Epstein-Barr virus-associated Kikuchi disease in two children

The authors describe two children with Kikuchi necrotizing lymphadenitis, the main manifestations of which were cervical lymphadenopathy, fatigue, and fever. The diagnosis was based on histopathologic findings after open biopsy. Results of serologic studies, immunoperoxidase staining for Epstein-Barr virus (EBV) latent membrane protein, in situ hybridization for Epstein-Barr encoded RNAs, and polymerase chain reaction amplification of EBV Epstein-Barr nuclear antigen-1 (EBNA) DNA suggested that EBV was the causative agent in both patients. The disease was mild and subsided after complete surgical resection in one patient, with a follow-up of 1 year. In the other patient, a short course of corticosteroids led to complete clinical remission within 2 months, but the child still has biologic signs of persistent EBV infection. He experienced relapse with a large cervical mass and fever 28 months after the initial onset. Histologic findings were identical to those at initial presentation. Symptoms again resolved spontaneously within 2 weeks, but the follow-up was short (12 mos) and the child's EBNA antibodies are still absent. No evidence of immunodeficiency was found in either child. The cause of Kikuchi disease is unknown, but a viral or postviral hyperimmune reaction has been proposed. Malignant lymphoma and systemic lupus erythematosus are differential diagnoses. Early recognition of Kikuchi disease minimizes potentially harmful and unnecessary investigations and treatments. These findings add Kikuchi disease to the protean manifestations of chronic EBV infection.

Human herpesviruses HHV-4 (EBV) and HHV-6 in Hodgkin's and Kikuchi's diseases and their relation to proliferation and apoptosis

BACKGROUND

Human herpesviruses types 4 and 6 (EBV, HHV-6) are frequently found in Hodgkin 's disease (HD) and--to a certain extent--in Kikuchi-Fujimoto's disease (KFD). Both viruses are apparently related to proliferative and/or apoptotic processes as represented by HD or KFD respectively.

OBJECTIVE

To correlate frequency and location of antigen- and DNA expression of both viruses in HD and KFD tissue sections in relation to markers for cell proliferation and apoptosis.

STUDY DESIGN

Archival lymph node biopsies from 103 patients with HD and 14 KFD patients were investigated immunohistologically for viral antigen expression (EBV LMP- 1: HHV-6 pl 10/60), Ki67/PCNR, marker for proliferation (MIB1)/p53 and WAF1 for apoptosis. Viral DNA was shown by in situ hybridization. Apoptosis was determined by ISEL and TUNEL techniques.

RESULTS

HD is frequently infected by both EBV and HHV-6 while KFD tends to be infected only by HHV-6. EBV in HD is present in HD cells and in Reed-Sternberg cells (HD/RS cells), HHV-6 preferentially in lymphocytes and in histiocytes in both HD and in KFD. Proliferation marker Ki67 is found in lymphocytes and histiocytes of both diseases and in HD and RS cells in HD. Apoptosis is demonstrated in lymphocytes and histiocytes preferentially in KFD and to a lesser extent also in HD.

CONCLUSION

Although EBVand HHV-6 may not be openly oncogenic in HD and KFD, they may well influence the course of the disease. Dual infection in HD appears to support proliferative processes, i.e. a predominance of EBV effects. Single infection with HHV-6 in KFD instead appears to favor an apoptotic course. These effects are--according to the literature--possibly cytokine-mediated.

Pulmonary haemorrhage in a patient with Kikuchi disease

Kikuchi disease is an immunologic disease and most commonly presents with cervical lymphadenopathy. It is usually self-limiting [1]. It is sometimes associated with systemic lupus erythematosus (SLE) [2], and can be associated with many complications including aseptic meningitis, neuropathy, brachial neuritis. It can also be associated with lymphoma, and may sometimes be misdiagnosed as such [3]. The following is the first reported case of Kikuchi disease associated with pulmonary haemorrhage. The patient died and no other cause of the pulmonary haemorrhage could be identified at post mortem.

