Catastrophic antiphospholipid syndrome and Kikuchi-Fujimoto disease: the first case reported

Kikuchi-Fujimoto Disease in a 25-Year-Old Female: A Case Report

BACKGROUND

Kikuchi-Fujimoto disease or histiocytic necrotizing lymphadenitis is a rare benign disease that presents as cervical lymphadenopathy and fever.

CASE PRESENTATION

A 25-year-old South Asian female dentist, recently married, presented to our emergency department due to two weeks of fever, sore throat, swollen neck, and cough. The patient initially presented to a private clinic and was prescribed antibiotics on two visits. On physical examination, her neck was swollen with palpable and tender right posterior and submandibular lymph nodes. Oropharyngeal examination revealed pharyngeal hyperemia without tonsillar enlargement, exudates, or mucocutaneous ulcers. Ultrasound imaging revealed enlarged neck and thoracic and abdominal lymph nodes. CBC showed leukopenia and anemia of chronic disease. B2 microglobulin, lactate dehydrogenase, and kappa light chains were elevated. Anti-ANA, anti-dsDNA, HIV polymerase chain reaction (PCR), Quantiferon-tuberculosis (TB), and rapid plasma reagin were all negative. A lymph node biopsy confirmed the diagnosis of Kikuchi-Fujimoto disease.

CONCLUSION

We believe this is the second case to be reported in the United Arab Emirates (UAE). Kikuchi-Fujimoto disease has a non-specific presentation that overlaps with several conditions including autoimmune, infectious, and malignant. Therefore, a thorough clinical approach and a high grade of clinical suspicion is required to rule out other possible differential diagnosis. Finally, Although Kikuchi-Fujimoto disease is mostly benign, clinicians should be careful as some patients might develop systemic lupus erythematosus (SLE), Still disease, or B cell lymphoma in the future.

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.

Multisystem Inflammatory Syndrome in Adults Accompanied with Kikuchi-Fujimoto Disease

We herein report a case of multisystem inflammatory syndrome in adults (MIS-A) complicated with Kikuchi-Fujimoto disease (KFD). A previously healthy 41-year-old man presented with painful swelling of the cervical lymph nodes, fever, diarrhea, conjunctivitis, edema, and hypotension one month after the onset of asymptomatic coronavirus disease 2019. Laboratory investigations revealed an elevation of CRP, and echocardiography indicated diastolic dysfunction. We diagnosed the patient to have MIS-A. Histopathology of the lymph nodes showed necrotizing lymphadenitis. After the initiation of hydrocortisone and diuretics, his symptoms resolved immediately. This case suggested that post-viral immune dysregulation in MIS-A could play a role in the etiology of KFD.

Kikuchi-Fujimoto Disease Complicated by Rheumatoid Arthritis, Type 1 Diabetes Mellitus, and Hypothyroidism

Kikuchi-Fujimoto disease (KFD) is a rare, benign, self-limited syndrome characterized by tender lymphadenopathy and low-grade fever. It may also present with rash, arthritis, fatigue, and splenomegaly. Data on the disease is limited, and its etiology remains largely unknown.

Here, we present the case of a 30-year-old female with a medical history of rheumatoid arthritis (RA), previously treated with etanercept, type 1 diabetes mellitus (DM-1), and Hashimoto’s hypothyroidism; she was brought in to an emergency department (ED) in Houston after a generalized tonic-clonic seizure and loss of consciousness. She was hypoglycemic, which was thought to have caused her DM-1 and seizure. CT scan of her chest showed multiple enlarged lymph nodes throughout the neck, superior mediastinum, and axilla, along with interstitial edema and bilateral pleural effusions. She was treated with dextrose drip and regained her consciousness. However, she had persistent pancytopenia, low-grade fever, and tender axillary lymphadenopathy. Infectious workup for tuberculosis (TB), human immunodeficiency virus (HIV), herpes simplex virus (HSV), Epstein-Barr virus (EBV), and parvovirus B-19 were negative. Her bone marrow biopsy revealed iron-deficiency anemia, while excisional axillary lymph node biopsy showed extensive necrosis consistent with KFD. She was treated with supportive care. Her neutrophilic fever resolved, and she was discharged home after 48-hours of remaining afebrile. Six months after her hospitalization, the patient remained well, and her complete blood count showed no abnormalities.

Due to the non-specific clinical features and laboratory findings of KFD, it is commonly misdiagnosed as infectious, autoimmune, or malignant lymphadenitis, leading to excessive diagnostic tests and unnecessary treatments. Physicians need to be cognizant of KFD and consider it in young patients presenting with tender lymphadenopathy, low-grade fevers, and leukopenia. To our best knowledge, this is the first reported case of a patient with concurrent RA, Hashimoto’s hypothyroidism, and KFD. This report elucidates the autoimmune nature of KFD and its association with other autoimmune diseases.

