Tissue-infiltrating immune cells contribute to understanding the pathogenesis of Kimura disease: A case report

RATIONALE

Kimura disease (KD) is a rare, chronic inflammatory disorder characterized by subcutaneous granuloma in the head and neck region, as well as increased eosinophil counts and high serum immunoglobulin E (IgE) levels. Kimura disease is suspected to be an IgE-mediated disease, associated with an allergic response, in which antigen-specific B cells are stimulated to undergo specific IgE class switching with disease-specific CD4+ T (Th) cells help. Thus, exploration of the Th cells in affected tissues with KD is a highly promising field of the investigation. However, there have been no reports with direct evidence to implicate Th cells in affected lesions with KD. Here we quantitatively demonstrate that CD4+ GATA3+ T cells and interleukin (IL)-4+ IgE+ c-kit+ mast cells prominently infiltrate in affected lesion with KD.

PATIENT CONCERNS

A 56-year-old Japanese man who exhibited painless swelling in the left parotid region.

DIAGNOSES

Diagnosis of KD was made based on characteristic histopathologic findings, in conjunction with peripheral eosinophilia and elevated serum IgE levels.

INTERVENTIONS

The patient underwent corticosteroid therapy and had been followed for 2 years.

OUTCOMES

We report a rare case of KD of the parotid region in a 56-year-old man, followed by corticosteroid therapy for 2 years. The mass decreased in size and skin itchiness decreased after therapy. He was discharged without any complications. Furthermore, we quantitatively demonstrate the dominance of CD4+ GATA3+ T cells in affected tissues of KD and detect IL-4+ IgE+ c-kit+ mast cells in lesions by multicolor staining approaches.

LESSONS

The findings from this case suggest that peripheral blood eosinophilia might serve as a marker of recurrent disease, long-term follow-up is necessary due to the possibility of recurrent. Interactions among expanded IgE+ B cells, CD4+ GATA3+ T cells, eosinophils, and activated mast cells might play a critical role in the pathogenesis of KD.

Increase of Th2 and Tc1 cells in patients with Kimura's disease

OBJECTIVE

A Th1/Th2 cytokine imbalance with a predominance of Th2 cytokines has been suggested to be of pathogenic importance in Kimura's disease.

METHODS

To evaluate the role of Th1/Th2 cytokines in Kimura's disease, the subsets of Th1, Th2, Tc1 and Tc2 cells from patients with Kimura's disease were examined by intracellular cytokine flow cytometry. The expressions of IL-5, eotaxin and RANTES in the lesions were investigated by RT-PCR.

RESULTS

The population of Th2 and Tc1 cells in Kimura's disease was significantly increased compared with these cells in control (p<0.05). Th1 and Tc2 cells in Kimura's disease were not significantly increased compared with control subjects. The titers of IgE and the number of Th2 cells were correlated. The expression of IL-5 and RANES was observed in the lesions of patients with Kimura's disease.

CONCLUSION

These results indicate that the predominance of Th2 and Tc1 cells might contribute to the mechanism in pathogenesis of Kimura's disease.

Angiolymphoid hyperplasia with eosinophilia successfully treated with oral steroids

Angiolymphoid hyperplasia with eosinophilia is a rare benign vascular lesion most commonly affecting the head and neck region. This article reports a case of a 26-year-old white woman with rapidly enlarging nodules of the upper lip and cheek treated successfully with oral corticosteroids and cetirizine. Morbidity and cosmetic deformity associated with radical surgery to the face and possible consequences of radiation treatment were avoided. There were no long-term complications.

Kimura’s Disease with Marked Proliferation of HLA-DR+CD4+ T Cells in the Skin, Lymph Node and Peripheral Blood

A 41-year-old female had atopic dermatitis-like skin lesions since the age of 21, and for the past 6 years many skin tumors developed on the body, lower extremities and other areas. The histological picture of the tumor, eosinophilia and high IgE in the peripheral blood were consistent with a diagnosis of Kimura's disease. Although the tumors were markedly reduced by oral prednisolone administration, thereafter papules appeared disseminated over the body with swelling of superficial lymph nodes. Immunohistochemical examination indicated marked proliferation of HLA-DR+CD4+ T cells in the skin and lymph nodes, and two-color flow cytometry confirmed it in the lymph nodes and peripheral blood.