Kikuchi's disease and the skin: case report and review of the literature

We report scattered indurated erythematous lesions that presented in an 18-year-old Japanese man with Kikuchi's disease (KD; histiocytic necrotizing lymphadenitis). A skin biopsy showed a proliferation of histiocytes and abundant nuclear debris without the presence of neutrophils, which is characteristic of KD. The specific dermatological and pathological details of KD have been yet to be fully described. In order to assess the typical skin features of KD better, we have reviewed all the previously well-documented reports of such lesions. As the clinical and histopathological cutaneous findings in KD are so heterogeneous, it is important that scattered indurated erythematous lesions should be included as one of the possible cutaneous manifestations of this disease.

Two cases of histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto's disease) following diffuse large B-cell lymphoma

Histiocytic necrotizing lymphadenitis (HNL) is often mistaken for malignant lymphoma clinically and is also sometimes difficult to differentiate from lymphoma even histopathologically. In this report, we describe the first 2 reported cases of HNL following non-Hodgkin's lymphomas. The patients were 27- and 30-year-old women who developed cervical and axillary lymph node swellings, respectively, in the course of remission of diffuse large B-cell lymphoma. The affected lymph nodes showed the typical histology of HNL: irregular-shaped "necrotic" foci with histiocytes engulfing apoptotic bodies intermingled with large-sized blastic lymphocytes. These findings mimicked the partial involvement of large-cell lymphoma. However, the blastic cells were almost exclusively T cells, and numerous apoptotic bodies were present, which excluded the possibility of recurrence of diffuse large B-cell lymphoma.

Management of Kikuchi's disease using glucocorticoid

Histiocytic necrotizing lymphadenitis, or Kikuchi's disease, is a self-limiting cervical lymphadenitis of unknown origin. Since no specific treatment has been reported for Kikuchi's disease to date, once a diagnosis of Kikuchi's disease has been established, the role of the physician has been limited only to treating the symptoms. Sometimes, however, the clinical manifestations of the disease can be very distressing for the patients. Thus, a more aggressive form of treatment may be required for the patients who suffer from severe and persisting symptoms and recurrence. We present three cases of Kikuchi's disease that benefited significantly from systemic administration of prednisone.

Haemophagocytic syndrome and histiocytic necrotising lymphadenitis (Kikuchi's disease)

A young boy presented with a rash, fever, and cervical lymphadenopathy, originally thought to be caused by tuberculosis. A lymph node biopsy showed the features of Kikuchi's disease, with necrosis and histiocytic infiltration without neutrophils. No evidence of tuberculosis was found on staining, culture, or the polymerase chain reaction. Bone marrow biopsy revealed prominent haemophagocytosis, and a diagnosis of haemophagocytic syndrome was reached. The aetiology of haemophagocytic syndrome, and its association with Kikuchi's lymphadenitis, is discussed.

Kikuchi's disease: report of 2 cases and a brief review of the literature

Kikuchi's lymphadenitis is a histiocytic necrotizing lymphadenitis without granulocytic infiltration, with fever and generally with a benign course, despite its pathologic resemblance to malignant lymphoma. The illness usually begins with localized cervical adenopathy in young adult females, predominantly before the fourth decade of life. Clinically, several agents could be the cause of such an illness--toxoplasmosis, herpes group viral infection, cat scratch disease, lymphoma, SLE and other infectious agents. The diagnosis is made by using a histological technique. The lymph node biopsy reveals fibrinoid necrosis, loss of lymph node structure with many histiocytes and an absence of granulomatous reaction. The immunohistochemical analysis shows that the main affected cellular components are the T cells. Laboratory exams show an erythrocyte sedimentation increase, neutropenia, leukopenia and lymphocytosis. We describe two cases that were followed since 1994 and 1996, respectively. Both were females under 25 years old, who developed a febrile disease with lymphadenopathy. Lymph node biopsies showed necrotizing lymphadenitis without granulocytic infiltrations. The patients had no evidence of other systemic diseases. Our objectives are to present a rare cause of febrile disease with enlargement of cervical lymph nodes, to review Kikuchi's disease, and to alert the medical community to this rare cause of fever and lymphadenopathy.