Systematic review of case reports of antiphospholipid syndrome following infection

OBJECTIVE

The objective of this study was to conduct a systematic review of case reports documenting the development of antiphospholipid syndrome or antiphospholipid syndrome-related features after an infection.

METHODS

We searched Medline, EMBASE, Web of Science, PubMed ePubs, and The Cochrane Library - CENTRAL through March 2015 without restrictions. Studies reporting cases of antiphospholipid syndrome or antiphospholipid syndrome-related features following an infection were included.

RESULTS

Two hundred and fifty-nine publications met inclusion criteria, reporting on 293 cases. Three different groups of patients were identified; group 1 included patients who fulfilled the criteria for definitive antiphospholipid syndrome (24.6%), group 2 included patients who developed transient antiphospholipid antibodies with thromboembolic phenomena (43.7%), and group 3 included patients who developed transient antiphospholipid antibodies without thromboembolic events (31.7%). The most common preceding infection was viral (55.6%). In cases that developed thromboembolic events Human immunodeficiency and Hepatitis C viruses were the most frequently reported. Parvovirus B19 was the most common in cases that developed antibodies without thromboembolic events. Hematological manifestations and peripheral thrombosis were the most common clinical manifestations. Positive anticardiolipin antibodies were the most frequent antibodies reported, primarily coexisting IgG and IgM isotypes. Few patients in groups 1 and 2 had persistent antiphospholipid antibodies for more than 6 months. Outcome was variable with some cases reporting persistent antiphospholipid syndrome features and others achieving complete resolution of clinical events.

CONCLUSIONS

Development of antiphospholipid antibodies with all traditional manifestations of antiphospholipid syndrome were observed after variety of infections, most frequently after chronic viral infections with Human immunodeficiency and Hepatitis C. The causal relationship between infection and antiphospholipid syndrome cannot be established, but the possible contribution of various infections in the pathogenesis of antiphospholipid syndrome need further longitudinal and controlled studies to establish the incidence, and better quantify the risk and the outcomes of antiphospholipid-related events after infection.

Cytomegalovirus-induced cutaneous microangiopathy manifesting as lower limb ischemia in a human immunodeficiency virus-infected patient

Cutaneous infections by cytomegalovirus (CMV) are rare and often difficult to diagnose both clinically and histopathologically. A wide range of different clinical manifestations have been described in the literature, especially in immunosuppressed patients. CMV-induced thrombosis has also been reported in these patients, and various mechanisms have been proposed to explain the role of CMV in the thrombotic process, including direct damage of the endothelial cells, activation of coagulation factors and inducing the production of antiphospholipid antibodies. We present the case of a human immunodeficiency virus (HIV)-infected woman who developed distal ischemic lesions of the lower extremities during a generalized CMV infection. We discuss the role of CMV and antiphospholipid antibodies in the pathogenesis of thrombosis in immunosuppressed patients.

[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.

Kikuchi's lymphadenopathy: a relatively rare but important cause of lymphadenopathy in Greece, potentially associated with the antiphospholipid syndrome

Kikuchi-Fujimoto disease is a form of reactive lymphadenopathy, which was firstly described in Japan, but is uncommon in the Western world. We retrospectively reviewed the medical records of nine cases of adult or adolescent Kikuchi's disease diagnosed in a single Haematology Unit in Athens, Greece between 1990 and 2006. The median age of the patients was 25 years (14-40) and 8/9 were females. All patients presented with cervical lymphadenopathy sparing the supraclavicular fossa; one had associated axillary lymphadenopathy, seven had fever and two were asymptomatic. The median duration of lymphadenopathy before presentation was 30 days (10-45). Just palpable splenomegaly was recorded in three patients. The median value of the maximal lymph node diameter was 2 cm (1-5) and only 1/9 had nodes >2 cm in their largest diameter. Lymphadenopathy was tender in two patients; hard nodes were observed in three patients. The median leukocyte count was 4.7 x 10(9)/l (2.2-4.9) with a normal differential in 7/9 patients. No infectious agent could be demonstrated. One patient had clinical and laboratory evidence of primary antiphospholipid syndrome (APLS). In conclusion, Kikuchi's disease represents a rare but important diagnostic possibility for patients presenting with lymphadenopathy in Greece and other western countries. In this setting, autoimmune disorders, mainly lupus and APLS, should be considered and excluded by the appropriate laboratory work-up.

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.

Therapeutic and prognostic considerations in catastrophic antiphospholipid syndrome

Catastrophic antiphospholipid syndrome (CAPS) is a rapidly progressive life-threatening disease that causes multiple organ thromboses in the presence of antiphospholipid antibodies. High index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation, corticosteroids, and plasma exchange or intravenous immunoglobulins can be initiated. Despite this multi-modal treatment, CAPS is associated with high mortality; evidence-based management recommendations do not exist due to the rarity of the condition and the lack of controlled studies. This article reviews the therapeutic and prognostic controversies that were addressed during the 1st International Symposium on CAPS.