Kikuchi's disease (histiocytic necrotizing lymphadenitis) with cutaneous involvement

Kikuchi-Fujimoto disease: A comprehensive review

Kikuchi-Fujimoto disease, a rare form of necrotizing lymphadenitis, is an uncommon, benign, self-limiting disorder of obscure etiology. It affects mostly young adults of both genders. Clinically, it presents with fever and lymphadenopathy of a firm to rubbery consistency frequently involving cervical lymph nodes while weight loss, splenomegaly, leucopenia, and elevated erythrocyte sedimentation rate feature in severely affected patients. Cutaneous involvement occurs in about 30%-40% of cases as facial erythema and nonspecific erythematous papules, plaques, acneiform or morbilliform lesions of great histologic heterogeneity. Both Kikuchi-Fujimoto disease and systemic lupus erythematosus share an obscure and complex relationship as systemic lupus erythematosus may occasionally precede, develop subsequently, or sometimes be associated concurrently with Kikuchi-Fujimoto disease. It is often mistaken for non-Hodgkin lymphoma while lupus lymphadenitis, cat-scratch disease, Sweet’s syndrome, Still’s disease, drug eruptions, infectious mononucleosis, and viral or tubercular lymphadenitis are other common differentials. Fine needle aspiration cytology mostly has features of nonspecific reactive lymphadenitis and immunohistochemistry studies usually show variable features of uncertain diagnostic value. Since its diagnosis is exclusively from histopathology, it needs to be evaluated more carefully; an early lymph node biopsy will obviate the need for unnecessary investigations and therapeutic trials. Its treatment with systemic corticosteroids, hydroxychloroquine, or antimicrobial agents mostly remains empirical. The article reviews clinicoepidemiological, diagnostic, and management aspects of KFD from the perspective of practicing clinicians.

Kikuchi-Fujimoto Disease in an Old Italian Woman: Case Report and Review of the Literature

Kikuchi-Fujimoto disease (KFD) is a rare, benign, generally self-limiting disease that has higher prevalence in Asian people with a few cases reported in European countries. It generally affects young subjects under 40 years of age and is characterized by regional lymphadenopathy. Here, we present a case of a 66-year-old Italian woman who was extensively examined for right unilateral laterocervical lymph nodes associated with fever, night sweats, fatigue, and weight loss. She was diagnosed as having the KFD only after an excision biopsy of the largest laterocervical lymph node and was then managed symptomatically with NSAIDs. We also made a review of the literature for better awareness of the disease among physicians especially in those countries, like Italy, where the disease is not prevalent and may be frequently misdiagnosed. In fact, to our best knowledge, only seven Italian cases of KFD have been published in the last 15 years with patients being younger than 40 years. We finally highlight that it is noteworthy to consider KFD as differential diagnosis of lymphadenopathy even in old patients, and, since a misdiagnosis of lymphoma is actually feasible, an early biopsy has to be taken into account for confirming diagnosis and helping in the timely and appropriate management.

Kikuchi-Fujimoto disease: a diagnostic dilemma

Kikuchi-Fujimoto disease is a benign, self-limiting condition characterized by lymphadenopathy and fever. Its diagnosis can be challenging, as the disease must be differentiated from lymphoma and systemic lupus erythematosus. Patients can present with nonspecific cutaneous lesions. Adequate clinical and histopathologic correlation can aid in the timely diagnosis of Kikuchi's disease, thus preventing the use of unnecessary diagnostic procedures and inappropriate treatments.

Kikuchi Disease-Like Inflammatory Pattern in Cutaneous Inflammatory Infiltrates Without Lymph Node Involvement: A New Clue for the Diagnosis of Lupus?