Serum concentrations of eosinophil cationic protein and eosinophils of patients with Kimura's disease

BACKGROUND

To clarify the role of eosinophils in the pathogenesis of Kimura's disease and the values of measuring serum levels of eosinophil cationic protein (ECP) for monitoring disease activity might be very important, but there are few reports about this matter.

METHODS

A total 14 serum and 7 tissue samples from patients with Kimura's disease were studied. The concentrations of ECP and cytokines (interleukin-4 (IL-4), granulocyte-macrophage colony-stimulating factor (GM-CSF), and interleukin 5 (IL-5)) in sera from patients with Kimura's disease were measured by enzyme-linked immunosorbent assay (ELISA). The density of eosinophils and the degree of activation of eosinophils in the tissue were also studied immunohistochemically.

RESULTS

The concentration of ECP in sera from patients with Kimura's disease was significantly higher than that in the control group (p<0.05). At the time of the remission, a significant decrease of ECP was observed. In interfollicular areas, most infiltrated eosinophils were positive for EG2 antibody (64.0-94.0%) and the mean percentage of EG2-positive eosinophils was 75.7%. The concentrations of IL-4, GM-CSF, and IL-5 in sera from patients with Kimura's disease were within normal ranges or below the detectable level in all sera examined.

CONCLUSIONS

Our findings suggest that eosinophils play an important role in the pathogenesis of Kimura's disease and ECP may be used as an additional parameter of disease activity.

Angiolymphoid hyperplasia with eosinophilia (epithelioid haemangioma) occurring within multiple deep lymph nodes and presenting with weight loss and raised CA-125 levels

We report a case of angiolymphoid hyperplasia with eosinophilia (epithelioid haemangioma) involving multiple deep mediastinal, abdominal and intramammary lymph nodes in a 52-year-old woman with weight loss and raised CA-125 levels. The unusual clinical presentation with raised CA-125 levels and its occurrence within multiple deep visceral lymph nodes has never been reported in literature.

Kimura's disease: a diagnostic and therapeutic challenge

INTRODUCTION

Kimura's disease (KD) is a rare, benign, chronic inflammatory disease with unknown aetiology. Its manifestation is protean. KD has a predilection for the head and neck area, and typically presents as tumour-like lesions that could be easily misdiagnosed. We review our experience with four recent cases.

METHODS

Over a four-year period, all patients admitted to Singapore General Hospital with KD of the head and neck region were retrospectively reviewed. Biodata, presenting symptoms and clinical parameters, especially serum eosinophil levels, preoperative investigations, type of surgical procedures and outcome were documented.

RESULTS

Four patients presented with KD of the head and neck and displayed varied manifestations of the disease. All the patients had raised serum eosinophil levels. None of them had renal involvement. Preoperative computed tomography were performed in two of the patients and showed features suggestive of KD. Fine-needle aspiration cytology that was performed in two patients was not useful in the diagnosis. All the patients underwent surgical excision of the lesions. Only one patient had multiple recurrence, both at the original and remote sites in the head and neck.

CONCLUSION

The clinical presentation and behaviour of KD is very variable. Preoperative imaging is useful in the diagnosis of the disease but the final diagnosis is histological. Surgical excision is the current treatment of choice but recurrence is common. A high index of suspicion and awareness is vital in the early diagnosis and management of KD.

Kimura's disease in the parotid and submandibular regions: two case reports

Two male patients (aged 13 and 50 years) who presented with a complaint of painless mass in the parotid and submandibular regions, respectively, were found to have eosinophilia and increased blood immunoglobulin E (IgE) levels. Following ultrasonographic examination of the masses, surgical excision was performed. Histopathologic evaluation revealed massive lymphocytic and eosinophilic infiltration. Histopathologic findings and the presence of peripheral eosinophilia and high IgE levels led to a diagnosis of Kimura's disease. Postoperatively, no recurrences were detected within a year follow-up.

[Kimura's disease on the hard palate in a patient from Martinique]

INTRODUCTION

We report an observation of Kimura's disease (angiolymphoid hyperplasia with eosinophilia) in a Black patient from West Indies, in a rare localisation on hard palate.

EXEGESIS

A 46-year-old male patient from French West Indies (Martinique) presented with a tumor of hard palate evolving from 2 years with locoregional lymph nodes. He had a history of chronic urticaria, prurigo, rhinitis and alopecia areata. Pathological examination of the tumor was consistent with the diagnosis of Kimura's disease. Blood tests showed hypereosinophilia, elevation of IgG and IgE. The serology of Toxocara canis with Western blott was positive. Corticosteroid therapy (0.7 mg/kg/d) and albendazole (800 mg/d) allowed regression of the tumor, lymph nodes, and urticaria. The remaining tumor was surgically excised.