Virus infection in patients with histiocytic necrotizing lymphadenitis in Taiwan. Detection of Epstein-Barr virus, type I human T-cell lymphotropic virus, and parvovirus B19

The relationship of Epstein-Barr virus (EBV), type I human T-cell lymphotropic virus (HTLV-I), and parvovirus B19 to histiocytic necrotizing lymphadenitis was studied prospectively in 10 Taiwanese patients using materials obtained by fine-needle aspiration and lymph node biopsy. The presence of EBV was detected by in situ hybridization for EBV-encoded RNA expression. Immunocytochemistry was used to detect virus-encoded protein for EBV and parvovirus B19. DNA in situ hybridization and polymerase chain reaction were performed to determine the existence of HTLV-I provirus. Expressions of EBV-encoded RNA and Fas ligand were detected in all cases. Expression of EBV-encoded protein was identified in only 1 case. Neither HTLV-I nor parvovirus B19 was detected in any case.

[An "exotic" lymphadenopathy: Kikuchi-Fujimotor histiocytic necrotizing lymphadenitis. Case report and discussion]

The case of a 25 year old women with isolated inguinal lymphadenopathy and persistent fever caused by necrotizing inguinal lymphadenitis Kikuchi-Fujimoto is reported. Diagnostic and differential diagnostic aspects of this self-limited disorder with unclear pathogenesis are discussed.

[Necrotizing lymphadenitis (Kikuchi-Fujimoto disease) as a rare cause of cervical lymphadenopathies. Diagnosis and differential diagnosis]

BACKGROUND

The ENT specialist is often confronted with the inquiry as to the cause of lymph node enlargements. Common causes include inflammations, neoplastic, or autoimmune diseases. We report on three cases of Kikuchi-Fujimoto disease as a benign self-limiting lymphadenopathy of unknown etiology, which is usually found in young women between 20 and 30 years of age. Main symptoms are indolent or light tender, enlarged lymph nodes in the neck area. The correct diagnosis requires the histologic examination of the lymph node. Even for the experienced pathologist the differential diagnosis of malignant systemic disorders can be difficult.

PATIENTS

Three female patients suffering from Kikuchi-Fujimoto disease were treated in our department between September 1997 and March 1998.

RESULTS

All patients showed indolent and enlarged lymph nodes in the neck. In one case we were able to diagnose an acute cytomegalovirus infection; in another case an acute Epstein-Barr virus infection. After 3-5 months the symptoms disappeared spontaneously in all patients. In two of the three cases, histologic lymph node examination revealed T-cell lymphoma and Hodgkin's disease and in one case led to initial chemotherapeutic treatment. As a result of a second histologic examination, both diagnoses were reviewed and Kikuchi-Fujimoto disease was diagnosed. Chemotherapy was discontinued.

CONCLUSIONS

Kikuchi-Fujimoto disease is a benign, self-limiting lymphadenopathy which is usually diagnosed in young women. Distinguishing Kikuchi-Fujimoto disease from malignant systemic disorders may even be difficult for pathologists using histological examination techniques and requires close cooperation between the ENT specialist and the pathologist. In order to minimize the risk of misdiagnosis and incorrect treatment, the ENT specialist should inform the pathologist about the differential diagnosis of Kikuchi-Fujimoto disease in such cases.

Recurrence of Kikuchi's lymphadenitis after 12 years

A 40 year old woman developed recurrent Kikuchi's disease 12 years after the original episode. The recurrence affected the same site (axilla) and occurred after the longest delay so far recorded in a European resident. Care must be taken to avoid misdiagnosis of Kikuchi's disease as lymphoma.

Differential diagnosis of Kikuchi's disease and systemic lupus erythematosus lymphadenopathy: clinicopathologic algorithm

The authors have described the first case of Kikuchi's disease in Bulgaria. The present study gives the clinicopathologic algorithm compiled by them to make the correct diagnosis and differentiate Kikuchi's disease from systemic lupus erythematosus lymphadenopathy.

