Clinical Presentations, Laboratory Results and Outcomes of Patients with Kikuchi's Disease: Emphasis on the Association Between Recurrent Kikuchi's Disease and Autoimmune Diseases

Kikuchi disease in acute leukaemia: a distinct clinical syndrome with HLA association

AIMS

To report the clinicopathological features of Kikuchi disease in patients with acute leukaemia, emphasising similarities among cases.

METHODS AND RESULTS

In a cohort of 454 Kikuchi disease patients, we identified three cases of concurrent acute leukaemia. These patients shared similar clinical traits, with Kikuchi disease emerging approximately a month after induction chemotherapy onset, featuring neck-region lymphadenopathy. Notably, two patients were middle-aged, deviating from the typical age distribution of Kikuchi disease. Histologically, these cases aligned with typical Kikuchi disease. Negative immunohistochemical stains (CD34, CD117, ERG, TdT) indicated the absence of extramedullary leukaemic infiltration. Herpes simplex virus immunohistochemical staining was also negative. Significantly, a human leucocyte antigen (HLA) association was observed in these three cases. HLA-B*15:01, C*04:01, and DRB1*04:06 were more prevalent in these patients compared to the general population (compared with three independent control cohorts: Taiwanese Han Chinese (n = 504), Tzu Chi Taiwanese bone marrow donors (n = 364) and Hong Kong Chinese (n = 5266)).

CONCLUSIONS

Our study underscores the unique link between Kikuchi disease and acute leukaemia, characterised by specific features and HLA associations. This underlines Kikuchi disease as a possible differential diagnosis in pertinent clinical scenarios. Furthermore, this syndrome offers insights into postchemotherapy immunology in acute leukaemia, enhancing comprehension.

Kikuchi–Fujimoto disease: literature review and report of four cases

Kikuchi–Fujimoto disease, or necrotizing histiocytic lymphadenitis, is one of the rare causes of benign lymphadeno-pathy. The diagnosis is based on histological and immunohistochemical analysis of the lymph node biopsy. The article presents four clinical cases of Kikuchi–Fujimoto disease. According to the results of the primary analysis of lymph node tissue three patients were misdiagnosed with lymphoma. due to the unusual for lymphoid malignancy course the primary material was reviewed. The diagnosis of Kikuchi–Fujimoto disease was put. In three patients the disease has a re-current course. during the observation period, the course of the disease in all the presented patients is benign with normal quality of life.

Case of recurring Kikuchi disease and autoimmune hepatitis

We present a case of a 47-year-old female patient with a history of diagnosed Kikuchi disease and autoimmune hepatitis 13 years ago who presented with recurrent fevers and a desquamative rash on the lower extremities. Computed tomography neck showed enlarged lymph nodes, and with her daily fevers and skin rashes the presentation was concerning for recurrence of her Kikuchi disease. The patient was also found to have an elevated anti-smooth muscle antibody titer, and subsequent liver biopsy confirmed the diagnosis of autoimmune hepatitis. She was started on methylprednisolone with improvement. Our case emphasizes the association of Kikuchi disease with autoimmune conditions other than systemic lupus erythematosus. Given the recurrence of the disease after a decade of quiescence, long-term follow-up of patients with Kikuchi disease should be implemented.

Repeated Necrotizing Lymphadenitis with MEFV Gene Mutations

We herein report a 36-year-old man with repeated necrotizing lymphadenitis due to MEFV gene mutations. The patient's chief complaints were a fever and painful cervical lymphadenopathy. We diagnosed him with necrotizing lymphadenitis based on the pathological findings of the lymph nodes and the exclusion of other differential diseases. The same episode recurred four times. We speculated the involvement of autoinflammatory backgrounds and detected MEFV gene mutations of E148Q (homo), P369S, and R408Q. Considering the elevation of interleukin-18, these mutations probably played roles in the repeated necrotizing lymphadenitis.

Self-limiting COVID-19-associated Kikuchi-Fujimoto disease with heart involvement: case-based review

Background

The association between COVID-19 infection and the development of autoimmune diseases is currently unknown, but there are already reports presenting induction of different autoantibodies by SARS-CoV-2 infection. Kikuchi-Fuimoto disease (KFD) as a form of histiocytic necrotizing lymphadenitis of unknown origin.

Objective

Here we present a rare case of KFD with heart involvement after COVID-19 infection. To our best knowledge only a few cases of COVID-19-associated KFD were published so far. Based on presented case, we summarize the clinical course of KFD and its association with autoimmune diseases, as well we discuss the potential causes of perimyocarditis in this case.

Methods

We reviewed the literature regarding cases of “Kikuchi-Fujimoto disease (KFD)” and “COVID-19” and then “KFD” and “heart” or “myocarditis” by searching medical journal databases written in English in PubMed and Google Scholar.

Results

Only two cases of KFD after COVID infection have been described so far.

Conclusion

SARS-CoV-2 infection can also be a new, potential causative agent of developing KFD.