CONCLUSION

Kimura's disease was first described in Japanese young men, between 20 and 40 years old, with subcutaneous nodules on head and neck area. Involvement of oral mucosa is rare, and the occurence in West Indian patients has been rarely reported.

Widespread cutaneous vascular papules associated with peripheral blood eosinophilia and prominent inguinal lymphadenopathy

A new section entitled "Dermatology Grand Rounds at the NIH" appears this month. The idea behind it is to provide a unique look at instructive dermatologic cases being presented at the weekly Dermatology Branch Grand Rounds at the National Cancer Institute, National Institutes of Health (NIH), Bethesda, Maryland. Patients seen at the NIH Clinical Center (which includes the NIH inpatient wards and outpatient clinics) are indeed unusual. To be evaluated here, they must be referred by an outside physician and must be placed in a research protocol. In other words, by this criterion, all NIH patients are considered research subjects. The diseases studied at the NIH range from the common to the obscure. Similarly, the dermatologic manifestations of these diseases are equally as diverse. Thus the purpose of this new section is to share some of these fascinating cases with the dermatologic community at large, as well as to provide a glimpse of exciting translational research that has relevance to clinical dermatologists. The format will be simple. Cases will be presented as unknowns, including relevant results from the history, physical examination, and histopathologic analyses. This will be done to challenge the clinicopathologic skills of the readers; authors will make every attempt to make the color clinical and pathologic photographs of the highest quality possible to assist readers in making the correct diagnoses. The discussion will be brief, focusing on the key teaching points of each case. These teaching points will vary from cases to case, covering clinical and histologic information, treatment issues, and/or novel laboratory advances with clinical relevance. Authors will emphasize brevity and clarity in all subsections of the case report, which I hope will promote a good learning experience for dermatology residents and busy practitioners alike. This section will initially be published 4 times annually. Finally, because the section is new to the JAAD, I welcome comments and suggestions to improve the quality of the articles.-Andrew Blauvelt, MD Feature Editor

[Soft tissue eosinophilic granuloma or Kimura's disease: a case report]

Soft tissue eosinophilic granuloma or Kimura's disease is a chronic inflammatory disorder of unknown etiology. It is endemic in the Far East but can occur sporadically in other populations especially Middle Eastern peoples as illustrated by the present case involving a 55-year-old man. Examination 8 years after an initial episode revealed masses in the cheek and submaxillary regions with hypereosinophilia and characteristic histological findings. The usual clinical presentation of Kimura's disease includes subcutaneous nodules with lymph node involvement or presence of tumor in the salivary glands. These clinicopathological findings require differential diagnosis with Hodgkin's lymphoma, dermopathic lymphoma, or Castelman's disease. However, the most difficult distinction involves angiolymphoid hyperplasia with eosinophilia. Final diagnosis requires anatomopathological study. The most frequently encountered histological criteria are preservation of node structure, highly developed germinal centers, eosinophilic infiltration, and presence of numerous postcapillary veinlets. Prognosis is favorable but multiple relapses are possible. Corticosteroid therapy is usually effective but radiation treatment may be necessary in patients with recurrent disease.

A case of eosinophilic myocarditis complicated by Kimura's disease (eosinophilic hyperplastic lymphogranuloma) and erythroderma

This report describes a patient with eosinophilic myocarditis complicated by Kimura's disease (eosinophilic hyperplastic lymphogranuloma) and erythroderma. A 50-year-old man presented with a complaint of precordial pain. However, the only abnormal finding on examinatioin was eosinophilia (1617 eosinophils/microl). Three years later, the patient developed chronic eczema, and was diagnosed with erythroderma posteczematosa. One year later, a tumor was detected in the right auricule, and a diagnosis of Kimura's disease was made, based on the biopsy findings. The patient developed progressive dyspnea 6 months later and was found to have cardiomegaly and a depressed left ventricular ejection fraction (17%). A diagnosis of eosinophilic myocarditis was made based on the results of a right ventricular endomyocardial biopsy. The eosinophilic myocarditis and erythrodrema were treated with steroids with improvement of both the eosinophilia and left ventricular function.

