autoimmune system in the pathogenesis is hypothesized. This self-limiting disease is often confused with malignancies. No specific management is generally required but long-term follow-up should be planned despite the low risk of recurrence, as recurrences have been described many years after the first episode and there is a high risk of development of an autoimmune disease or even lymphoma. We review the clinical and histological features of KFD and report an unusual case presenting with cervical and supraclavicular lymphadenopathy, and persistent fever.

Histiocytic necrotizing lymphadenitis without granulocytic infiltration (the so called Kikuchi-Fujimoto disease)

The report describes five cases of a rare disorder--necrotizing lymphadenitis--diagnosed in Polish patients in the Department of Pathomorphology, Collegium Medicum, Jagiellonian University, Krakow, in the years 1993-2006. The disease was firstly described by Kikuchi and Fujimoto in the Oriental population of Japan in 1972 and for this reason it is called Kikuchi-Fujimoto disease (or Kikuchi lymphadenitis). Its characteristic histological picture includes necrosis without granulocytic infiltrate surrounded by plasmocytoid monocytes, histiocytes (CD68+, lysozyme+, myeloperoxidase+) and immunoblasts, sometimes with atypia, with concomitant lymphocytes, predominantly cytotoxic T CD8+. The histology together with the rare occurrence of the disease in Poland may be a considerable diagnostic challenge for a pathologist, leading to misdiagnosing the lesion as a neoplastic process (malignant lymphoma).

[A rare cause of cervical adenopathy]

We report the case of a young woman, who presented a sus-clavicular adenopathy with fever and inflammatory syndrome. A cervico-thoracic scan reveals sus-clavicular and hilar adenopathies with central necrosis. Laboratory studies, including blood culture and viral serologies were negative, and excluded an infectious aetiology. Clinical features and anti-nuclear antibody tests were not compatible with an inflammatory autoimmune disease. Bone marrow examination and lymph node histology didn't show any malignant cell. Histology analysis of the lymph node showed a typical aspect of histiocytic necrotizing lymphadenitis. This is compatible with the diagnosis of Kikuchi's disease.

Clinicopathological study of Kikuchi's disease

Kikuchi's disease (KD) is a necrotizing lymphadenopathy with a self-limiting course commonly affecting young people. We conducted a clinico-pathological study of 20 cases of KD received at our department between July 2000 and December 2003. Our study confirmed that KD commonly involves the cervical lymph nodes of young adults, with a female predominance. One patient had associated cutaneous involvement. The hematological parameters were non-specific. The histological features were distinctive and included easy fragmentation on handling, karyorrhexis, crescentic histiocytes and the absence of neutrophils. The differential diagnosis on histology is also discussed.

Kikuchi's disease associated with hemophagocytosis

We report the case of a 40 year-old Nepali man admitted to the hospital with a one month history of fever associated with swelling, pain, and redness on the right side of the neck. On examination, tender lymph nodes were palpated in the right posterior cervical triangle. Bone marrow aspiration and biopsy showed hemophagocytosis. Cervical lymph node biopsy showed the typical necrotizing lymphadenitis of Kikuchi's disease. The patient was given non-steroidal anti-inflammatory drugs (Naproxen 500 mg twice daily orally). After ten days, the fever and lymphadenopathy subsided and he was consequently discharged.

Kikuchi's disease displaying a t(2:16) chromosomal translocation

Kikuchi's disease is a rare self-limiting lymphoproliferative condition of unknown aetiology, characterised by acute or subacute necrotising lymphadenitis. It is a benign condition that can mimic malignant lymphoma. In this report, a case of Kikuchi's disease associated with a chromosomal abnormality is described. This is the first report in the literature of such a case and it highlights an important learning point; benign lymphoproliferative conditions can be associated with chromosomal abnormalities that are more typically associated with malignant lymphoproliferative conditions such as malignant lymphoma. The report illustrates the necessity for interpreting cytogenetic data in the relevant clinical and histopathological context in a multidisciplinary setting to avoid misdiagnosis and inappropriate treatment.

Recurrent Kikuchi–Fujimoto disease: Case report

Kikuchi-Fujimoto disease, also known as histiocytic necrotising lymphadenitis, is a self-limiting condition of uncertain aetiology characterised by lymphadenopathy, pyrexia, and neutropenia. Some reported cases have been associated with systemic lupus erythematosus and there have been suggestions that Kikuchi's disease could represent a mild form of lupus but without definite evidence. We describe an unusual case of histiocytic necrotising lymphadenitis in an Asian woman who had recurrent episodes for five years before a diagnosis was made.

