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Qin W, Yang S, Zhang L, Liu M, Tian J, Yang J, Zhou G, Rong X. Kikuchi-Fujimoto disease evolves into lupus encephalopathy characterized by venous sinus thrombosis: a case report. Front Immunol 2024; 15:1389993. [PMID: 38665917 PMCID: PMC11043565 DOI: 10.3389/fimmu.2024.1389993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Kikuchi-Fujimoto disease (KFD) is a benign, self-limiting illness that can progress to systemic lupus erythematosus (SLE) in approximately 30% of cases. Neurological injuries can occur in both diseases, albeit with distinct presentations. Venous sinus thrombosis is a serious cerebrovascular complication in patients with neuropsychiatric SLE but is rarely observed in patients with KFD. The involvement of various antibodies, particularly antiphospholipid antibodies, can cause vascular endothelial cell injury, resulting in focal cerebral ischemia and intracranial vascular embolism in SLE. However, there are cases in which thrombotic pathology occurs without antiphospholipid antibody positivity, attributed to vascular lesions. In this report, we present a case of KFD and lupus encephalopathy featuring cerebral venous sinus thrombosis, despite the patient being negative for antiphospholipid antibody. We also conducted a comparative analysis of C3 and C4 levels in cerebrospinal fluid (CSF) and peripheral blood, along with the protein ratio in CSF and serum, to elucidate the pathological changes and characteristics of lupus encephalopathy.
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Affiliation(s)
- Wenyi Qin
- Department of Rheumatology and Immunology/Department of Integrated Traditional Chinese and Western Medicine. The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuangshuang Yang
- Department of Laboratory, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lijuan Zhang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mengqi Liu
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayu Tian
- Department of Rheumatology and Immunology/Department of Integrated Traditional Chinese and Western Medicine. The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juan Yang
- Department of Rheumatology and Immunology/Department of Integrated Traditional Chinese and Western Medicine. The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guoqing Zhou
- Department of Rheumatology and Immunology/Department of Integrated Traditional Chinese and Western Medicine. The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaofeng Rong
- Department of Rheumatology and Immunology/Department of Integrated Traditional Chinese and Western Medicine. The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Silverman ED. The History of Macrophage Activation Syndrome in Autoimmune Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:21-31. [PMID: 39117805 DOI: 10.1007/978-3-031-59815-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
In 1979, it became recognized in the literature that what we call hemophagocytic lymphohistiocytosis (HLH) was a nonmalignant disease of histiocytes. Subsequently a familial form and a secondary form of HLH were differentiated. When HLH is secondary to an autoimmune disease, rheumatologists refer to this entity as macrophage activation syndrome (MAS) to differentiate it from HLH itself. Although the first cases of MAS likely appeared in the literature in the 1970s, it was not until 1985 that the term activated macrophages was used to describe patients with systemic juvenile idiopathic arthritis (sJIA) complicated by MAS and the term macrophage activation syndrome first appeared in the title of a paper in 1993.MAS is one of the many types of secondary HLH and should not be confused with primary HLH. Experience has taught that MAS secondary to different autoimmune diseases is not equal. In the 30 years since initial description in patients with sJIA, the clinical spectrum, diseases associated with MAS, therapy, and understanding the pathogenesis have all made significant gains. The diagnostic/classification criteria for MAS secondary to sJIA, SLE, RA, and KD differ based on the different laboratory abnormalities associated with each (Ahn et al., J Rheumatol 44:996-1003, 2017; Han et al., Ann Rheum Dis 75:e44, 2016; Ravelli et al., Ann Rheum Dis 75:481-489, 2016; Borgia et al., Arthritis Rheumatol 70:616-624, 2018). These examples include the thrombocytosis associated with sJIA, a chronic generalized activation of the immune system, leading to elevations of fibrinogen and sIL-2R, low platelet count associated with SLE, and more acute inflammation associated with KD. Therefore, individual diagnostic criteria are required, and they all differ from the diagnostic criteria for HLH, which are based on a previously non-activated immune system (Ahn et al., J Rheumatol 44:996-1003, 2017; Han et al., Ann Rheum Dis 75:e44, 2016; Ravelli et al., Ann Rheum Dis 75:481-489, 2016; Borgia et al., Arthritis Rheumatol 70:616-624, 2018; Henter et al., Pediatr Blood Cancer 48:124-131, 2007). This helps to explain why the HLH diagnostic criteria do not perform well in MAS.The initial treatment remains high-dose steroids and IVIG followed by the use of a calcineurin inhibitor for resistant cases. IVIG can be used if there is a concern about malignancy to wait for appropriate investigations or with steroids. Interluekin-1 inhibition is now the next therapy if there is a failure to respond to steroids and calcineurin inhibitors. Advances in understanding the mechanisms leading to MAS, which has been greatly aided by the use of mouse models of MAS and advances in genome sequencing, offer a bright future for more specific therapies. More recent therapies are directed to specific cytokines involved in the pathogenesis of MAS and can lead to decreases in the morbidity and mortality associated with MAS. These include therapies directed to inhibiting the JAK/STAT pathway and/or specific cytokines, interleukin-18 and gamma interferon, which are currently being studied in MAS. These more specific therapies may obviate the need for nonspecific immunosuppressive therapies including high-dose prolonged steroids, calcineurin inhibitors, and etoposide.