Kikuchi-Fujimoto disease (KFD) is a rare and benign disorder that usually occurs in young adults with enlarged lymph nodes containing infiltrate of cytotoxic T cells and nuclear debris. It can be a manifestation of systemic lupus erythematosus (SLE) although the strength of this association has varied among studies. Although specific KFD cutaneous lesions are well described, pure cutaneous lesions have never been reported. We studied a series of patients prospectively entered into a database between 2007 and 2014 with skin biopsies showing diffuse or localized inflammatory infiltrates reminiscent of cutaneous KFD, without lymph-node-related KFD. We called these skin lesions "Kikuchi disease-like inflammatory pattern" (KLIP). Twenty-nine patients, whose median age was 49 years at the time of skin biopsy, were selected and retrospectively analyzed using standardized clinical and histology charts. In skin biopsies, KLIP was localized to restricted areas within the inflammatory infiltrate (17%) or diffuse (83%), and was the only histological finding (45%) or accompanied interface dermatitis with or without dermal mucinosis (55%). Clinical dermatological findings varied widely. A definite diagnosis could be established for 24 patients: 75% had connective tissue diseases or vasculitis, mainly cutaneous lupus erythematosus (CLE) (n = 16, 67%), including 5 SLE with satisfying American College of Rheumatology criteria; 3 of the remaining patients had malignant hemopathies. CLE patients were mostly young females with acute (n = 5), subacute (n = 4), or chronic CLE (n = 6) or lupus tumidus (n = 1). Two were classified as having anti-tumor necrosis factor-alpha-induced lupus. Because two-thirds of these patients were finally diagnosed with CLE, we think that KLIP may represent a new histopathological clue for the diagnosis of lupus based on skin biopsy, requiring clinical-immunological comparison to make the correct diagnosis. KLIP should not be considered a variant of classical KFD, but rather as an elementary pattern of cutaneous inflammation, that might be the expression of the same cytotoxic process within skin infiltrates as that involved in KFD. This lesion might reflect a particular T-cell-mediated autoimmune process directed against mononuclear cells within cutaneous lupus infiltrates.

Pathogenesis, diagnosis, and management of Kikuchi-Fujimoto disease

BACKGROUND

Kikuchi-Fujimoto disease (KFD) is a rare lymphohistiocytic disorder with an unknown etiopathogenesis. This disease is misdiagnosed as malignant lymphoma in up to one-third of cases and is associated with the development of systemic lupus erythematosus (SLE).

METHODS

The medical literature between the years 1972 and 2014 was searched for KFD, and the data were collected and analyzed regarding the epidemiology, clinical presentations, diagnosis, management, and suggested diagnostic and treatment algorithms.

RESULTS

Although KFD has been reported in other ethnic groups and geographical areas, it is more frequently diagnosed in young women of Asian descent. Patients with the disease typically present with rapidly evolving tender cervical lymphadenopathy, night sweats, fevers, and headache. Diagnosis is based on histopathological examination. Excisional lymph node biopsy is essential for a correct diagnosis. Apoptotic coagulation necrosis with karyorrhectic debris and the proliferation of histiocytes, plasmacytoid dendritic cells, and CD8(+) T cells in the absence of neutrophils are characteristic cytomorphology features. Interface dermatitis at the onset of KFD may be a marker for the subsequent evolution of SLE. The natural course of the disease is typically benign. Short courses of steroids, nonsteroidal anti-inflammatory drugs, or hydroxychloroquine can be administered to patients with more severe symptoms.

CONCLUSIONS

Although KFD was described more than 40 years ago, the etiology of this disease remains unsolved. Infectious or autoimmune processes were proposed but have not been definitively confirmed. Clinical presentation with systemic B symptoms and adenopathy may lead to an erroneous diagnosis of malignant lymphoma. The introduction of modern methods into hematopathology, including immunohistochemistry, flow cytometry, and molecular clonality studies, has decreased the probability of misdiagnosis. Until reliable prognostic markers are available, patients with KFD should have continued long-term follow-up care due to their increased risk of SLE.

Recurrence of histiocytic necrotizing lymphadenitis: A case report and literature review

Histiocytic necrotizing lymphadenitis (HNL) is a unique form of self-limiting lymphadenitis with an unknown cause. The majority of cases resolve within several months and the disease has a low recurrence rate of 3–4%. In the present study, a prolonged recurrent case of HNL was reported. A 44-year-old female developed recurrent HNL with generalized lymphadenopathy 14 years after the original episode.