Kikuchi-Fujimoto Disease: A Rare Cause of Cervical Lymphadenopathy

Kikuchi-Fujimoto disease (KFD) is a rare benign disease, clinically characterized by fever and tender cervical lymphadenopathy affecting the posterior cervical lymph nodes. This disease is usually accompanied by night sweats, rashes, and headaches. It generally affects young individuals, especially females, of Oriental-Asian origin. The etiology of KFD remains uncertain, but associations have been noted with viral diseases including Epstein-Barr virus (EBV), herpes simplex virus (HSV), and varicella-zoster virus (VZV), as well as autoimmune disorders including systemic lupus erythematosus (SLE) and Sjogren's syndrome. This review points out the etiology of KFD with cervical lymphadenopathy alongside its clinical presentation, histological highlights, lab investigations, complications, and treatment. Accurate diagnosis of this disease depends on lymph node excisional biopsy. Three histological patterns of KFD are recognized: proliferative, necrotizing, and xanthomatous. Distinction from lymphadenopathy-associated alternate disorders (e.g., SLE, malignancy, tuberculosis, or another infectious lymphadenitis) is essential to ensure appropriate therapy. This self-limited condition entails nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief with consideration of corticosteroids and hydroxychloroquine in severe cases.

Distinguishing lupus lymphadenitis from Kikuchi disease based on clinicopathological features and C4d immunohistochemistry

OBJECTIVES

Distinguishing Kikuchi disease (KD) from lupus lymphadenitis (LL) histologically is nearly impossible. We applied C4d immunohistochemical (IHC) stain to develop diagnostic tools.

METHODS

We retrospectively investigated clinicopathological features and C4d IHC staining in an LL-enriched development cohort (19 LL and 81 KD specimens), proposed risk stratification criteria and trained machine learning models, and validated them in an external cohort (2 LL and 55 KD specimens).

RESULTS

Clinically, we observed that LL was associated with an older average age (33 vs 25 years; P=0.005), higher proportion of biopsy sites other than the neck [4/19 (21%) vs 1/81 (1%); P=0.004], and higher proportion of generalized lymphadenopathy compared with KD [9/16 (56%) vs 7/31 (23%); P=0.028]. Histologically, LL involved a larger tissue area than KD did (P=0.006). LL specimens exhibited more frequent interfollicular pattern [5/19 (26%) vs 3/81 (4%); P=0.001] and plasma cell infiltrates (P=0.002), and less frequent histiocytic infiltrates in the necrotic area (P=0.030). Xanthomatous infiltrates were noted in 6/19 (32%) LL specimens. Immunohistochemically, C4d endothelial staining in the necrotic area [11/17 (65%) vs 2/62 (3%); P<10-7], and capillaries/venules [5/19 (26%) vs 7/81 (9%); P=0.048] and trabecular/hilar vessels [11/18 (61%) vs 8/81 (10%); P<10-4] in the viable area was more common in LL. During validation, both the risk stratification criteria and machine learning models were superior to conventional histological criteria.

CONCLUSIONS

Integrating clinicopathological and C4d findings could distinguish LL from KD.

Identification of genes associated with Kikuchi-Fujimoto disease using RNA and exome sequencing

Kikuchi-Fujimoto disease (KFD) is an extremely rare disease, and although it is reported to have a worldwide distribution, young Asian women are most likely to be affected. Although this disease is generally benign and self-limiting, distinguishing it from other diseases that cause lymphadenopathy (e.g., leukemia, lymphoma, and infectious diseases) is challenging. A lymph node biopsy is a definitive diagnostic technique for KFD and only requires skillful pathologists. There are no specific symptoms or laboratory tests for KFD, and more than 50% of KFD patients have suffered from being misdiagnosed with lymphoma, which leads to improper treatment. In this study, lymph node tissue samples from KFD patients were used to reveal their exomes and transcriptomes using a high-throughput nucleotide sequencer. Fourteen single nucleotide polymorphisms (SNPs) were identified as candidate KFD markers and were compared with a healthy lymph node exome dataset. The mutation of these genes caused disruptive impact in the proteins. Several SNPs associated with KFD involve genes related to human cancers, olfaction, and osteoblast differentiation. According to the transcriptome data, there were 238 up-regulated and 1,519 down-regulated genes. RANBP2-like and ribosomal protein L13 were the most up-regulated and down-regulated genes in KFD patients, respectively. The altered gene expression involved in the human immune system, chromatin remodeling, and gene transcription. A comparison of KFD and healthy datasets of exomes and transcriptomes may allow further insights into the KFD phenotype. The results may also facilitate future KFD diagnosis and treatment.

Recurrent Aseptic Meningitis Associated with Kikuchi's Disease (Histiocytic Necrotizing Lymphadenitis): A Case Report and Literature Review

We herein report a 31-year-old man with recurrent aseptic meningitis associated with Kikuchi's disease. Although aseptic meningitis is the most common neurological complication of Kikuchi's disease, its characteristics remain unclear, especially in recurrent cases. A literature review revealed that aseptic meningitis associated with Kikuchi's disease was more likely to occur in men and was associated with a low cerebrospinal fluid (CSF)/serum glucose ratio. Lymphadenopathy tended to occur simultaneously or after the onset of meningitis. When encountering a patient with aseptic meningitis of unknown etiology, it may be worthwhile to focus on the CSF/serum glucose ratio and lymphadenopathy with a careful examination.