Kikuchi's disease (histiocytic necrotizing lymphadenitis): report of one case

Kikuchi's disease (histiocytic necrotizing lymphadenitis) is a self-limited disease of unknown cause. The disease often presents with persistently intermittent fever and enlarged cervical lymph nodes. It usually occurs in adult group and is unresponsive to antibiotic therapy. The diagnosis can be confirmed by histopathological findings of lymph node in open biopsy. We report a pediatric case of Kikuchi's disease in an 8-year-8-month-old school-age boy with generalized lymphadenopathy. He was hospitalized under the impression of fever of unknown origin. A diagnosis of Kikuchi's disease was made by cervical lymph node histology. Reviewing the literature of Kikuchi's disease, we found very few reports in young pediatric group. We conclude that Kikuchi's disease should be considered in the differential diagnosis of fever of unknown origin in children, even in the absence of cervical lymphadenopathy.

Kikuchi-Fujimoto lymphadenitis with cutaneous involvement

We report a case of Kikuchi-Fujimoto disease with cutaneous involvement in a European man. In contrast, the disease is most prevalent in women of Asian descent. The condition is probably under-recognized when histology is not used to identify lymphadenitis of protracted course. Skin lesions may mimic clinically other unrelated disorders including lymphomas and immune or infectious dermatoses. Histology of skin lesions may bring a clue to the diagnosis when apoptotic plasmacytoid monocytes are recognized. The relationship between Kikuchi-Fujimoto disease and lupus erythematous remains a matter of debate.

The histopathology of cutaneous lesions of Kikuchi's disease (necrotizing lymphadenitis): a report of five cases

Kikuchi's disease (KD) is an idiopathic, self-limited necrotizing lymphadenitis that can clinically and histologically mimic high-grade lymphoma, including Hodgkin's disease, or can be mistaken for the lymphadenitis of systemic lupus erythematosus (SLE). Involvement of extranodal sites is unusual but well documented, especially in Asia, where KD is more common than in North America or Europe. The successful distinction of KD from malignant lymphoma and SLE is imperative for the appropriate treatment of affected patients. We describe five patients with cutaneous involvement by KD, all of whom presented with fever, lymphadenopathy, and an eruption on the skin of the upper body, which in one case was clinically suspected to be due to SLE and in another, polymorphous light eruption. The patients ranged in age from 10 months to 42 years (median, 33 years) and included three females and two males. All five patients had negative serologic studies for collagen vascular disease. Each patient had a lymph node biopsy showing the typical necrotizing lymphadenitis of KD. Skin biopsies from all five patients shared a specific constellation of histologic features: vacuolar interface change with necrotic keratinocytes, a dense lymphohistiocytic superficial and deep perivascular and interstitial infiltrate, varying amounts of papillary dermal edema, and abundant karyorrhectic debris with a conspicuous absence of neutrophils and a paucity of plasma cells, paralleling the nodal histology in KD. CD68 immunohistochemistry on paraffin-embedded sections showed many histiocytes and plasmacytoid monocytes in all cases, whereas CD3, CD4, and CD8 showed highly variable staining among the cases. There was only rare staining with TIA-1 and CD30. We believe that the papular eruption of KD has recognizable histopathologic features and that a CD68 stain that marks many cells that initially seem to be lymphocytes can be performed to confirm the diagnosis.

[Necrotizing lymphadenitis presenting as mesenteric lymphadenopathy]

A 15-year-old girl was admitted to our hospital because of fever, diarrhea, and right lower abdominal pain on November 11, 1997. Computed tomographic and ultrasound studies of the abdomen disclosed enlarged mesenteric lymph nodes. Hematologic and serologic findings included WBC 3000/microliter, LDH 550 IU/l, IFN-gamma 264 pg/ml, IL-6 9.74 pg/ml, sIL-2R 781 U/ml, and ferritin 720 ng/ml. Although the patient was treated with antibiotics, high fever and abdominal pain persisted with progressive anemia and leucocytopenia (1800/microliter). Bone marrow aspiration specimens revealed an increase of histiocytes with phagocytosis. Appendectomy and lymphadenectomy were performed on November 21. A lymph node specimen showed necrosis with infiltration by large mononuclear cells. The resected appendix revealed reactive lymphoid hyperplasia. Based on these findings, a diagnosis of necrotizing lymphadenitis (NL) was made. The postoperative course was satisfactory and systemic symptoms resolved gradually without specific treatment. However, high fever and abdominal pain recurred with right cervical lymph node swelling on December 15. The patient's general condition improved after treatment with prednisolone. In NL, lymphadenopathy is usually observed in the cervical region, and the involvement of intra-abdominal lymph nodes is quite rare. Our findings indicated the possibility that IFN-gamma may play an important role in the pathogenesis of NL with hemophagocytic syndrome.