[Kikuchi-Fujimoto disease]

Kikuchi-Fujimoto disease is a necrotizing lymphadenitis, involving young patients, predominantly females. Lymphadenopathy is usually localized, particularly in the cervical area, mostly unilateral and tender. Fever is present in one third of cases. Associated skin lesions, arthralgia, myalgia, splenomegaly or hepatomegaly are rare. Laboratory evaluation shows a slight increase of erythrocyte sedimentation rate and leukopenia. Kikuchi-Fujimoto has been reported in association with other diseases, including systemic lupus, Still's disease, hemophagocytosis, pregnancy, other autoimmune diseases, and cancer. A viral or bacterial origin has been suspected but not confirmed. Lymph node biopsy allows the diagnosis and shows necrotizing lymphadenitis with acidophil necrosis, CD68+ histiocyte infiltrate, presence of plasmacytoid monocytes, multiple apoptotic cells (CD8+ T cell) with nuclear dust, immunoblastic reaction and the absence of neutrophils or eosinophils. The disease course is usually spontaneously favourable in few weeks or months, requiring corticosteroids only occasionally.

Mucocutaneous manifestations of Epstein-Barr virus infection

This review focuses on Epstein-Barr virus (EBV) infection, diagnosis, and current treatment, with emphasis on EBV-associated mucocutaneous manifestations in primary infections, acute EBV-associated syndromes, chronic infections, lymphoproliferative disorders, and lymphomas. In primary infection, EBV infects B cells and can cause mucocutaneous manifestations in infectious mononucleosis or acute EBV-associated syndromes such as Gianotti-Crosti syndrome and hemophagocytic syndrome. EBV then persists in the majority of humans generally without causing disease. In some cases, however, latent EBV infection may result in diseases such as hydroa vacciniforme, hypersensitivity to mosquito bites, and lymphoproliferative disorders such as plasmablastic lymphoma, oral hairy leukoplakia, and post-transplant lymphoproliferative disorders, particularly in immunocompromised patients. Latent EBV infection has also been implicated in a variety of malignant conditions such as Burkitt lymphoma, Hodgkin lymphoma, nasopharyngeal carcinoma, and Kikuchi histocytic necrotizing lymphadenitis. Since the immune system is critical in preventing the progression of EBV disease, the immunologic status of the patient plays a crucial role in the subsequent development of pathologies.

Interface dermatitis in skin lesions of Kikuchi–Fujimoto’s disease: a histopathological marker of evolution into systemic lupus erythematosus?

Kikuchi’s disease (KD) is a self-limiting histiocytic necrotizing lymphadenitis (HNL). Cutaneous manifestations are frequent and usually show histopathological findings similar to those observed in the involved lymph nodes. HNL with superposed histological features to KD has been described in patients with lupus erythematosus (LE), and a group of healthy patients previously reported as having HNL may evolve into LE after several months. Up to date, features to predict which HNL patients will have a self-limiting disease and which could develop LE have been not identified. In order to clarify the characteristics of skin lesions associated with KD, we report a case of HNL with evolution into systemic lupus erythematosus (SLE) and a review of previous reports of KD with cutaneous manifestations. A 17-year-old woman presented with a 4-month history of fever and generalised lymphadenopathy. A diagnosis of HNL was established based on a lymph node biopsy. One month later, she developed an erythematoedematous rash on her upper body, with histopathological findings of interface dermatitis. After 8 months, anti-nuclear antibodies (ANA) at titre of 1/320, anti-DNA-ds antibodies and marked decrease of complement levels were detected. During the following 2 years, she developed diagnostic criteria for SLE, with arthralgias, pleuritis, aseptic meningitis, haemolytic anaemia and lupus nephritis. To our knowledge, 27 cases of nodal and cutaneous KD have been reported, 9 of which later developed LE. In all these patients, the skin biopsy revealed interface dermatitis. Skin biopsy revealed a pattern of interface dermatitis in all reviewed KD cases, which evolved into LE. Even this histopathological finding was not previously considered significant; it might be a marker of evolution into LE.