Kikuchi-Fujimoto disease of 16 children in a single center of Korea

Kikuchi-Fujimoto disease (KFD) is subacute necrotizing lymphadenitis characterized by fever, leukopenia and cervical lymphadenopathy. There are few reports on the clinical characteristics and laboratory findings of KFD in the pediatric literature. In this study, we evaluate the characteristics and outcome of KFD in children. A total of 412 patients were studied with fever and peripheral lymphadenopathy at Pusan National University Hospital from January 1998 to December 2003. Among the total 412 there were 16 patients diagnosed with KFD by lymph node biopsy. We analyze the clinical, laboratory and outcome after review of the medical records retrospectively. The mean age of the patients was 10.6 +/- 3.4 yr (range: 4-17 yr). The male to female ratio was 1:1. Almost all patients, except two, had cervical lymph node swelling. The size of the involved lymph node was less than 4 cm in the greatest dimension in 75% of the patients. All the children had fever as the chief complaint and the mean duration of the fever was 17.7 +/- 11.2 days (range: 2-122 days). Approximately 87% of the patients had leukopenia (WBC < 4000/mm(3)) and 43.8% of the patients had a mild increase in the transaminases on liver function testing. A total of 8 out of the 16 patients were initially misdiagnosed as an infectious disease and treated with antibiotics which caused prolonged hospitalization for most patients. Six patients were treated with prednisone and the prolonged fever subsided immediately after steroid therapy. KFD should be considered in the differential diagnosis of prolonged fever in children with cervical lymphadenopathy. Early cervical lymph node biopsy is necessary to minimize inappropriate examinations and treatments in such cases.

Uncommon lymphadenopathies of immunopathogenesis can be misinterpreted as malignant diseases

Lymphadenomegaly is a common sign of benign and malignant disorders. In our practice, only every fifth patient is found to have primary or secondary nodal malignancy. Benign disorders, including banal infections and other non-neoplastic conditions, however, cause most of the cases. Among these, there are some rare entities, resulting in persistent lymphadenopathy that may cause differential diagnostic problems in the daily practice. We report here three patients, having Rosai-Dorfman disease, multicentric Castleman's disease and Kikuchi's lymphadenitis, who exemplify such cases. Our purpose with this presentation is to emphasise importance of vigorous co-operation between clinicians and pathologists. In general, it is imperative to prefer specialised haematopathological laboratories that may facilitate proper diagnosis.

[Kikuchi's histiocytic necrotising lymphadenitis: a benign disorder--not to be confused with malignant lymphoma]

A 26-year-old woman who later turned out to have the rarely seen histiocytic necrotising lymphadenitis of Kikuchi was twice diagnosed incorrectly with malignant T-cell lymphoma. She was treated with standard chemotherapy, whereas Kikuchi's disease has a self-limiting course. Fear for recurrent lymphoma greatly affected the patient's life until the proper diagnosis was ultimately made. This occurred after the patient herself had seen in her dossier that the diagnosis 'Kikuchi's histiocytic lymphadenitis' had been proposed by two pathologists of the consulted regional lymphoma board in the past, but had been rejected by the board after external consultation.

Kikuchi-Fujimoto disease: A case report and review of literature

Kikuchi-Fujimoto disease (KFD) is a benign and self-limiting disease. The entity was first described in 1972 by Kikuchi and Fujimoto in Japan independently. KFD is prevalent in Asia, although it may be seen in a wide geographic distribution. It commonly affects young women. Cervical lymphadenopathy is the most prominent sign and should be differentiated from lymphoproliferative, autoimmune, and infectious diseases. We report a female patient with KFD presenting with enlarged tender cervical lymph nodes and provide a brief review of the literature. The diagnosis is established on the basis of histology of lymph node excisional biopsy.

[Kikuchi-Fujimoto disease (histiocytic necrotizing lymphadenopathy) clinicopathologic and immunohistochemical study of 14 cases and its differential diagnosis with other reactive and neoplastic necrotizing lymphadenopathies]

Kikuchi-Fujimoto disease also known as histiocytic necrotizing lymphadenopaty (HNL) is a rare entity, originally described in Japanese population, although currently it has been described all over the world. It is more frequent in young women and it is usually located in cervical lymph nodes. We report 14 cases of HNL in Mexican population, their clinicopathological and immunohistochemical study as well as a comparative study with other necrotizing lymphadenopaties due to B or T-cell lymphomas, tuberculosis, Epstein Barr virus infection, and non-specific necrosis. In our study we found that there was more expression of the immunomarkers CD68, MPO, CD123 and antikerat in OSCAR in the cases of HNL in contrast with the lesser or even null expression of the same markers in the necrotized lymph nodes of the comparative study group.