Histiocytic necrotizing lymphadenitis (Kikuchi's disease): clinicopathologic characteristics of 23 cases and literature review

Kikuchi's disease or histiocytic necrotizing lymphadenitis is a self limiting disorder which usually affects young women and manifests clinically by cervical lymphadenopathy with or without fever. Though the disease has been described since 1972, many clinicians and pathologists are unaware of its existence. We therefore reviewed 23 cases of Kikuchi's disease in Songklanagarind Hospital from 1987 to 1996. Clinical data, histopathology including immunostaining were presented together with brief literature review. We found 18 women and 5 men with the age range 9-57 years. The sites of nodal enlargement were cervical in 17, axillary in 3 and unknown in 3 cases. Typical histologic features namely patchy paracortical lymphohistiocytic aggregates with variable karyorrhexis and absence of granulocytic infiltration were seen. Immunostaining confirmed that the principle cells were histiocytes and T-lymphocytes. Importance in the recognition of the entity was emphasized for it may be mistaken for other infective lymphadenitis or lymphoma.

Kikuchi's disease: an uncommon cause of fever of unknown origin

Kikuchi's disease or histiocytic necrotizing lymphadenitis is an uncommon clinical condition that causes diagnostic difficulties because of its lack of specific signs, symptoms and serological markers. Diagnosis is based on histopathological findings, but overlapping of the histological features requires a differential diagnosis among histiocytic necrotizing lymphadenitis and a number of infectious, autoimmune and lymphoproliferative lymphadenopathies. We report a case of Kikuchi's disease in a 19-year-old woman presenting with generalized lymphadenopathy and persistent fever.

[Histiocytic necrotizing lymphadenitis: Kikuchi-Fujimoto disease. Apropos of 6 cases]

Necrotizing Histiocytic Lymphadenitis or Kikuchi-Fujimoto disease is a benign process of lymphatic system that consists of lymphadenopathy which may be accompanied by fever, rash and some haematological alterations as anaemia. It affects usually young people, mostly women. Although it is more frequent in Oriental countries, there have been some notices about this disease in Europe recently. We present six patients that have been diagnosed in our Hospital between 1986 and 1996. All presented as cervical masses and fever. The diagnostic procedure was the lymph node biopsy, which showed the typical pathology of this disease: some foci of necrosis which contained plasmocytoides cells and atypical lymphocytes. It is also suggestive of this entity the absence of polymorphonuclear cells. Then, the diagnosis of the Necrotizing Histiocytic Lymphadenitis is made by the histology. The treatment is symptomatic. In all cases the evolution is the whole remission of symptoms. In our patients the illness was self-limited and none presented any other symptom. Our proposal with this article is to remind the clinicians of this entity when people ask for cervical masses and fever.

Histiocytic necrotizing lymphadenitis (Kikuchi's disease): the necrotic appearance of the lymph node cells is caused by apoptosis

We report a case of histiocytic necrotizing lymphadenitis in a 28-year-old woman. The biopsy specimen of the enlarged lymph node showed lymphocytes, histiocytes, and a large amount of nuclear debris as well as marked eosinophilic deposits. We found DNA fragments by means of the modified TUNEL method, especially in the transitional area between intact cells and the foci of eosinophilic deposits and the cells positive for anti-Fas antibody in the biopsied lymph node. Therefore, the necrotic appearance of the lymph node was thought to be caused by apoptosis induced by the Fas-Fas ligand system. We hypothesize that the apoptosis was strongly related to the pathogenesis of this disease.