Kikuchi's disease: case report and systematic review of cutaneous and histopathologic presentations

Kikuchi's disease, also known as histiocytic necrotizing lymphadenitis, is a systemic illness with classic clinical findings of cervical lymphadenopathy and fever. Diagnosis is confirmed by lymph node histology, which reveals paracortical foci of necrosis and a histiocytic infiltrate. Kikuchi's disease has been associated with a number of infections, but no single source has been identified. Diverse, often nonspecific, cutaneous findings have been described in up to 40% of cases. Description of the histopathologic findings of skin lesions is limited to single case reports and one case series. We describe a 24-year-old woman with fevers, lymphadenopathy, hepatic and hematologic abnormalities, and a skin eruption involving the face, neck, trunk, and extremities with characteristic lymph node and cutaneous histopathologic findings. We completed a systematic review of the clinical presentations and histopathology of Kikuchi's disease.

Lymphadénite histiocytaire nécrosante ou maladie de Kikuchi-Fujimoto

Kikuchi-Fujimoto disease (KFD), first described independently by Kikuchi and Fujimoto in 1972, is a subacute necrotizing lymphadenitis of unknown cause. Although most frequent in young Asian women, KFD has a worldwide distribution. Clinically, KFD is characterized by lymphadenitis of one or more lymph nodes, predominantly in the posterior cervical region, fever, and leukopenia in up to 50% of cases. Extranodal manifestations can occur, especially skin lesions and aseptic meningitides. Diagnosis is usually confirmed by analysis of samples from an excisional biopsy of the affected nodes. Histologically, the lesions affect the cortical and paracortical areas of the node. Characteristic features include focal necrosis predominantly in the paracortical region with abundant karyorrhectic debris and atypical mononuclear cells around the necrotic zone (crescent-shaped histiocytes, plasmacytoid monocytes, and small lymphocytes and immunoblasts, mostly CD3(+)/CD8(+)), most often with an intact lymph node capsule, an absence of neutrophils, and a paucity of plasma cells. KFD has been classified into three histological subtypes and is thought to progress from the proliferative type (> 50%) to the necrotizing type (30%) and finally resolve into the xanthomatous type (< 20%). Differential diagnoses should include malignant lymphoma, infectious diseases such as toxoplasmatic lymphadenitis, tuberculous lymphadenitis and cat scratch disease, and systemic lupus erythematosus (SLE). The cause of KFD is unknown: a viral infection has been suggested, but not demonstrated, possibly involving human herpes virus 8 or Epstein-Barr virus. Apoptotic cell death plays a role: proliferating CD8(+) T-lymphocytes act as both killers and victims in the apoptotic process via Fas and perforin pathways. The course is usually benign with resolution in a few months with the use of antiinflammatory drugs. Regular follow-up is required because SLE may develop several years after the onset of Kikuchi-Fujimoto disease.

Kikuchi-Fujimoto Disease: analysis of 244 cases

Kikuchi-Fujimoto Disease (KFD) was first described in Japan in 1972. The disease frequently mimics tuberculous lymphadenitis, malign lymphoma, and many other benign and malignant conditions. To our knowledge, there is no previous study comparing the clinical and laboratory characteristics of patients from different geographical parts of the world. We searched literature records beginning from 1991 and analyzed epidemiological, clinical, and laboratory data of 244 patients (including cases diagnosed in our institution) reported in 181 publications. Of the 244 cases, 33% were male and 77% were female. Mean age was 25 (1-64) and 70% was younger than 30. Most of the cases were reported from Taiwan (36%), USA (6.6%), and Spain (6.3%). Fever (35%), fatigue (7%) and joint pain (7%) were the most frequent symptoms, while lymphadenomegaly (100%), erythematous rashes (10%), arthritis (5%), hepatosplenomegaly (3%), leucopenia (43%), high erythrocyte sedimentation rate (40%), and anemia (23%) being the most common findings. KFD was associated with SLE (32 cases), non-infectious inflammatory diseases (24 cases), and viral infections (17 cases). SLE was more frequent in cases from Asia than Europe (28 and 9%, respectively). The disease was self-limiting in 156 (64%) and corticosteroid treatment was necessary in 16 (16%) of the cases. The mortality rate was 2.1%. Early diagnosis is crucial as the clinical and laboratory presentation generally imitates situations needing lengthy and costly diagnostic and therapeutic interventions. Additionally, association with SLE needs further investigation.