Kikuchi-Fujimoto disease

Kikuchi-Fujimoto disease (KFD) is a benign and self-limited disorder, characterized by regional cervical lymphadenopathy with tenderness, usually accompanied with mild fever and night sweats. Less frequent symptoms include weight loss, nausea, vomiting, sore throat. Kikuchi-Fujimoto disease is an extremely rare disease known to have a worldwide distribution with higher prevalence among Japanese and other Asiatic individuals. The clinical, histopathological and immunohistochemical features appear to point to a viral etiology, a hypothesis that still has not been proven. KFD is generally diagnosed on the basis of an excisional biopsy of affected lymph nodes. Its recognition is crucial especially because this disease can be mistaken for systemic lupus erythematosus, malignant lymphoma or even, though rarely, for adenocarcinoma. Clinicians' and pathologists' awareness of this disorder may help prevent misdiagnsois and inappropriate treatment. The diagnosis of KFD merits active consideration in any nodal biopsy showing fragmentation, necrosis and karyorrhexis, especially in young individuals presenting with posterior cervical lymphadenopathy. Treatment is symptomatic (analgesics-antipyretics, non-steroidal anti-inflammatory drugs and, rarely, corticosteroids). Spontaneous recovery occurs in 1 to 4 months. Patients with Kikuchi-Fujimoto disease should be followed-up for several years to survey the possibility of the development of systemic lupus erythematosus.

Different T-bet expression patterns characterize particular reactive lymphoid tissue lesions

AIMS

To investigate T-bet expression profiles in various lymphoid tissue diseases caused by intracellular pathogens and to compare them in disorders without an infective aetiology. Murine and in vitro experiments have shown that the expression/induction of T-bet, the master regulator of Th1 differentiation, can be achieved by obligate intracellular pathogens and high interferon (IFN)-gamma levels.

METHODS

Lymph node biopsies were analysed immunohistochemically employing single and double labelling for T-bet and CD20, CD4, CD8 and CD30 detection.

RESULTS

In disorders associated with high IFN-gamma levels and intracellular pathogens (infectious mononucleosis, HIV-associated lymphadenopathy, cat-scratch disease, and toxoplasmic lymphadenitis), T-bet-expressing CD4 cells were accompanied by significant numbers of T-bet-positive CD8 and B cells. A similar profile was also found in histiocytic necrotizing (Kikuchi) lymphadenitis, a disease of unknown cause. In contrast, T-bet expression in disorders without an infective aetiology was observed in only a small portion of lymphocytes.

CONCLUSIONS

Increased T-bet expression does not only identify intracellular infections in lymphoid tissue associated with high IFN-gamma levels, but also implies that, under these conditions, it becomes induced in B cells, which apparently support the Th1 response. T-bet expression in Kikuchi lymphadenitis underscores the hypothesis that it is caused by an intracellular microorganism.

Quantitative analysis of herpesvirus load in the lymph nodes of patients with histiocytic necrotizing lymphadenitis using a real-time PCR assay

The cause of histiocytic necrotizing lymphadenitis (HNL) has been ascribed to viral infection, but its pathogenesis still remains unknown. Real-time PCR assays are useful not only for their sensitivity of detection but also for the quantitation of viral DNA with a wide linear range. We accordingly used this technique to estimate for each patient the viral load of the following members of the herpesvirus family: Epstein-Barr virus (EBV), cytomegalovirus (CMV), and human herpesvirus (HHV) types 6, 7, and 8. Samples of patients diagnosed as reactive lymphadenopathy (RL) were included for control. Thirty percent (6/20 cases) and 63% (12/19 cases) of the HNL and RL patients were positive for EBV, and the mean of the detectable EBV viral load of the HNL and that of the RL patients were 463 and 355 (copies/mug DNA), respectively. By in situ hybridization, EBV-encoded RNA could be detected in the lymph tissue samples with more than 14.3 copies/mug of EBV DNA. No significant difference was detected between the number of HNL patients with HHV6 DNA (3/20, 15%) or HHV7 DNA (2/20, 10%) and RL controls. CMV and HHV8 were not detected in the DNA from any patient. In this study, we were unable to definitively identify the causative herpesvirus for HNL; however, 1 HNL case had an extremely large copy number of HHV6-DNA and displayed positive immunostaining for the HHV6 early/late antigen in lesional areas of the node, suggesting that HHV6 infection may be associated with some cases of HNL.