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Affiliation(s)
- Earl D Silverman
- Hospital for Sick Children (SickKids), University of Toronto, Toronto, ON, Canada.
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Arya P V A, Alam MM, Bernhisel A, Degirolamo A, Huang R. Diagnostic Dilemma in a Case of Necrotizing Lymphadenitis With Macrophage Activation Syndrome. Cureus 2023; 15:e42267. [PMID: 37605695 PMCID: PMC10440125 DOI: 10.7759/cureus.42267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/23/2023] Open
Abstract
Necrotizing lymphadenitis is a histological diagnosis that can arise from various conditions, including lupus lymphadenitis (LL), Kikuchi disease (KD), and infectious causes. Distinguishing between Kikuchi disease and lupus lymphadenitis can be challenging in clinical practice. In this report, we present the clinical scenario of a young female patient with lymphadenopathy and elucidate the process through which we ultimately arrived at a diagnosis of systemic lupus erythematosus (SLE) with macrophage activation syndrome. This case underscores the significance of recognizing Kikuchi disease as a condition that can mimic lupus and sheds light on the distinguishing features of necrotizing lymphadenitis, with a particular focus on Kikuchi disease and lupus lymphadenitis.
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Affiliation(s)
| | - Md Mashiul Alam
- Cardiovascular Disease, Mayo Clinic, Rochester, USA
- Internal Medicine, Bridgeport Hospital, Bridgeport, USA
| | - Andrew Bernhisel
- Pathology, Yale School of Medicine, Yale University, New Haven, USA
| | | | - Rex Huang
- Rheumatology, Yale University, New Haven, USA
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Mahajan VK, Sharma V, Sharma N, Rani R. Kikuchi-Fujimoto disease: A comprehensive review. World J Clin Cases 2023; 11:3664-3679. [PMID: 37383134 PMCID: PMC10294163 DOI: 10.12998/wjcc.v11.i16.3664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/29/2023] [Accepted: 04/27/2023] [Indexed: 06/02/2023] Open
Abstract
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.
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Affiliation(s)
- Vikram K Mahajan
- Department of Dermatology, Venereology and Leprosy, Dr. Radhakrishnan Government Medical College, Hamirpur 177001, Himachal Pradesh, India
| | - Vikas Sharma
- Department of Dermatology, Venereology and Leprosy, Dr. Radhakrishnan Government Medical College, Hamirpur 177001, Himachal Pradesh, India
| | - Neeraj Sharma
- Department of Dermatology, Venereology and Leprosy, Dr. Radhakrishnan Government Medical College, Hamirpur 177001, Himachal Pradesh, India
| | - Ritu Rani
- Department of Dermatology, Venereology and Leprosy, Dr. Radhakrishnan Government Medical College, Hamirpur 177001, Himachal Pradesh, India
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Scarcella A, Marrani E, Coniglio ML, Simonini G, Sieni E. Kikuchi-Fujimoto disease complicated with hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2023; 70:e30222. [PMID: 36715142 DOI: 10.1002/pbc.30222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Antonio Scarcella
- Pediatric Residency, IRCCS Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, ERN ReCONNET Center, IRCCS Meyer Children's University Hospital, Florence, Italy
| | - Maria Luisa Coniglio
- Department of Paediatric Oncohematology, IRCCS Meyer Children's University Hospital, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, ERN ReCONNET Center, IRCCS Meyer Children's University Hospital, NEUROFARBA Department, University of Florence, Florence, Italy
| | - Elena Sieni
- Department of Paediatric Oncohematology, IRCCS Meyer Children's University Hospital, Florence, Italy
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Shen Z, Ling J, Zhu X, Yang J, He T. Macrophage activation syndrome in children with Kikuchi-Fujimoto disease. Pediatr Rheumatol Online J 2023; 21:10. [PMID: 36698152 PMCID: PMC9875483 DOI: 10.1186/s12969-023-00788-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/11/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Kikuchi-Fujimoto disease (KFD) is typically a benign, self-limiting inflammatory disease. However, some patients may have a prolonged or recurrent disease course, or present with life-threatening complications such as macrophage activation syndrome (MAS). In this study, we aimed to describe the incidence and clinical features of MAS in KFD and to access potential laboratory markers for the diagnosis of KFD-associated MAS. METHODS Patients with KFD were retrospectively