Kikuchi-Fujimoto Disease Triggered by Systemic Lupus Erythematosus and Mycoplasma pneumoniae Infection-A Report of a Case and a Review of the Literature

ABSTRACT

Kikuchi-Fujimoto disease (KFD) is a necrotizing histiocytic lymphadenitis that was described for the first time in 1972 in Japan. Its etiology is still not fully understood. It has been reported in association with many different agents, diseases, and triggering factors without any conclusive result. To the best of our knowledge, we report for the first time a case of KFD with systemic lupus erythematosus in a child in association with a polymerase chain reaction (PCR)-positive throat swab for Mycoplasma pneumoniae. Although difficult to prove, the acute M. pneumoniae infection might have served as a triggering event for the development of KFD in our case. We encourage further studies to investigate a potential relationship between KFD and M. pneumoniae, which should also use PCR-based testing for this pathogen in patients with KFD.

Risk Assessment of Recurrence and Autoimmune Disorders in Kikuchi Disease

Purpose

Kikuchi disease (KD) is typically a benign disease. Recent studies reporting recurrence or serious cases suggest a possible association of KD with systemic autoimmune disorders. We performed a long-term analysis of the characteristics of KD in patients of all ages and assessed KD recurrence or progress to systemic autoimmune disorders.

Patients and Methods

Electronic medical records of patients diagnosed with KD between April 1995 and May 2017 were reviewed for clinical and laboratory manifestations.

Results

In total, 480 patients were confirmed to have KD based on histopathology findings. The mean age at KD diagnosis was 24.4 years. Recurrence occurred in 11.3% of patients; 2.7% developed autoimmune diseases after KD diagnosis. Patients who experienced recurrence had more extranodal symptoms, lymphopenia, and a longer lymphopenia-recovery duration. Patients who developed autoimmune diseases after KD were more likely to have extranodal symptoms, KD recurrence, and anti-nuclear antibody positivity.

Conclusion

KD patients with risk factors need to be followed-up for KD recurrence and the development of systemic autoimmune diseases.

Rare Presentation of Self-Limiting Kikuchi-Fujimoto Disease in Relapsing Nature

Background

Kikuchi–Fujimoto disease (KFD) is a rare, benign, and self-limiting disease that is commonly associated with cervical lymphadenopathy and fever. The disease has a wide spectrum of clinical manifestations, and definitive diagnosis is based on the histological appearance in the excision biopsy of the lymph nodes. Recurrence of KFD is reported rarely. Case Presentation. A 56-year-old Iranian woman with a background history of thrombocytopenia presented with fever, malaise, loss of appetite, and weight loss with cervical lymphadenopathy. The excision biopsy of the cervical lymph nodes confirmed the diagnosis of KFD, and she made a full recovery with improvement of symptoms, regression of cervical lymph nodes, and normalization inflammatory markers. One year after remission, she presented with similar clinico-biochemical profile, and repeat biopsy confirmed KFD.

Conclusion

Although the rate of recurrence of the disease is very low, the treating physician should consider the possibility and confirm it histologically.

Diagnosis of Kikuchi-Fujimoto disease in an 11-year-old girl with fever and sickle cell disease

Kikuchi-Fujimoto disease (KFD) is a rare lymphohistiocytic disorder which can cause prolonged fever and other systemic B symptoms including diffuse lymphadenopathy. Given its clinical presentation, there is often initial concern for lymphoma and diagnosis requires lymph node biopsy. It most frequently affects young women of Asian descent; it is less commonly encountered in paediatric patients. KFD is typically a benign, self-limited process, however, there is an association with development of systemic lupus erythematosus. Given its rarity, it remains unclear if KFD is associated with other chronic conditions. Here we present the third case of KFD occurring in a paediatric patient with sickle cell disease.

Intensive care management of a rare case of pyrexia of unknown origin (Kikuchi-Fujimoto disease)

Kikuchi-Fujimoto disease is a rare, benign cause of necrotising lymphadenitis often presenting with fever. We describe a case of a 17-year-old boy with non-verbal autism presenting to our intensive care unit with prolonged fever of unknown cause. This case highlights the role of the intensive care unit in cases of diagnostic dilemma. The critical care community should be aware of Kikuchi-Fujimoto disease as although it is usually benign, it can rarely lead to acute airway compromise.