[Kikuchi disease]

Histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease (KFD) was described in 1972. Painful, palpable lymphadenitis is localized to one or two sites in the head and neck territories in young adults (third decade) and is associated with fever. Other clinical manifestations are infrequent: arthromyalgias, cutaneous rash, sweating, splenomegaly. Leukopenia is present in 50% of the cases with sometimes "atypical" lymphocytes. A spontaneously favorable outcome is noted after a mean 3 months. Histopathology of the lymph node is the key for the diagnosis of KFD showing lymph node necrosis of 25 to 75% of the surface, in the cortex and the medulla of the lymph nodes with histiocytic proliferation and plasma cells. Histochemistry shows positive straining for monocytic markers (CD68+, KiM1P+). Alpha-beta CD8+ T cells are abundant, NK and B cells are scarce. Pathological examination enables to differentiate KFD from other types of necrotizing lymphadenitis (SLE, malignant lymphoma, pyogenic infections). Kikuchi disease can be the result of local hyperimmune stimulation after viral, bacterial or parasitic infection. CD4+ cells would then become apoptotic cells. In some cases KJD is associated with systemic diseases such as systemic lupus erythematosus or adult Still's disease.

[Subacute necrotizing lymphadenitis associated with mononeuritis multiplex. A case report]

A 20-year-old man noticed lymph node swelling in his neck in May 1997. He was admitted to our hospital on July 30 because of numbness and weakness in the right hand and bilateral lower extremities. Neurological examinations revealed that the patient had right ulnar and bilateral deep peroneal nerve palsies. Nerve conduction study showed severe axonopathy in these nerves. The sural nerve biopsy demonstrated axonal degeneration and thickening of the small arterial wall. There was no significant increase of virus titer in the serum, such as EB virus, nor human herpesvirus 6. CSF examination was normal. During the course of this disorder, he acutely developed severe pain in his right testis. Pathological finding of the testis showed necrosis with vasculitis in the small arteries. Treatment with corticosteroid was effective. Usually subacute necrotizing lymphadenitis has been thought to be a benign disease. Only a few neurological complications, such as aseptic meningitis and cerebellar ataxia have been reported. Mononeuritis multiplex associated with subacute necrotizing lymphadenitis has not been reported. We speculated that the present case initially had some viral infection, and its reaction of the host produced subacute necrotizing lymphadenitis and mononeuritis multiplex.

Histiocytic necrotizing lymphadenitis (Kikuchi's disease) with aseptic meningitis

Histiocytic necrotizing lymphadenitis, or Kikuchi's disease (KD), is a self-limited clinicopathologic entity recognized increasingly worldwide. A 27-year-old man with cervical lymphadenopathy and fever who was diagnosed with KD developed mild headache with no nuchal rigidity. The cerebrospinal fluid (CSF) was sterile and contained 78 white blood cells/mm3 with lymphocytes predominating, accompanied by smaller numbers of monocytes and granulocytes. This abnormality normalized spontaneously over 5 weeks. Eleven similar cases have been reported, all but one from Japan. The development of meningitis in KD was observed in four (9.8%) of 41 KD patients we have treated, suggesting that the meningitis was related to KD and not merely coincidental.

[Kikuchi-Fusimoto disease: the differential diagnosis of cervical lymphadenitis with recurrent attacks of fever]

HISTORY AND CLINICAL FINDINGS

A 49-year-old, otherwise healthy woman had recurrent fever and lymphadenopathy with leukopenia for nineteen years. Her symptoms prompted successless antibiotic therapy and extensive evaluations of fever of unknown origin. At admission there were several enlarged cervical lymph nodes and subfebrile temperatures.

INVESTIGATIONS

Neither laboratory findings nor imaging did show an infectious, rheumatologic or hematologic cause of her symptoms. Histopathological examination of an lymph node biopsy revealed histiocytic, necrotizing lymphadenitis (Kikuchi-Fusimoto disease) as the underlying disease.

TREATMENT AND COURSE

After spontaneous resolution without specific therapy the patient is now symptomless and well 9 months after diagnosis.

CONCLUSION

Kikuchi-Fusimoto disease is a cause of benign and usually self-limiting lymphadenopathy. Clinicians and pathologists should be aware of this uncommon differential diagnosis since early histologic recognition will minimize potentially and unnecessary evaluations and treatments.