A case of pathophysiologic study in Kimura's disease: measurement of cytokines and surface analysis of eosinophils

BACKGROUND

Kimura's disease is a rare but distinctive eosinophilic inflammatory disorder of unknown etiology; few reported case studies have focused on the immunopathologic background of this unique disease.

OBJECTIVE

To define better the immunopathogenetic features of Kimura's disease, we attempted to quantitatively analyze values of cytokines and soluble interleukin-2 receptor (sIL-2R) in peripheral blood (PB), as well as perform surface immunophenotypic analysis of eosinophils from a Japanese patient with chronic relapsing Kimura's disease.

RESULTS

Granulocyte macrophage-colony stimulating factor (GM-CSF), tumor necrosis factor-alpha (TNF-alpha) and sIL-2R were elevated, and newly expressed antigens on eosinophils CD4, CD25, and HLA-DR were found to be involved in the pathophysiology of this disorder.

CONCLUSIONS

Kimura's disease may be a disease in which activated lymphocytes release cytokines, and these released cytokines, such as GM-CSF and TNF-alpha cause eosinophil activation. These processes may be related to the pathogenesis of this disorder.

In vivo expression of IL-4, IL-5, IL-13 and IFN-gamma mRNAs in peripheral blood mononuclear cells and effect of cyclosporin A in a patient with Kimura's disease

Semiquantitative reverse transcription-polymerase chain reaction was used to analyse the expression of cytokine mRNAs in freshly isolated peripheral blood mononuclear cells obtained from a patient with Kimura's disease. The patient was treated with cyclosporin A (CsA) after incomplete tumour resection and irradiation of lesions. Levels of interleukin (IL)-4, IL-5 and IL-13 mRNA were elevated and the level of interferon (IFN)-gamma mRNA was within normal limits before treatment. The levels of IL-4, IL-5 and IL-13 mRNA, the number of eosinophils, and the serum level of IgE decreased markedly after surgery and radiation therapy. CsA treatment suppressed these values in a dose-dependent manner, but had a minimal effect on the level of IFN-gamma mRNA. The number of peripheral eosinophils decreased in association with decreases in the levels of IL-4, IL-5 and IL-13 mRNAs during CsA therapy; the serum level of IgE remained low during therapy and did not fluctuate in association with changes in cytokine levels. These results suggest the Th2 cytokines play a part in the development of Kimura's disease and that CsA suppresses the activity of this disease.

Serum concentrations of IL-5, GM-CSF, and IL-3 and the production by lymphocytes in various eosinophilia

The concentrations of interleukin-5 (IL-5), granulocyte-macrophage colony-stimulating factor GM-CSF, and interleukin-3 (IL-3) in serum and in IL-2-stimulated lymphocyte culture medium (L-IL2-CM) prepared from patients with reactive eosinophilia were measured by enzyme-linked immunosorbent assay (ELISA). Serum IL-5 levels were increased in 16 out of 42 cases. GM-CSF and IL-3 were below the detectable levels in all sera examined. The concentrations of IL-5 and GM-CSF in L-IL2-CM were increased in 10 out of 29 patients. IL-3 was below the detectable levels in all L-IL2-CM.

IL-5 mRNA expression in blood lymphocytes from patients with Kimura's disease and parasite infection

Blood lymphocytes from patients with eosinophilia are known to produce interleukin-5 (IL-5) with appropriate stimulation in vitro. To determine whether blood lymphocytes from these patients produce IL-5 in vivo, we tested the IL-5 mRNA expression in blood lymphocytes immediately after separation by reverse-transcriptase polymerase chain reaction (RT-PCR) method. We found that lymphocytes from eosinophilic patients expressed IL-5 mRNA, but lymphocytes from normal volunteers did not express the lymphokine. These findings suggest that in patients with eosinophilia, peripheral blood lymphocytes produce IL-5 in vivo.

Kimura's disease with high serum levels of eosinophil cationic protein and major basic protein

This study reports a case of Kimura's disease. The patient was a 58-year-old man and satisfied the clinico-pathological findings of Kimura's disease. Serum eosinophil cationic protein (ECP) and major basic protein (MBP) levels in this patient were also measured. In the active stage of the disease, the patient's serum ECP and MBP levels were higher than those of healthy controls and declined in the remission stage. This finding suggests that ECP and MBP may be important agents in the development of Kimura's disease.

