Histiocytic necrotizing lymphadenitis preceding systemic lupus erythematosus

The Differential Diagnosis of Bilateral Pleural Effusion and Multiple Mediastinal Lymphadenopathies Includes Kikuchi-Fujimoto Disease

Kikuchi-Fujimoto disease is an uncommon lymphohistiocytic disorder that frequently presents with acute or subacute clinical disease course. Cervical lymphadenopathy is the most common involved lymph node. Very rare cases of pathologic diagnosis of Kikuchi-Fujimoto disease with bilateral pleural effusion and multiple mediastinal lymphadenopathies have been reported in the literature. In this article, we report the case of a 60-year-old male presented with bilateral pleural effusion and multiple mediastinal lymphadenopathies. He received video-assisted thoracoscopic surgery of the right pleura and thoracoscopic excision of the mediastinal lymph node. The pathologic findings from the lymph node and pleura were compatible with Kikuchi-Fujimoto disease. He was treated with oral hydroxychloroquine and oral prednisolone. A computed tomography scan of the chest 4 months later showed regressive mediastinal lymphadenopathy and bilateral pleural effusion. Our case is a first reported case of Kikuchi-Fujimoto disease diagnosis by the pathology of the lymph node and pleura in the literature. Results from our case suggest that Kikuchi-Fujimoto disease should be included in the differential diagnosis of bilateral pleural effusion and multiple mediastinal lymphadenopathies.

Kikuchi-Fujimoto disease: evaluation of prognostic factors and analysis of pathologic findings

CONCLUSION

In Kikuchi-Fujimoto disease (KFD), a low ratio of blastic cells (<70%) in lymph node specimens and absence of atypical lymphocytes in peripheral blood are predictive of a protracted clinical course.

OBJECTIVES

Since KFD is a self-limiting disorder that does not require any specific management, prognostic factors have received little attention. The present study identified clinical and pathological factors that may affect the period from onset to cure of KFD.

METHODS

This retrospective study investigated 43 KFD patients who underwent lymph node biopsy diagnosed by immunohistochemical staining at Okayama University Hospital and Okayama Medical Center from January 2001 to December 2013.

RESULTS

Mean total period from onset to cure was 6 months (median =9.4 months; range =1-37 months). Low ratios of blastic cell proliferation area (<70%) in lymph node specimens (p = 0.011) and absence of atypical lymphocytes in peripheral blood (p = 0.026) were associated with a relatively long duration of KFD.

Autoimmune manifestations of Kikuchi disease

OBJECTIVES

Kikuchi's disease (KD) has been associated with the presence of autoantibodies, systemic lupus erythematosus (SLE), and other autoimmune diseases. The aim of this study was to assess the frequency of autoimmune manifestations in a KD cohort with a long follow-up.

METHODS

Twenty patients with histologically confirmed KD since January 1990 until December 2010 were studied; 12 of them were periodically followed up as outpatients. Another 7 patients were contacted by telephone to offer them a specific consultation and a complete autoimmunity study.

RESULTS

Thirteen of 20 patients were women (65%) with a mean age of 29 years (range, 15-79). The age at diagnosis was higher in men (44 vs 27 years, P < 0.05). Lymphopenia was present in 75% of the patients (15/20) and was the more frequent hematological abnormality. The mean follow-up of the 17 patients included in the autoimmunity study was 119 months (range, 15-252). Autoimmune diseases were detected in 9 women (53%): SLE was diagnosed in 4 patients (2 SLE before, 1 simultaneous, and 1 after KD), 2 patients developed primary Sjögren's syndrome after KD, 1 thyroiditis before KD, 1 SLE-like, and 1 antiphospholipid antibodies after KD. Leukocytoclastic vasculitis was found in 2 patients; 1 of them eventually developed SLE. Female sex, painful adenopathies, and cytopenias were significantly associated with autoimmune diseases.

CONCLUSIONS

Among patients with KD, only women developed autoimmune manifestations. Therefore, long-term follow-up and active surveillance of autoimmune diseases in patients with KD, especially women, are recommended.

Histiocytic necrotizing lymphadenitis in the context of systemic lupus erythematosus (SLE): Is histiocytic necrotizing lymphadenitis in SLE associated with skin lesions?

Histiocytic necrotizing lymphadenitis (HNL), or Kikuchi's disease, is a benign and self-limiting lymphadenopathy that typically affects young Asian females. It presents with lymphadenopathy, usually cervical, accompanied by fever, chills and leukopenia. Although the association between systemic lupus erythematosus (SLE) and HNL is rare, the number of reports of HNL in SLE patients is increasing. We present nine cases of HNL in patients with SLE. Among the seven patients with diverse skin manifestations, three had skin manifestations that were histologically compatible with SLE. A review of previous reports in the literature showed that cutaneous involvement was commonly found in HNL in association with SLE. In the patients who had simultaneous onset of both diseases, lupus flare-ups were commonly observed. We suggest that HNL in SLE patients is associated with cutaneous manifestations. This report contributes to our understanding of the relationship between these diseases.

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.

Kikuchi-Fujimoto's disease associated with systemic lupus erythematosus: case report and review of the literature

Kikuchi-Fujimoto's disease (KFD) or histiocytic necrotising lymphadenitis is a benign and self-limited disease, of unknown aetiology, which affects mainly young women. It presents with localised lymphadenopathy, predominantly in the cervical region, accompanied by fever and leukopenia in up to 50% of the cases. KFD has been rarely described in association with systemic lupus erythematosus (SLE), and its diagnosis can precede, postdate or coincide with the diagnosis of SLE. We present a patient with the diagnosis of SLE characterised by arthritis, leukopenia, malar rash, photosensitivity and positive ANA, besides cervical lymphadenopathy whose biopsy was compatible with KFD, which improved after using prednisone. Although the presence of lymphadenopathy is not uncommon in SLE patients, particularly in the phases of disease activity, the concomitance with KFD has rarely been reported in the literature. Its recognition is necessary because one can avoid laborious investigation for infectious and lymphoproliferative diseases.