Apoptotic cell death in Kikuchi's disease: a TEM study

The pathogenesis of Kikuchi's disease (Kikuchi-Fujimoto disease, histiocytic necrotizing lymphadenitis) remains unclear. However, some previous studies have suggested that a disorder in cellular immunity is responsible for this disease, and apoptotic cell death appears to be the principal finding in the histogenesis of this disease. In the present study, a lymph node from a female patient with Kikuchi's disease was examined by transmission electron microscopy (TEM). TEM revealed specific morphological features of apoptotic cells, such as nuclear chromatin condensation and fragmentation along the nuclear membrane with intact organelles, and the presence of histiocytes phagocytosing karyorrhectic debris (apoptotic bodies) in areas affected by Kikuchi's disease. Although neither the role nor the trigger of apoptosis in Kikuchi's disease has been clearly determined, our findings show that apoptotic cell death clearly plays a role in the pathogenesis of Kikuchi's disease.

[Cutaneous-lymph node Kikuchi-Fujimoto disease]

INTRODUCTION

The subacute necrotizing histiocytic lymphadenitis was reported for the first time in 1972 in Japan by Kikuchi and by Fujimoto and his colleagues. This idiopathic disease can affect the skin. We report a case of Kikuchi-Fujimoto disease with skin and lymph node involvement.

OBSERVATION

The Yemani man developed cervical lymphadenitis and arciform papulo-nodular lesions of the face. The histologic examination revealed a necrotizing lymphadenitis with blast cells but devoid of neutrophils. The cutaneous involvement corresponded to an angiocentric infiltration by mononuclear cells among which plasmacytoid cells and caryorrhexis were recognized. A spontaneous resolution of the disease occurred spontaneously within three months.

COMMENTARY

The clinical and histologic aspects of the present case resemble in part the presentation of lupus erythematosus. However, some distinctive features suggest Kikuchi-Fujimoto disease cannot be termed a classical type of lupus erythematosus.

Kikuchi-Fujimoto's syndrome masquerading as tuberculosis

We report a case of a 27-year-old Asian man presenting with the typical features of tuberculous cervical lymphadenitis who was commenced on anti-tuberculous therapy on the strength of the clinical presentation. Histological examination of an excised cervical lymph node however, revealed the diagnosis of Kikuchi's syndrome; a histiocytic necrotizing lymphadenitis which is usually self-limiting.

[Self-limited lymphadenopathy mimicking lymphoma or lupus (Kikuchi-Fujimoto disease)]

Kikuchi-Fujimoto disease in a self-limited lymphadenopathy that can be confused histologically and clinically with lymphoma or systemic lupus erythematosus. It was diagnosed in a 37-year-old woman presenting with fever, cervical, submandibular and axillary lymphadenopathy, weight loss and recurrent urinary tract infections. Lymph node biopsy was consistent with the diagnosis of a histiocytic necrotizing lymphadenitis. Early diagnosis of Kikuchi-Fujimoto disease can prevent harmful treatment.

[Kikuchi-Fujimoto subacute necrotizing lymphadenitis: two histologic forms observed in the same patient]

Histiocytic necrotizing lymphadenitis, also known as Kikuchi-Fujimoto disease is a rare self-limited condition of young adults usually misdiagnosed as malignant hematologic disease. The diagnosis depends on microscopic findings. Two histologic types are classically described, proliferative and necrotic types. This is a case report of 17 year-old girl who presented cervical lymphadenopathy. The first lymph node biopsy was in favor of malignant lymphoma. The second lymph node biopsy, done one month later, showed typical histiocytic necrotizing lymphadenitis. To our knowledge, this is the first time that the two forms of this disease are described in the same patient.