Intraparotid Kikuchi-Fujimoto disease masquerading as a parotid gland tumor

The Kikuchi-Fujimoto disease, also known as histiocytic necrotizing lymphadenitis, is a self-limiting lesion of unknown cause first described in 1972 independently by Kikuchi and Fujimoto et al. This self-limiting disorder usually occurs in Asian women in their late 20s or early 30s. Typically, it runs a benign course and appears to resolve spontaneously 1 to 6 months after definite diagnosis. The Kikuchi-Fujimoto disease usually manifests as a localized cervical lymphadenopathy; therefore, most patients with this disease are seen in ears, nose, and throat practice. Nodal involvement other than in the neck area or extranodal involvement is rare. In this situation, however, the Kikuchi-Fujimoto disease is easily confused with other less-benign conditions. We describe a case of Kikuchi-Fujimoto disease in a 30-year-old man that presented as a parotid gland tumor. This is the third study to document intraparotid Kikuchi-Fujimoto disease in the English literature. Our report illustrates the clinical features of this unusual condition and emphasizes potential confusion with other diagnoses.

Kikuchi-Fujimoto disease: hydroxychloroquine as a treatment

We describe a case of recurrent Kikuchi's disease in a South Asian-American man that was treated successfully with chloroquine and on recurrence with hydroxychloroquine. Each treatment led to a very prompt response.

Kikuchi?s disease involving the supraclavicular lymph nodes and associated with transient eruption

A 26-year-old woman presented with high fever, marked supraclavicular lymphadenopathy, and morbilliform eruptions and was diagnosed with Kikuchi's disease (KD) based on pathologic findings from biopsied lymph nodes. All her manifestations of KD improved, however, without any specific treatment. The picture of transient morbilliform eruptions typified in KD here is seldom shown in the literature. In general, KD would run a benign course of supraclavicular lymphadenopathy.

Pediatric Kikuchi-Fujimoto disease masquerading as a submandibular gland tumor

Kikuchi-Fujimoto disease, also known as histiocytic necrotizing lymphadenitis, is a rare disorder that typically affects the cervical lymph nodes. The disease usually occurs in women in their late 20s or early 30s. Reports in the pediatric literature are sparse. Most authors consider Kikuchi-Fujimoto disease as a self-limiting disorder that requires no specific management but long-term follow-up. The clinical features of Kikuchi-Fujimoto disease are easily confused with other less-benign conditions. Thus, an early biopsy is instrumental in making definite diagnosis and preventing unnecessary investigations. We describe a case of Kikuchi-Fujimoto disease in an 8-year-old boy which presenting as a submandibular gland tumor. The case illustrates the clinical features of this unusual condition and emphasizes the potential confusion with other diagnoses.

Histiocytic necrotising lymphadenitis (Kikuchi's disease): A rare cause of cervical lymphadenopathy

Both Head and Neck Surgeons and General Surgeons are frequently referred patients with cervical lymphadenopathy. An uncommon but important cause is histiocytic necrotising lymphadenitis. This is a benign self-limiting disease that has been confused with malignant lymphomas. Some patients may also experience distressing and debilitating symptoms which can last for months. We describe four cases to illustrate the varied clinical presentation of this disease and present new signs seen in association with it. A remarkable therapeutic response to a short course of oral corticosteroids was observed in one case.

Kikuchi's disease (necrotizing lymphadenitis) with cutaneous involvement associated with subacute cutaneous lupus erythematosus

Necrotizing histiocytic lymphadenopathy (Kikuchi's disease) is a rarely observed clinical entity characterized by fever, and solitary or multiple lymphadenopathy predominantly in the posterior cervical region. Kikuchi's disease has been reported to precede, coexist with or follow the diagnosis of systemic lupus erythematosus. In only rare instances has its association with cutaneous lupus erythematosus without systemic involvement been reported. We report a 45-year-old woman who presented characteristic systemic and cutaneous manifestations of Kikuchi's disease. Several months later, after sun exposure, she developed lesions of subacute cutaneous lupus erythematosus. The American Rheumatism Association criteria for systemic lupus erythematosus were not fulfilled. The possible pathogenic relationships between the two processes are discussed.