Kikuchi-Fujimoto Disease in Children: An Important Diagnostic Consideration for Cervical Lymphadenitis

Kikuchi-Fujimoto disease (KFD), or histiocytic necrotizing lymphadenitis, is a rare, benign, and self-limited disease that causes lymphadenopathy and has a characteristic histological appearance. The etiology of this disease is unknown, but a possible infectious trigger has been hypothesized. In the adult population this disease is more common in females; however, in the pediatric population it is more common in males. Descriptions in the pediatric literature are lacking, particularly in the United States. The authors report three cases of pediatric KFD that presented at the same institution in a 9-month time period. All three patients were male and of non-Asian descent who were diagnosed with KFD by histopathologic specimen after presenting with unilateral cervical lymphadenitis. Each patient had additional laboratory evidence of a possible bacterial infection at the time of diagnosis. These three cases highlight the importance of considering KFD early when a pediatric patient presents with unilateral cervical lymphadenitis. The authors discuss the epidemiology, etiology, clinical manifestations, diagnostic approaches, and treatment of KFD. [Pediatr Ann. 2019;48(10):e406-e411.].

Kikuchi-Fujimoto disease in children: two case reports and a review of the literature

BACKGROUND

Kikuchi-Fujimoto disease is a rare, idiopathic and generally self-limiting cause of lymphadenitis of unknow etiology with a low recurrence rate. The typical clinical signs are cervical lymphadenopathy, fever, and symptoms of respiratory infection, and less frequently chills, night sweats, arthralgia, rash, and weight loss.

CASE PRESENTATION

Here we describe two case reports of Kikuchi Fujimoto disease presenting in Milan within the space of a few months. The first involved the recurrence of KFD in a young boy from Sri Lanka; the second was a rare case of severe KFD complicated by HLH.

CONCLUSIONS

Pediatricians must consider KFD in the differential diagnosis of fever of unknown origin in children, even in western countries. Although rare, recurrence and severe complications are possible. Where symptoms suggest KFD, a systematic diagnostic approach is key. Since no guidelines on the management of KFD are available, further studies should be conducted to investigate the therapeutic options and long term outcome in children.

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.

Fever with lymphadenopathy - Kikuchi Fujimoto disease, a great masquerader: a case report

Background

Kikuchi Fujimoto disease is an uncommon benign condition of necrotizing histiocytic lymphadenitis commonly seen in East Asian and Japanese populations. It commonly presents with fever, cervical lymphadenopathy, and elevated inflammatory markers. Diagnosis of Kikuchi Fujimoto disease is based on histopathological studies of the involved lymph nodes. The presentation of Kikuchi Fujimoto disease can mimic many sinister conditions including lymphoma. Treatment is mainly supportive provided that accurate diagnosis is made and sinister conditions like lymphoma ruled out.

Case presentation

We report the case of an 18-year-old Sri Lankan Moor woman who presented with fever and cervical lymphadenopathy for 1 month. She had elevated inflammatory markers with high lactate dehydrogenase and ferritin levels. She had an extensive work-up including an excision biopsy of an involved lymph node and bone marrow biopsy. Finally, a diagnosis of Kikuchi Fujimoto disease was based on histopathology of the lymph node and negative bone marrow biopsy.

Conclusions

Although Kikuchi Fujimoto disease is a self-limiting condition, it is a great masquerader which mimics the clinical features of many sinister conditions including tuberculosis, lymphoma, and adult-onset Still’s disease. Early recognition of the disease is of crucial importance in minimizing potentially harmful and unnecessary evaluations and treatments.

Kikuchi-Fujimoto disease: an unusual presentation of meningitis in a returning traveller

A 19-year-old, previously healthy woman developed a pruritic erythematous maculopapular rash on her bilateral palms and wrists, right-sided tender cervical lymphadenopathy and nightly fevers and headaches 5 days after returning from a 1-month trip to Cambodia. She presented 2 weeks after her trip due to ongoing nightly fevers to a maximum of 38.8°C. She was given empiric doxycycline for possible rickettsial disease, though an extensive infectious workup returned without positive findings. Lumbar puncture was performed on hospital day 4, and spinal fluid analysis was consistent with aseptic meningitis. On hospital day 5, core biopsy and fine-needle aspiration were performed on the largest anterior cervical lymph node. Her fever curve gradually improved, and she was discharged on hospital day 6. Results of the lymph node biopsy were finalized 5 days after discharge and were compatible with Kikuchi's lymphadenitis. Symptoms had completely resolved on follow-up with infectious disease and rheumatology.

Pediatric Kikuchi-Fujimoto disease: A clinicopathologic study and the therapeutic effects of hydroxychloroquine

BACKGROUND

To investigate the clinical features of Kikuchi-Fujimoto disease (KFD) in children, and place an emphasis on the therapeutic effects of hydroxychloroquine as monotherapy.

METHODS

We retrospectively reviewed the medical records of all children diagnosed with KFD during the period January 1992 to September 2016 at a tertiary medical center in Taiwan.

