Kimura's disease with eosinophilic panniculitis--treated with cyclosporine: a case report

Orbital Kimura disease: maintenance therapy using mycophenolate mofetil

Kimura disease (KD) is a rare, chronic, inflammatory condition, predominantly found in male patients of Asian ethnicity. It typically presents between 50-60 years of age and usually with bilateral disease. Angiolymphoid hyperplasia with eosinophilia (ALHE) remains the main differential diagnosis, although histological analysis is essential in differentiating from other similarly presenting pathologies. In this case, we present an atypical case of unilateral orbital KD in a middle-aged, Caucasian, male gentleman and no evidence of regional lymphadenopathy along with a literature review of orbital KD and the differential diagnoses, histological features and management modalities available, adding to the sparse literature on the topic. At present, no recognised diagnostic criteria for KD are available, with histopathological analysis through incisional or excisional biopsy being the primary diagnostic method. Complete surgical excision with or without corticosteroid management remains the most common treatment modality although management is shifting to steroid-sparing immunomodulatory therapy. To the best of our knowledge, this is the first case to describe maintenance therapy of KD using mycophenolate mofetil.

Kimura's Disease in Unusual Anatomical Locations: Clinical and Radiological Characteristics

Purpose

To explore the clinical and imaging features of rare site Kimura's disease (KD).

Methods

Retrospective analysis was conducted on the clinical manifestations, laboratory examinations, and imaging features of five patients with rare site KD. All imaging data, including the location, quantity, size, uniformity, boundary, and enhanced appearance of the lesion were evaluated by two independent radiologists.

Results

Of the five patients, four were asymptomatic, and one experienced localized skin itching. Four cases involved subcutaneous nodules in the upper arm, while one was in the inguinal region. The main manifestations were single (three cases) or multiple (two cases) subcutaneous nodules/masses, with three patients accompanied by local lymph node enlargement. Four patients exhibited elevated eosinophil counts in their peripheral blood. Four patients had lesions with vascular flow voids; in three of these, the lesions also showed prominent enhancement. Notably, the lesion in a 5-year-old did not show vascular flow voids but displayed significant enhancement. Additionally, two patients showed edema around the lesions.

Conclusion

The presence of solitary or multiple subcutaneous nodules/masses in the upper arm or inguinal area, accompanied by lymph node enlargement, elevated eosinophils in the peripheral blood, and the observation of internal vascular within the lesion, can aid in the diagnosis of KD occurring in uncommon anatomical locations.

Kimura's disease: A clinicopathological study of 23 cases

Introduction

Kimura's disease (KD) is an uncommon lymphoproliferative fibroinflammatory disorder. Patients present with head and neck subcutaneous nodules with or without lymphadenopathy. Peripheral blood eosinophilia and elevated serum immunoglobulin E (IgE) levels are typical. This study was designed to delineate the clinicopathological features, pattern of care, and disease course of 23 Taiwanese patients with KD.

Methods

We retrospectively analyzed the clinical data of 23 consecutive cases (16 male and 7 female; age at diagnosis: 12-77 years) of KD diagnosed at our institution from 2015 to 2020.

Results

The median time from presentation to diagnosis was 1 month. Twenty-one patients presented with unilateral or bilateral head and neck masses. The remaining two presented with right flank and right arm lesions, respectively. Peripheral blood eosinophilia was observed in nine, and elevated IgE levels were observed in four. All were diagnosed using either excisional or core-needle biopsy. Seven patients underwent fine needle aspiration without a diagnostic yield. Salivary gland and lymph node involvement was observed in three and seven patients, respectively. Most lesions showed tissue eosinophilia (100%) and florid follicular hyperplasia (78.26%). Three cases had histological KD-IgG4-RD overlap and three had comorbid IgG4-RD were recognized. Thirteen patients underwent surgical resection, one received adjuvant therapy, and two received prednisolone monotherapy.

Conclusion

KD should be considered in patients with subcutaneous masses, eosinophilia, and elevated IgE levels. Biopsy remains the gold standard of diagnosis. Increased recruitment of IgG4⁺ plasma cells is a common feature. Consideration of IgG4-RD in all KD patients may be prudent.

Current concepts of Kimura disease: pathophysiology and evolution of treatment

Kimura disease (KD) is a chronic inflammatory disorder that frequently involves the subcutaneous tissue of the head and neck regions. It often manifests as regional lymphadenopathy or salivary gland enlargement in the affected area. The histologic architecture of the lymph nodes in KD patients is preserved, while the affected tissues show follicular hyperplasia and eosinophilic infiltration. No single modality has been adopted as an optimal treatment for KD. This article concentrates on the fundamental features of KD and reviews current approaches to its treatment.