Kikuchi-Fujimoto disease: a case report

We describe a rare but typical case of Kikuchi-Fujimoto disease (KFD). Two subcutaneous nodules appeared suddenly on the right of the neck of a 15-year-old girl. Microscopy of a surgical specimen of the larger nodule showed necrotizing lymphadenitis. Prompt treatment with mepirizole resulted in the disappearance of the smaller nodule. No recurrence was noted during 6 months of follow-up. KFD is a rare, self-limiting, necrotizing histiocytic lymphadenitis that needs to be differentiated from malignant lymphoma. Any nodal biopsy showing fragmented nuclei, necrosis, and karyorrhexis without prominent neutrophils should alert the physician to consideration of KFD, especially in a young woman presenting with cervical lymphadenopathy.

Kikuchi disease presenting as a flu-like illness with rash and lymphadenopathy

Kikuchi-Fujimoto disease (Kikuchi Disease) is a self-limited and benign systemic lymphadenitis of unknown cause, originally described by Kikuchi and Fujimoto and coworkers in 1972. Although relatively uncommon, it is increasingly discussed in the medical literature. Clinical presentation typically includes adenopathy, particularly cervical, with fever and flu-like symptoms. This constellation of symptoms, in the presence of a characteristic histiocytic necrotizing lymphadenitis, provides the clinicopathologic diagnosis. The immunopathogenesis of Kikuchi disease may lie in a hyperactive response to viral infection. We describe an African American man with Kikuchi disease, unusual in the extent of his rash and debilitation, and in the relapse of his clinical symptoms.

Spontaneous clearance of psoriasis during the course of Kikuchi-Fujimoto disease

A 23-year-old woman had psoriasis vulgaris since childhood. She noted painless enlargement of several lymph nodes in the cervical region accompanied by fever and malaise. A biopsy specimen from a cervical lymph node revealed histiocytic necrotizing lymphadenitis without granulocyte infiltration (Kikuchi-Fujimoto disease), a rare and benign lymphadenopathy of unknown cause. During the course of the Kikuchi-Fujimoto disease, the patient's recalcitrant psoriatic lesions spontaneously subsided. Complete clearance of psoriatic lesions continued until remission of Kikuchi-Fujimoto disease.

Kikuchi's disease (histiocytic necrotizing lymphadenitis) with cutaneous involvement

We report a case of Kikuchi's disease (histiocytic necrotizing lymphadenitis) in a 22-year-old Japanese man who presented with cervical and axillary lymphadenopathy and who developed edema of lips with desquamation and erosions and transient indurated erythematous papules on the face, neck and upper extremities. A lymph node biopsy specimen showed the typical necrotizing lymphadenitis of Kikuchi's disease. A skin biopsy specimen showed a dense, lymphohistiocytic, superficial, deep perivascular, and interstitial infiltrate, papillary dermal edema, and abundant nuclear debris with a conspicuous absence of neutrophils, paralleling the nodal histology of Kikuchi's disease. CD68 immunohistochemistry showed many plasmacytoid monocytes. Oral corticosteroid (prednisolone 40 mg) therapy improved the skin lesions and other clinical symptoms. Lip involvement by Kikuchi's disease has not been reported, and should be included as one of the possible cutaneous manifestations of Kikuchi's disease.

Kikuchi's Disease: A Case Report and Review of the Literature

Kikuchi's disease is a necrotizing lymphadenitis that is prevalent in Asia and is being increasingly recognized in other areas of the world. It usually occurs in women in their late 20s or early 30s and manifests as a posterior cervical adenopathy. It resolves spontaneously, usually over a period of several weeks to 6 months. Its initial clinical appearance is commonly similar to that of a lymphoma, and it can be pathologically misdiagnosed as such. Kikuchi's disease might be associated with systemic lupus erythematosus. We report a case of Kikuchi's disease that occurred in a 36-year-old Asian woman. We discuss the clinical features, differential diagnosis, radiographic evaluation, and pathology of this case, and we review the literature in an effort to assist otolaryngologists in diagnosing this benign and uncommon entity.