RESULTS

40 patients were histopathologically confirmed as KFD, and the mean age of the patients was 13.9 ± 3.1 years. The male to female ratio was 1:1. The lymph node involvements were often cervical (95%) with features of unilateral predisposition (75%), polyadenopathy (84.4%) and tenderness (56.3%). Fever, cough, rhinorrhea, and tonsillitis were other common presentations. Laboratory findings included leukopenia (56.5%), monocytosis (63.6%), with positive results of EB-VCA IgG (88.9%), EB-VCA IgM (22.2%), EBEA IgG (22.2%) and EBNA IgG (88.9%). The univariate analyses of prolonged fever with lymphopenia, monocytosis, thrombocytopenia and necrotizing type in histopathology were disclosed as statistically significant (P < 0.05). Corticosteroids and hydroxychloroquine were administered in 15.6% of patients respectively, along with symptomatic treatments for the rest. Recurrence occurred in 13.0% of patients without corticosteroids or hydroxychloroquine treatment. There were neither recurrences nor relevant major adverse effects in all the five KFD cases treated with hydroxychloroquine.

CONCLUSION

KFD should be suspected in children with febrile cervical lymphadenopathy, especially when concomitant with leukopenia and monocytosis. Lymphopenia, monocytosis, thrombocytopenia and necrotizing type in histopathology are reliable predictors for prolonged fever. Hydroxychloroquine may be an alternative choice to corticosteroids for its favorable effects and safety.

Kikuchi-Fujimoto disease in the regional lymph nodes with node metastasis in a patient with tongue cancer: A case report and literature review

Kikuchi-Fujimoto disease (KFD), also known as histiocytic necrotizing lymphadenitis, is a rare self-limiting disorder typically affecting the cervical lymph nodes (LNs), which is often misdiagnosed as other LN-associated diseases. KFD frequently presents with necrotic lesions and recurrences, which are also features of metastatic LNs. Clinicians may thus suspect LN metastasis when they encounter ipsilateral cervical lymphadenopathy in a patient with head and neck cancer. The present study reports the case of a 48-year-old man with tongue cancer and KFD affecting the right edge of his tongue and ipsilateral cervical LNs. LN metastasis was initially suspected, but pathological examination of the dissected LNs revealed one necrotic metastatic lesion and two necrotic KFD lesions. Ipsilateral cervical lymphadenopathy recurred 6 years after the initial surgery, and it was not possible to differentiate clinically between a second primary tumor and recurrent KFD prior to treatment. To the best of our knowledge, this is the first reported case of simultaneous tongue cancer, regional LN metastasis and KFD. This highlights the requirement to consider KFD in the event of LNs with necrotic lesions but no cancerous cells. A combination of clinical and pathological approaches may aid in the diagnosis of KFD, in addition to ruling out LN metastasis in initial and recurrent lymphadenopathies. The present study indicate that a diagnosis of KFD should be considered in patients with head and neck cancer that exhibit necrotic LNs lacking cancerous cells. This is important, as misdiagnosis of KFD as LN metastasis may lead to unnecessary adjuvant therapy.

Kikuchi-Fujimoto disease and systemic lupus erythematosus

Kikuchi-Fujimoto disease, or histiocytic necrotizing lymphadenitis, is an infrequent idiopathic disorder. It has been associated with autoimmune disorders, of which systemic lupus erythematosus is the most outstanding. The basis of its diagnosis relies on the histological examination of lymph nodes, which typically reveals necrosis surrounded by histiocytes with crescentic nucleus, immunoblasts and plasma cells, and absence of neutrophils. We report the case of a 27-year-old Argentinian female patient without any relevant past medical history to demonstrate the correlation between Kikuchi-Fujimoto disease and systemic lupus erythematosus.

An uncommon presentation of Kikuchi Fujimoto disease: a case report with literature review

BACKGROUND

Kikuchi-Fujimoto disease is so named because Kikuchi and Fujimoto were the first scientists to describe it in Japan in 1972. Although the disease has been reported from all over the world and more so from Asia, it is rare. To date only eight cases have been reported from Nepal. Cervical lymphadenopathy, fever and raised Erythrocyte Sedimentation Rate are usual presenting features of this disease. We describe a case which presented with thrombocytopenia and axillary lymphadenopathy in addition to the usual features. Out of the total eight cases that have been reported from Nepal so far, no patients had thrombocytopenia and only one patient had axillary lymphadenopathy.

CASE PRESENTATION

A 24-year-old Nepali female presented with a 3-week history of low-grade fever, headache, and painful, discrete, unilateral left-sided cervical and axillary lymphadenopathy. Among the multitude of tests that were carried out, Erythrocyte Sedimentation Rate was raised and there was thrombocytopenia while other tests were normal. Painful lymphadenopathy pointed to bacterial lymphadenitis while chronic low-grade fever suggested tuberculosis. A cervical lymph node was excised for histopathological examination to reach an accurate diagnosis. On the basis of pathognomonic features viz., paracortical foci composed of various types of histiocytes including crescentic type in the background of abundant apoptotic karyorrhectic debris, a diagnosis of Kikuchi-Fujimoto disease was made. On follow-up evaluation after 6 weeks, the patient had no systemic symptoms, enlarged lymph nodes had regressed in size significantly, and Erythrocyte Sedimentation Rate and platelet count had become normal.