enrolled from January 2015 to November 2021 at Shenzhen Children's Hospital. Clinical data were collected from inpatient or outpatient medical records. Data collected included clinical manifestations, laboratory and imaging findings, treatment, and clinical outcomes. Data were analyzed using GraphPad Prism 8.0 statistical software (GraphPad Software Inc., La Jolla, CA, USA). A receiver operating characteristic (ROC) curve analysis was further performed to access the potential predictors for the KFD-MAS diagnosis. RESULTS Of 58 patients with a histological diagnosis of KFD, 15 (25.9%) patients had MAS. Compared to patients without MAS, patients with KFD-MAS presented with a higher proportion of skin rash (26.7%, p = 0.01), glucocorticoid treatment (80%, p = 0.003), and disease recurrence (33.3%, p = 0.04). KFD-MAS patients had lower absolute peripheral white blood cell (WBC, p = 0.02), platelet (p = 0.002), serum albumin levels (p = 0.01), and lymphocyte count (p < 0.0001), and higher lactate dehydrogenase (LDH) levels (p < 0.0001). ROC curve analysis showed that the cutoff values of absolute lymphocyte count, an absolute platelet count, serum albumin level, and serum LDH level for KFD-MAS diagnosis were < 1235/μL, < 171 × 106/μL, < 35.6 g/L, and > 679 IU/mL, respectively. CONCLUSIONS The presence of KFD-MAS in children may be more common than previously expected, especially in those with skin rash. KFD-MAS may be associated with a higher recurrence rate. An extremely elevated serum LDH level and moderate to severe lymphopenia may be useful diagnostic markers for MAS in KFD. TRIAL REGISTRATION Not applicable; this was a retrospective study.
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Affiliation(s)
- Zixuan Shen
- grid.452787.b0000 0004 1806 5224Department of Rheumatology and Immunology, Shenzhen Children’s Hospital, 7019 Yitian Road, Shenzhen, 518038 China
| | - Jiayun Ling
- grid.452787.b0000 0004 1806 5224Department of Rheumatology and Immunology, Shenzhen Children’s Hospital, 7019 Yitian Road, Shenzhen, 518038 China
| | - Xiaona Zhu
- grid.452787.b0000 0004 1806 5224Department of Rheumatology and Immunology, Shenzhen Children’s Hospital, 7019 Yitian Road, Shenzhen, 518038 China
| | - Jun Yang
- grid.452787.b0000 0004 1806 5224Department of Rheumatology and Immunology, Shenzhen Children’s Hospital, 7019 Yitian Road, Shenzhen, 518038 China
| | - Tingyan He
- Department of Rheumatology and Immunology, Shenzhen Children's Hospital, 7019 Yitian Road, Shenzhen, 518038, China.
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Muacevic A, Adler JR, Duarte V, Baptista L, Jesus G. Relapsing Kikuchi-Fujimoto Disease With Hemophagocytic Lymphohistiocytosis. Cureus 2022; 14:e32344. [PMID: 36632255 PMCID: PMC9827933 DOI: 10.7759/cureus.32344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2022] [Indexed: 12/13/2022] Open
Abstract
Kikuchi-Fujimoto disease is a rare, benign, and self-limited disease of uncertain etiology, affecting mostly young female patients. It usually manifests as posterior cervical lymphadenopathy and fever. Its diagnosis is based on typical histopathological changes after the exclusion of other diseases such as lupus, lymphoma, or infectious lymphadenitis. The authors present a 47-year-old female patient with recurring episodes of high fever, urticarial rash, myalgia, arthralgia, fatigue, sore throat, and generalized lymphadenopathy. Blood tests showed increased inflammatory parameters and positive antinuclear antibodies. In the two times the patient was admitted to the hospital there were no infectious agents isolated. The patient didn't fulfill the criteria for diagnosis of lupus or any other autoimmune disease and there was also no evidence of lymphoma or other neoplastic diseases. A positron emission tomography/computed tomography (PET/CT) was performed at the first and second hospitalizations, showing generalized lymphadenopathy. At the first hospitalization, a mediastinal lymph node biopsy was obtained, excluding lymphoproliferative or granulomatous disease. During the course of the second hospitalization, a cervical lymph node was excised for biopsy, the histopathological changes of which suggested the diagnosis of Kikuchi-Fujimoto disease. The clinical course was complicated by hemophagocytic lymphohistiocytosis, with a significant increase in inflammatory markers and liver dysfunction. The patient was treated with prednisolone 1 mg/kg/day, with complete resolution of clinical and biochemical changes.
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