Kimura's disease of the left arm

Kimura's disease is a rare, benign entity that causes subcutaneous angioblastic lymphoid hyperplasia with eosinophilia. It usually presents with subcutaneous lymphoid swellings with regional lymphadenopathy and salivary gland masses. Kimura's disease is frequently associated with renal involvement, which includes proteinuria and nephrotic syndrome as the most common presentations. This report presents a case of a man in his early 20s with a swelling in the medial aspect of the distal left arm with two previous episodes of nephrotic syndrome. Multiple enlarged axillary lymph nodes and epitrochlear nodes were noted. Ultrasonography revealed a mixed echogenic mass with enlarged lymph nodes. MRI showed a heterogeneous hyperintense lesion. Image-guided fine-needle aspiration showed multiple lymphocytes and eosinophils suggestive of Kimura's disease. The swelling was surgically excised under general anaesthesia. Histopathology of the excised mass confirmed the diagnosis of Kimura's disease.

Kimura's disease: effects of age on clinical presentation

BACKGROUND

Kimura's disease (KD) is known to be dominant among young Asian men, but it can also occur in middle- and advanced-aged people. The clinical characteristics of KD, especially by age, are not well known.

AIM

This study was performed to investigate the effects of age on the clinical characteristics of KD.

DESIGN

We conducted a case series study.

METHODS

All case studies of patients diagnosed with KD were collected via a PubMed search of studies published until August 2018. The data were analyzed by age group.

RESULTS

In total, 215 studies were reviewed (238 patients; mean age of 36 years). The male:female ratio was 4:1 overall, 17:1 in patients aged <20 years, 4:1 in patients aged 20-39 years and 2:1 in patients aged ≥40 years (P = 0.01). The percentage of patients with pruritus was 15.4% overall, 3.8% in patients aged <20 years, 15.5% in patients aged 20-39 years and 21.7% in patients aged ≥40 years (P = 0.02). The time to diagnosis was 5.3 years overall, 3.2 years in patients aged <20 years, 4.7 years in patients aged 20-39 years and 7.1 years in patients aged ≥40 years (P < 0.01).

CONCLUSIONS

The proportion of female patients affected the incidence of pruritus, and the time to diagnosis increased as the patients' age increased. There were no significant age-related differences in region/race, complications, multiplicity, laterality, anatomical distribution, maximum size, eosinophil count, immunoglobulin E level, initial treatment, recurrence or outcomes. This may be useful information for the diagnosis of KD.

Painless lymphadenopathy, eosinophilia and nephrotic syndrome: a diagnostic challenge in an era of increased migration

Kimura’s disease is a rare chronic inflammatory condition of unknown cause that most frequently affects Asian adults. It is characterized by painless lymphadenopathy in the head and neck region and eosinophilia, often associated with nephrotic syndrome. Α young Asian male presented to our Department with œdema at the lower limbs and scrotum, retroauricular masses, eosinophilia and proteinuria. Diagnosis was reached by a combination of the clinical picture, the patient’s origin and a histological examination, which revealed well-developed lymph follicles with increased numbers of eosinophils and fibrosis, a finding typical of Kimura’s disease. In case of a young Asian male who is otherwise healthy, but presents head/neck masses and/or unexplained eosinophilia associated with nephrotic syndrome, consider Kimura’s disease in the differential diagnosis.

Kimura's Disease without Peripheral Eosinophilia: An Unusual and Challenging Case Simulating Venous Malformation on Imaging Studies-Case Report and Review of literature

Kimura's Disease (KD) is a rare chronic inflammatory disorder presenting as multiple painless solitary subcutaneous nodules, predominantly in the head and neck region and frequently associated with regional lymphadenopathy and/or salivary gland involvement. Because of painless nature and indolent course, there is usually a delay in the patient's presentation. KD may radiologically mimic other chronic inflammatory conditions like tuberculosis, vascular malformations and neoplasms. Clinical correlation and histological evaluation along with elevated peripheral eosinophil and serum IgE level are considered important for confirmatory diagnosis. We report a case of painless swelling over right submandibular region extending to the right superficial parotid. The haematological reports were within normal limits. Ultrasound (USG), Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) favoured a diagnosis of venous malformation. However, histopathological examination of excised lesion confirmed a diagnosis of KD. This case proves the possibility of the KD even in the absence of peripheral eosinophilia and/ or elevated serum IgE level, and may mimic venous malformation on imaging studies. Therefore, KD must find a place in the differentials of solitary painless neck swelling even in the absence of peripheral eosinophilia and/or elevated IgE level.