Kikuchi disease with facial rash and erythema multiforme

Kikuchi disease, or histiocytic necrotizing lymphadenitis, is a benign illness characterized by fever and cervical lymphadenopathy predominantly in young women. It has a self-limiting course. Skin changes occur in about one-third of patients and are of a nonspecific nature. A case of Kikuchi disease with cutaneous involvement in the guise of erythema multiforme and a facial rash is reported. The differential diagnosis with systemic lupus erythematosus and Rowell syndrome is discussed.

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.

Kikuchi-Fujimoto necrotizing lymphadenitis associated with cutaneous lupus erythematosus: a case report

Histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease is a rare entity, and even more rarely, it is associated with other diseases. In a few cases, the condition is associated with cutaneous lupus erythematosus (CLE). Histiocytic necrotizing lymphadenitis predominantly affects young women, who present with solitary or multiple cervical lymphadenopathy accompanied by symptoms such as fever, weight loss, sweating, or, in exceptional cases, hepatosplenomegaly. Laboratory examinations show normal or nonspecific results. The disease is of unknown origin, although a viral origin has been suggested, with the suspected agents including Epstein-Barr virus, herpesvirus type 6, and cytomegalovirus (CMV). Although the first and most of the more recent cases have been reported in Oriental patients, the disease has a wide geographic distribution. The clinical evolution is favorable, with spontaneous remission in less than 4 months in almost all cases. We present a case of a 37-year-old woman from Peru who presented with cervical adenopathies on two occasions. Biopsy of a lymph node revealed a histopathologic picture compatible with Kikuchi-Fujimoto histiocytic necrotizing lymphadenitis. The adenopathy disappeared in a few months. A year later, she presented with a maculopapular rash in the nasal and malar regions. The results of the skin biopsy and immunofluorescence examination were compatible with chronic CLE. The results of the serology testing for CMV were positive. Treatment with chloroquine was initiated, with almost complete recovery by 5 months. No manifestations of systemic lupus erythematosus have occurred since. The epidemiologic, clinical, and anatomopathologic aspects as well as the differential diagnosis of this entity are reviewed.

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.

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.

Skin involvement in Kikuchi's disease: an immunocytochemical and immunofluorescence study

Kikuchi's disease (KD) is a benign self-limiting febrile illness usually affecting young women, which is manifested clinically by fever and cervical lymphadenopathy. Skin involvement in KD is very rare and is evident clinically in the form of skin rashes and nodules. We describe one such case of KD in a 33-year-old Bulgarian woman who presented with cervical and axillary lymphadenopathy and who developed a transient facial rash. Biopsy of axillary lymph nodes showed the characteristic features of KD with infiltration of the lymph node paracortex by apoptotic plasmacytoid monocytes. Biopsies of the facial skin showed two features: (1) dermal infiltration by apoptotic plasmacytoid monocytes; (2) on immunofluorescence studies of frozen sections prepared from involved and uninvolved facial skin, deposition of immunoglobulins and complement at the dermoepidermal junction and in the walls of dermal blood vessels. Such immunofluorescence findings in the skin of patients with KD have never been described. These findings suggest the presence of an autoimmune reaction as a component of KD.

Kikuchi's disease: report of three cases and an overview

We describe, to our knowledge, the first native Finnish patients with Kikuchi's histiocytic necrotizing lymphadenitis. The diagnosis was based in all cases on histopathological findings in open biopsy. The disease was first detected in Japan in 1972, but in Scandinavia, until this decade, there had been no cases reported. Our patients were young, otherwise healthy women who had cervical lymphadenopathy, fever, and fatigue as their main symptoms. In two of them, the disease was mild and subsided spontaneously within 2-6 months. One patient with more fulminant lymphadenopathy was treated with antimicrobial and antiinflammatory drugs. She became symptomless in 3 months. The cause of Kikuchi's disease is unknown. A viral or postviral hyperimmune reaction has been proposed as its etiology. Malignant lymphoma and systemic lupus erythematosus are differential diagnoses. Histopathological findings are pathognomonic and pathologists must be aware of its typical characteristics.