Kaposi's sarcoma-associated herpesvirus in Kikuchi's disease

Kikuchi's disease is a fairly common self-limited disorder among Orientals that usually involves the cervical lymph nodes of young individuals and occurs predominantly in females. Frequently, the disease is associated with fever or flu-like symptoms, an elevated erythrocyte sedimentation rate (ESR), neutropenia, and lymphocytosis with atypical lymphocytes in the peripheral blood, suggesting a viral origin. However, no infectious agent has been identified. The presence of Kaposi sarcoma-associated herpesvirus, known as human herpesvirus 8 (KSHV/HHV 8), was investigated by polymerase chain reaction (PCR) in archival tissue from 26 cases of Kikuchi's disease using published sequences of KSHV/HHV 8 as primers. PCR products were further characterized by Southern blot analysis. Forty reactive lymph nodes and a case of Kaposi sarcoma (KS) were included as negative and positive controls, respectively. Patients consisted of 10 men and 16 women with a mean age of 27 years. All patients were previously healthy and presented with cervical or axillary lymphadenopathy. None were positive for human immunodeficiency virus (HIV) or otherwise immunocompromised. Viral DNA was amplified by PCR in six cases of Kikuchi's disease (23%) and the control KS tissue. Southern blot analysis confirmed that the amplified products were KSHV/HHV 8. In the reactive lymph nodes, no viral genome was amplified by PCR. The presence of DNA sequences of KSHV/HHV 8 in a substantial portion of Kikuchi's disease suggests that KSHV/HHV 8 might play an important role in the pathogenesis of a subset of Kikuchi's disease.

Pseudolymphomatous phase of Kikuchi-Fujimoto disease

Kikuchi-Fujimoto lymphadenitis is a distinctive entity which is easily recognised in its classical histology. However, cases which are biopsied in the early stage of the disease, before entering the necrotic phase may be misdiagnosed as non-Hodgkin's lymphoma. Ten cases of Kikuchi-Fujimoto disease which mimicked non-Hodgkin's lymphoma and in which less than 10% of the lymph node was occupied by necrosis were chosen for this study. The patients included 4 males and 6 females with an age range of 15-40 years. Eight patients presented with cervical lymphadenopathy. The pathologic areas ranged from 70% to 95% of the total nodal area. The features that helped distinguish this lesion from non-Hodgkin's lymphoma were: 1) a sprinkling of karyorrhectic debris throughout the node 2) plasmacytoid monocytes as well as "histiocytes" in the company of transformed lymphocytes (immunoblasts) 3) enlarged mottled T-zone areas, and 4) presence of residual lymphoid follicles. Follow up on six patients revealed no evidence of disease.

Kikuchi's disease of the neck (histiocytic necrotizing lymphadenitis)

Histocytic necrotizing lymphadenitis (HNL), also known as Kikuchi's disease is a benign self limiting disease of unknown origin. It effects cervical lymph nodes, predominantly in young females. It is well described in the pathology literature, but little is written about this in the ENT literature, as few clinicians are probably aware of this condition. Five cases of cervical Kikuchi's disease are presented with a brief review of the literature.

Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease): continuing diagnostic difficulties

AIMS

To describe the clinicopathological and immunophenotypic features of 25 cases of Kikuchi-Fujimoto disease (K-F), which remains a poorly recognized entity and is still frequently confused with malignant lymphoma, and to discuss the main diagnostic problems experienced by the referring pathologist.

METHODS AND RESULTS

Haematoxylin and eosin sections of 27 lymph node biopsies were re-examined. Immunostains for B-lymphocytes, T-lymphocytes and macrophages were performed. Clinical and follow-up data were obtained through a questionnaire to the referring pathologist or from the patients' notes where available. The suggested initial diagnoses are discussed. The lymph nodes showed a necrotizing process characterized by patchy or confluent areas of necrosis associated with karyorrhexis and absence or paucity of granulocytes. This was associated with a proliferation of large blastic cells consisting of a mixture of T-lymphocytes and histiocytes. Fragmentation of the biopsy was a frequent feature. The diagnosis of K-F was suggested by the referring pathologist in three cases only. The most common suggested diagnosis was that of a non-Hodgkin's lymphoma.

CONCLUSION

This series documents continuing difficulties in the diagnosis of Kikuchi-Fujimoto disease in the UK and emphasizes that cases are still being mistakenly diagnosed as malignant lymphomas. The diagnosis of Kikuchi-Fujimoto disease merits active consideration in any nodal biopsy showing fragmentation, necrosis and karyorrhexis, especially in young women presenting with cervical lymphadenopathy.