CONCLUSION

Kikuchi-Fujimoto disease should be kept in the differential diagnosis of lymphadenopathy in young patients, female or male even in tuberculosis-endemic countries and even in patients who have unusual features; for example thrombocytopenia and involvement of axillary lymph nodes in addition to cervical lymph nodes as in this case.

A Case of Recurrent Kikuchi-Fujimoto Disease

Introduction:

Kikuchi-Fujimoto Disease (KFD) is a benign, self-limited, inflammatory disorder, first reported in Japan. This condition is more prevalent among women and typically occurs in the third decade of life. It normally manifests as persistent, isolated cervical adenopathy with a recurrence rate of 3%. The identification of this condition is of high significance, given the risk of misdiagnosis with other disorders such as malignant lymphoma and extensive necrosis.

Case Presentation:

The patient was a 32-year-old female diagnosed with Kikuchi-Fujimoto disease via neck lymph node biopsy in August 2006 in the city of Mashhad, Iran. The disease regressed with proper follow-up, although after eight years the patient was readmitted to the hospital with severe weight loss, high fever, and uncommon symptoms of generalized adenopathy in cervical, axillary and inguinal regions.

Conclusions:

Although KFD is an uncommon condition, it should be featured in the list of differential diagnoses of tender lymphadenopathy, especially lymphadenopathy localized to the cervical region. We reported a case of KFD with a prolonged relapse of eight years. Full recovery with a good response to corticosteroid regimen was achieved after the recurrence.

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.

Kikuchi-Fujimoto disease: an unusual cause of neck swelling in pregnancy

Kikuchi-Fujimoto disease (KFD) is an unusual cause of lymphadenopathy and fever. Pregnancy associated with KFD presents as a diagnostic dilemma for clinicians. The diagnosis can be confirmed with invasive biopsies or non-invasive gene analysis. We report a case of a 24-year-old woman at 18 weeks' gestation with a neck lump and histologically confirmed KFD.

Histiocytic necrotising lymphadenitis (Kikuchi-Fujimoto disease) of axillary lymph nodes

Kikuchi-Fujimoto disease (KFD) or histiocytic necrotising lymphadenitis is a rare entity, occurring most commonly in young Asian adults. KFD is characterised by fever with tender lymph node enlargement. The cervical group of lymph nodes is most commonly involved, and the diagnosis is conclusively made by lymph node biopsy and histopathology. KFD is a self-limiting condition, which usually resolves over 1-4 months. Symptomatic treatment with antipyretics and/or non-steroidal anti-inflammatory drugs is recommended. Here we describe an uncommon presentation of KFD in a young woman in which only the axillary lymph nodes were enlarged.

[Kikuchi-Fujimoto disease prior to childhood-systemic lupus erythematosus diagnosis]

Kikuchi-Fujimoto disease (KFD) is a self-limiting histiocytic necrotizing lymphadenitis of unknown origin. Of note, KFD was infrequently reported in adult systemic lupus erythematosus (SLE), with rare occurrence in childhood-SLE (C-SLE) patients. To our knowledge, the prevalence of KFD in the paediatric lupus population was not studied. Therefore, in a period of 29 consecutive years, 5,682 patients were followed at our institution and 289 (5%) met the American College of Rheumatology classification criteria for SLE, one had isolated KFD (0.03) and only one had KFD associated to C-SLE diagnoses, which case was reported herein. A 12 year-old female patient had high fever, fatigue and cervical and axillary lymphadenopathy. The antinuclear antibodies (ANA) were negative, with positive IgM and IgG herpes simplex virus type 1 and type 2 serologies. Fluorine-18-fluoro-deoxy-glucose positron emission tomography/computed tomography (PET/CT) imaging demonstrated diffuse lymphadenopathy. The axillary lymph node biopsy showed necrotizing lymphadenitis with histiocytes, without lymphoproliferative disease, compatible with KFD. After 30 days, she presented spontaneous regression and no therapy was required. Nine months later, she developed malar rash, photosensitivity, oral ulcers, lymphopenia and ANA 1:320 (homogeneous nuclear pattern). At that moment the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score was 10 and she was treated with prednisone (1.0mg/kg/day) and hidroxychloroquine showing progressive improvement of hers signs and symptoms. In conclusion, KFD is a benign and rare disease in our paediatric lupus population. We also would like to reinforce the relevance of autoimmune diseases diagnosis during the follow-up of patients with KFD.

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.

Comparison of clinical features and EBV expression in histiocytic necrotizing lymphadenitis of children and adults

OBJECTIVE

Histiocytic necrotizing lymphadenitis (HNL) is a self-limiting disease characterized by cervical lymphadenopathy and fever. Epstein-Barr virus (EBV) has been implicated as a cause of HNL in some reports but not in others. The aim of this study was to compare the clinical features and laboratory findings in children and adults with HNL and to evaluate the relationship between EBV infection and HNL.