Panniculitis: A summary

The diagnosis of panniculitis is felt to be a confusing topic by some pathologists. This summarical article presents inflammatory diseases of the subcutis in a systematic fashion, based on whether they are centered on fibrovascular septa or the adipose lobules, and whether morphologic vasculitis is present or not. Septocentric, non-vasculitis disorders include erythema nodosum, panniculitis that follows the use of "biological" therapeutic agents, lipodermatosclerosis, post-irradiation panniculitis, morphea profunda, and necrobiosis lipodica profunda. Polyarteritis nodosa and Behçet's disease are the conditions that are based in the subcutaneous septa with vasculitis. Predominantly-lobular panniculitides with no vasculitis include pancreatogenic panniculitis, the panniculitis of alpha-1-antitrypsin deficiency, panniculitis associated with lupus erythematosus and dermatomyositis, subcutaneous Sweet syndrome, eosinophilic panniculitis, factitial panniculitis, cold panniculitis, panniculitis following injections of corticosteroids, lipomembranous (ischemic) panniculitis; sclerema neonatorum and subcutaneous fat necrosis of the newborn, and Rosai-Dorfman disease of the subcutis. Erythema induratum and infectious panniculitis are vasculitic and lobulocentric conditions. This article reviews the histological features of these diseases.

Eosinophilia and multiple lymphadenopathy: Kimura disease, a rare, but benign condition

Kimura disease is a benign rare chronic inflammatory disorder of unknown aetiology. This disease is mainly endemic in Asia, although cases have also been reported in Europe and America. We describe a case in a 34-year-old Chinese man presenting with severe eosinophilia and multiple lymphadenopathy. Since our initial aim was to rule out the diagnosis of lymphoma, and given the limitations of our laboratory, we decided to perform an excision of one of the cervical lymph nodes. The histological diagnosis was consistent with Kimura disease. We review the epidemiology, the aetiology and clinical features of this entity.

Pulmonary embolism as the initial clinical presentation of Kimura disease: case report and literature review

Pulmonary embolism is clinically critical in that if misdiagnosed or delayed, the mortality is very high. The recognition of its risk factor or underlying disease is important for prevention of recurrence. Kimura disease is a rare, chronic inflammatory disease, which is seldom associated with thrombosis. We reported a 47-year-old male case presenting with pleural pain and dyspnoea and was found to have pulmonary embolism. After successful management of pulmonary embolism, he was noticed to have eosinophilia and lymphadenopathy. Pathologic examination of a resected lymph node has confirmed the diagnosis of Kimura disease. The patient was treated with corticosteroid and cyclosporine A, with a significant improvement of the symptoms and signs of Kimura disease and no recurrence of any thromboembolism. Associated literatures were reviewed to explore the pathogenesis underlying the thrombotic event in Kimura disease cases. It is suggested that hypereosinophilia may play a key role in thrombosis formation. The control of hypereosinophilia may contribute to the prevention of thrombosis and its recurrence in patients with Kimura disease.

An Overlap of Angiolymphoid Hyperplasia with Eosinophilia and Kimura's Disease: Successful Treatment of Skin Lesions with Cryotherapy

Kimura's disease is characterized by a triad of painless subcutaneous masses, eosinophilia in the peripheral blood and in tissues with marked increase in Serum Ig E. Angiolymphoid hyperplasia with eosinophilia (ALHE) manifests with the presence of dermal papules and nodules. Unique clinical, histopathological, and biochemical findings are noted in these individual entities. A 32-year-female presented with multiple nodules in the axillae for 2 years. Peripheral smear showed eosinophilia with AEC of 6080. Histopathological examination showed features of overlap. Antinuclear antibody immunoflorescence was was negative. CD31, CD34, and FVIII were positive in vascular component. A CT chest revealed left axillary lymphadenopathy. The patient was treated with Cryotherapy and there was complete regression of skin lesions, with no recurrence after 1 year of follow-up. ALHE and KD are common in the head and neck region, but no reports of an overlap, presenting with lesions in the axillae are available to date, to the best of our knowledge. Response of skin lesions to cryotherapy is highlighted.

Eosinophilic panniculitis in a female child: An unusual presentation

Eosinophilic panniculitis (EP) is characterized by prominent infiltration of subcutaneous fat with eosinophils. The etiology is diverse. This is not a disease but represents a reaction pattern that may occur in a variety of circumstances. The exact pathogenesis of the disease is still unclear. We present the case of a 6-year-old girl child who was diagnosed with EP.