Presence of C5a-potentiating activity in the plasma of a patient with Kimura's disease

To determine whether the response to the active complement fragment C5a in polymorphonuclear leukocytes (PMN) obtained from a patient with Kimura's disease is similar to that in normal subjects, we evaluated superoxide anion (O2-) generation after stimulation with C5a. The patient's PMN produced more O2- than did those from healthy controls after stimulation with human C5a in vitro. The response returned to normal with the improvement in clinical indicators after initiation of steroid administration. We conducted the following experiments with the plasma of this patient during the active disease stage to establish the presence of a humoral factor that potentiated the C5a-response of PMN. Incubation of PMN from normal controls having the same blood type as the patient at 37 degrees C for 2 h with the patient's plasma at the active disease stage revealed that the cells generated abundant O2- after stimulation with C5a. Incubation of normal PMN with the patient's plasma during the inactive disease stage showed no potentiated response to C5a. This activity was lost after incubation at 56 degrees C for 30 min. Coincubation of PMN with methylprednisolone up to 100 micrograms/ml did not suppress this activity. Although the plasma concentration of C5a at the active stage was mildly elevated (13 ng/ml), it was below the limit of detection (< 10 ng/ml) at the inactive stage. These results suggest the presence of a heat-labile, humoral factor in the patient's plasma that upregulated the response of PMN to C5a and that was not suppressed by in vitro treatment with a steroid. This factor may influence the acute inflammatory reaction in this disorder.

Mechanism of eosinophil infiltration in the patient with subcutaneous angioblastic lymphoid hyperplasia with eosinophilia (Kimura's disease). Mechanism of eosinophil chemotaxis mediated by candida antigen and IL-5

Kimura's disease is a chronic granulomatous disease of unknown etiology. Although eosinophilia is one of the characteristic features in this disease, little is known about the mechanism of eosinophilia. In the present study it was demonstrated that interleukin-5 (IL-5) was produced and released from the site of a granuloma and lymph nodes after stimulation with candida antigen. It was also shown that peripheral blood eosinophils from patients with Kimura's disease contained a large proportion of hypodense eosinophils and that their viability was prolonged. These results strongly suggest that locally produced IL-5 induced by candida antigen contributes to the eosinophilia in this disease.

Chemotactic heterogeneity of eosinophils in Kimura's disease

We evaluated the chemotactic heterogeneity of eosinophils in Kimura's disease. Patients with Kimura's disease were divided into two groups according to their clinical findings: one group had no other symptoms (KD), and another was accompanied with atopic dermatitis (KD + AD). The chemotactic response of eosinophils from two groups to 5 eosinophil chemotactic factors (ECF) derived from STO-2, an established T cell line. Eosinophils from KD were attracted only by ECF-PI5 and PI6 but not by ECF-PI7, PI8 and PI9. On the other hand, eosinophils from KD + AD responded to all 5 ECF. Eosinophils were further fractionated into normodense and hypodense eosinophils, and assessed for their chemotactic response. We thus found that there was little essential difference in their chemotactic responses to STO-2-derived ECF except ECF-PI9, though random migration of hypodense eosinophils was enhanced. The hypothesis that hypodense eosinophils are in the activated form was not always true, especially in the chemotactic response to ECF.

Distribution of adhesion molecules, IgE, and CD23 in a case of angiolymphoid hyperplasia with eosinophilia

Angiolymphoid hyperplasia with eosinophilia developed in a 13-year-old boy. The immune phenotype of infiltrating cells and the distribution of adhesion molecules of the integrin, immunoglobulin, and selectin families were analyzed with monoclonal antibodies. The infiltrate consisted mainly of helper lymphocytes, monocytes, eosinophils, CD1+ dendritic cells, and mast cells. A CD23/Fc epsilon receptor was present on 40% of these cells, and surface bound IgE was present on 30% of these cells. The latter was found on all cell types. A cellular adhesion molecule analysis revealed that the proliferating endothelial cells were expressing constitutive ICAM-1, LFA-3, VLA-1, VLA-3, VLA-5, alpha 6, and beta 3-integrin chain as well as activation-dependent VLA-2, VCAM-1, and human lymphocyte antigen-DR. The infiltrating cells expressed LFA-1 and CD2, the correlating ligands for ICAM-1 and LFA-3. Our studies support previous observations of an unusual IgE-mediated immune reaction, and suggest an additional pathogenic role for adhesion events in the development of the pathognomonic cellular composition in angiolymphoid hyperplasia with eosinophilia.