METHODS

The records of patients diagnosed with biopsy-confirmed HNL at Gyeongsang National University Hospital from May 2009 to December 2012 were retrospectively reviewed. Clinical features, laboratory data (blood count, biochemistry, and serology), and computed tomography findings were collected. Immunohistochemistry for CD4, CD8, CD68, and myeloperoxidase (MPO), and in situ hybridization for EBV RNA were performed on archived lymph node biopsies from pediatric and adult patients.

RESULTS

A total of 16 children and 31 adults were diagnosed with HNL. Fever was present in 87.5% of children and 25.8% of adults (P<0.0001). Fever duration was longer for children (mean, 5.06 days) than for adults (mean, 0.63 days; P=0.008). Necrosis of the involved lymph nodes was observed in eight (50%) children and six (19.4%) adults (P=0.045). HNL recurred in five (31.35%) children and one (3.2%) adult (P=0.015). All had detectable CD4, CD8, CD68, and MPO immunoreactivity. EBV reactivity was higher in children (26.7%) than in adults (6.7%) without statistical support.

CONCLUSIONS

There is more variability in the clinical presentation and laboratory findings in children with HNL than in adults. In particular, the degree and duration of fever was more severe in children than in adults, and necrosis of lymph nodes was more frequent in children than in adults. There was no definitive correlation between EBV reactivity and NHL. Further study of the relationship between EBV and HNL is needed with a larger number of patients.

Characteristics of Kikuchi-Fujimoto disease in children compared with adults

Kikuchi-Fujimoto disease (KFD) is a benign, self-limiting disease characterized by cervical lymphadenopathy. Although it was primarily thought to be a disease of young adults, it has been increasingly recognized in children. To define the characteristics of KFD in children, we reviewed the medical records of patients younger than 18 years of age who were diagnosed with KFD from 2001 to 2012 at Korea University Medical Center, as well as worldwide published reports of KFD. A total of 140 pediatric patients and 733 patients of all ages was analyzed. Compared to the female predominance found in adults (2:1), young boys were more commonly affected than young girls (1.4:1). Cervical lymphadenopathy was the most common clinical finding in children, as it was in adults. Lymphadenopathy was more likely to be tender (69 vs. 44 %, p < 0.001) but less generalized (1 vs. 8 %, p < 0.05) in children compared to adults. Fever (82 vs. 35 %, p < 0.001) and rash (10 vs. 4 %, p < 0.05) were observed in children more commonly than in adults. Leukopenia was observed in 50 and 38 % of children and adults, respectively. Rates of recurrence and association with autoimmune diseases in children were comparable to those of adults. Cervical lymphadenopathy was the most common clinical manifestation of KFD in all ages. While fever and rash were more common in children with KFD compared to adults, generalized lymphadenopathy was rarer.

Features of Sequential CT and US-guided Biopsy in Recurrent Kikuchi Disease of the Neck: A Case Report

A 26-year-old woman presented with recurrent Kikuchi disease 7 years after her initial episode. Computed tomography (CT) and ultrasonography demonstrated enlarged lymph nodes with extensive necrosis at the same site as the initial episode. Cytologic and histologic examinations were not conclusive. CT performed 1 month later demonstrated a complete resolution of the lymphadenopathy, which confirmed the diagnosis of recurrent Kikuchi disease. Care must be taken to avoid misdiagnosis of recurrent Kikuchi disease as tuberculous lymphadenitis.

[An atypical presentation of Kikuchi-Fujimoto disease]

INTRODUCTION

Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease) is a rare clinical entity characterized by the association of enlarged lymph nodes in the posterior cervical region and fever. The disease is more frequent in young women.

CASE REPORT

We report a 41-year-old African patient who presented with atypical features of Kikuchi's disease including cutaneous lupus, haemophagocytosis, and lymphocytic meningitis. The ethnic origin and the clinical presentation were initially suggestive of tuberculous meningitis. However, microbiological analyses remained negative, histological findings were suggestive of Kikuchi's disease and HHV6 DNA integration was documented in our patient.

CONCLUSION

Kikuchi's disease should be suspected in an African patient when lymphocytic meningitis is associated with enlarged cervical lymph nodes, hemophagocytosis and HHV6 DNA integration.

Recurrent histiocytic necrotizing lymphadenitis with a long latency in a patient with autoimmunity: a case report and review of literature

Kikuchi-Fujimoto disease (KFD), a histiocytic necrotizing lymphadenitis (HNL), characteristically presents as cervical lymphadenopathy in young Asian women. Most resolve spontaneously with rare recurrences described. We report a patient with biopsy-proven recurrence of KFD-like HNL after almost 8 years and analyze 65 additional published cases with recurrences. While those with recurrences similarly affect young (average age = 27 years), Asian (80%) women (76%), 73% had multiple sites of involvement and 32% of those tested had underlying autoimmune conditions. Our case is unusual with respect to the following: (a) Age: 50 years, the oldest among the reported patients with recurrences. (b) Race: African descent, with only 3 others reported with recurrent HNL. Of these 4 cases, 2 had underlying autoimmunity. (c) Underlying condition: Her clinical and laboratory features were best felt to represent Sjögren's syndrome (SjS). Only 2 other cases of SjS-associated HNL have been reported; in 2 recently reported cases SjS developed subsequently.

Kikuchi disease with skin lesions mimicking lupus erythematosus

BACKGROUND

Kikuchi disease (Kikuchi-Fujimoto disease, histiocytic necrotizing lymphadenitis) is a systemic illness of unkown etiology. It is characterized by cervical lymphadenopathy and fever. The skin is the most frequently affected extranodal organ. Cuta-neous Kikuchi-Fujimoto disease can mimic both clinically and histolo-gically skin lesions in lupus erythema-tosus, a disorder with which it seems to be closely related. A close follow up is required as systemic lupus erythema-tosus develop-ment has been reported.

MAIN OBSERVATION

We report a case of a 23-year-old woman, who was admitted to our depart-ment with high fever, skin lesions and arthralgia. Scaly and erythematous plaques were noted on both cheeks and earlobes. In pads of feet and hands and periungual area, multiple purple papules with a perilesional erythematous halo were evident. A thoraco-abdominal computed tomography scan revealed lateral cervical, mediastinal, paratracheal, subcarinal and submandi-bular lympha-denopathy. Excisional node biopsy was consisten with Kikuchi disease with skin involvement.

CONCLUSION

It has to be kept in mind that Kikuchi disease is a differential diag-nosis in case of fever, lymphade-nopathy and lupus-like skin lesions. Skin lesions in this disease and may resemble clinically and histologically to those of subacute lupus erythema-tosus or systemic erythema-tosus lupus.

Clinicopathological review of immunohistochemically defined Kikuchi-Fujimoto disease-including some interesting cases

Kikuchi-Fujimoto Disease (KFD) is a benign, self-limited disease characterized by tender regional lymphadenopathy with fever. KFD remains a poorly defined disease, and no clear diagnostic criteria are available. Here, we assess the clinical, laboratory, and histopathologic findings of KFD cases and report two unusual cases. Forty KFD patients that underwent lymph node (LN) biopsy and diagnosed by immunohistochemical staining, from January 2003 to November 2010, were enrolled in this retrospective study. The patients had a mean age of 29.3 years, and 29 (72.5 %) were women. Affected LNs were mainly located unilaterally in the cervical area. Mean LN size was 15.3 mm. Twenty-eight (70 %) patients had LN tenderness, and 25 (62.5 %) patients had fever. Leukopenia was observed in 18 of 35 evaluable patients. C-reactive protein and erythrocyte sedimentation rate were elevated in most patients. Anti-nuclear antibody was positive in four of 19 evaluable patients, but all had been diagnosed with concurrent systemic lupus erythematosus. Histologically, the 40 cases were classified into three types, that is, as proliferative (37.5 %), necrotizing (55.0 %), or xanthomatous (7.5 %). Interesting cases: Case 1 was a 35-year-old female with KFD and uveitis, retinal vasculitis, and superior sagittal sinus thrombosis. Case 2 was a 47-year-old male with KFD and bone marrow involvement and presented with severe bicytopenia. Although KFD is an uncommon self-limited benign disorder, it must be included in the differential diagnosis of lymphadenopathy with fever and cytopenia. It is important that the clinical features of KFD be understood to reach a correct diagnosis.

Prevalence of connective tissue diseases in egyptian patients presenting with Fever of unknown origin

OBJECTIVE

To estimate the prevalence of connective tissue diseases in patients presenting with fever of unknown origin (FUO).

PATIENTS AND METHODS

In this study thirty patients diagnosed as FUO (Group 1), in 2008, were included in an observational study and diagnostic workup. Additionally, retrospective analysis of seventy patients' files (Group 2), for patients who presented with prolonged unexplained pyrexia to the same hospital in the previous two years, was performed. Patients were subjected to: full clinical assessment including full history taking, thorough clinical examination, laboratory investigations including the basic investigations for patients with prolonged fever, complete blood count, erythrocytes sedimentation rate, urine analysis and culture, blood culture, sputum culture and plain chest X ray. Further diagnostic work up and/or procedures were requested according to the potential diagnostic clues (PDC) present in every patient.

RESULTS

Out of 100 FUO patients, 50% were found to have infectious diseases, 24% were found to have connective tissue diseases, 8% miscellaneous causes and 7% neoplastic diseases (P < 0.05). In 11 patients no definite cause for FUO could be identified. Connective tissue patients were: eight systemic lupus patients (33.3%), five patients with familial mediterranean fever (20.8%), four patients with rheumatoid arthritis (16.6%), three patients (12.5%) with Still's disease and Rheumatic fever and one patient with Behçet syndrome/Crohn's disease (4.3%), (P < 0.05).

CONCLUSIONS

Despite the advanced technology, FUO remains a challenging medical problem. Infections were the most common cause of FUO in Egypt, confirming the trends found in other parts of the world. There was an increased prevalence of connective tissue patients presented with prolonged unexplained fever. A keen clinical eye, meticulous history taking and repeated physical examination remained the most important diagnostic tools in FUO patients.