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1c&#41;&#46; Immunochemical analysis revealed that the lymphoid infiltrate was predominantly CD3&#43;&#44; with CD8 positive cells predominating over CD4 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>d&#41;&#46; By the other side CD68&#44; CD163 and myeloperoxidase &#40;MPO&#41; immunostaining disclosed the presence of many histiocytes&#44; and CD123 revealed that there were some plasmacytoid monocytes<span class="elsevierStyleBold">&#46;</span> Neutrophils and eosinophils were absent&#44; and no granulomas were evidenced&#46; Vasculitis was not a feature&#46; Lymph node biopsy showed paracortical hyperplasia&#44; patchy necrosis with abundant cellular debris and profuse peripheral histiocytic cells&#46; She was diagnosed with Kikuchi-Fujimoto disease &#40;KFD&#41; with cutaneous involvement&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">KFD&#44; also known as histiocytic necrotizing lymphadenitis&#44; was first described by Kikuchi<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and Fujimoto<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> in 1972&#46; 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suggests the involvement of autoimmune mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis is confirmed by lymph node biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Involved lymph nodes characteristically demonstrate architecture partially effaced by confluent paracortical necrotic foci with abundant karyorrhectic debris&#44; surrounded by CD68&#43; and MPO&#43; histiocytes&#44; immunoblasts&#44; CD8&#43; T-cells and CD123&#43; plasmacytoid dendritic cells&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Neutrophils and eosinophils are absent&#46; KFD has been classified into three histological subtypes&#44; and is thought to progress from the proliferative type &#40;expanded paracortex with an increase in histiocytes and plasmacytoid dendritic cells and karyorrhectic nuclear debris&#41; to the necrotizing type &#40;predominance of necrosis&#41;&#44; and finally resolve into the xanthomatous type &#40;predominance of foamy histiocytes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The skin is the most frequently affected extranodal organ&#44; as cutaneous involvement has been reported in 16-40&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Although some cases of KFD cutaneous lesions mimicking urticarial&#44; morbilliform&#44; rubella-like or drug-eruption-like rashes have been described&#44; cutaneous KFD usually presents as erythematous papules and plaques&#44; predominantly on the face&#44; arms and upper neck&#46; The histopathological findings of skin biopsies might mimic those of discoid lupus erythematosus&#59; however&#44; karyorrhectic debris without neutrophils&#44; and the presence of CD68 and MPO positive cells are characteristic of KFD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The skin lesions of KFD resolve after several weeks to months along with the resolution of lymphadenopathy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Misdiagnosing KFD as lymphoma or SLE is not uncommon due to the similarity of clinical and histopathological features of these diseases&#46; Identification of the characteristic histiocytes and abundant karyorrhectic debris instead of malignant lymphoma cells or SLE-pathognomonic haematoxylin bodies would provide the clue for the diagnosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As the evidence suggests&#44; it seems that individuals with KFD are more susceptible to SLE<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#59; in particular&#44; KFD can precede&#44; postdate or coincide with the diagnosis of SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Although&#44; the relationship between SLE and KFD remains a matter of debate&#44; regular follow-up is required because SLE may develop several years after the onset of KFD&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">KDF is typically self-limiting&#44; resolving within 1 to 4 months&#44; though a possible recurrence rate of 3 to 4&#37; has been reported&#46; There is no specific treatment for KFD&#44; although analgesics&#44; antipyretics and nonsteroidal anti-inflammatory drugs may be used to alleviate lymph node tenderness and fever&#46; The use of corticosteroids has been recommended in severe extranodal or generalized KFD&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and if symptoms persist&#44; intravenous immunoglobulins can be prescribed&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our patient presented with leukopenia and positive antinuclear antibodies&#44; however&#44; she did not fulfill the American College of Rheumatology criteria for the diagnosis of SLE&#46; She was given oral ibuprofen daily for three months&#44; lymphadenopathies gradually diminished and the scalp plaque disappeared&#46; After one-year follow up&#44; only few&#44; small and non-specific lymph nodes remain in CTS&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Kikuchi-Fujimoto disease is rare&#46; Clinicians should be aware of this condition as early diagnosis of the disease will avoid unnecessary medical tests and will lessen concerns of the patient and their relatives&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Kikuchi-Fujimoto Disease with Scalp Involvement
Enfermedad de Kikuchi-Fujimoto con compromiso de cuero cabelludo
A. Combaliaa,
Autor para correspondencia
andreacombalia@gmail.com

Corresponding author.
, X. Fustà-Novella, A. García-Herrerab, J. Ferrandoa
a Unidad de Dermatología, Hospital Clinic de Barcelona, Barcelona, España
b Unidad de Patología, Hospital Clinic de Barcelona, Barcelona, España
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1c&#41;&#46; Immunochemical analysis revealed that the lymphoid infiltrate was predominantly CD3&#43;&#44; with CD8 positive cells predominating over CD4 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>d&#41;&#46; By the other side CD68&#44; CD163 and myeloperoxidase &#40;MPO&#41; immunostaining disclosed the presence of many histiocytes&#44; and CD123 revealed that there were some plasmacytoid monocytes<span class="elsevierStyleBold">&#46;</span> Neutrophils and eosinophils were absent&#44; and no granulomas were evidenced&#46; Vasculitis was not a feature&#46; Lymph node biopsy showed paracortical hyperplasia&#44; patchy necrosis with abundant cellular debris and profuse peripheral histiocytic cells&#46; She was diagnosed with Kikuchi-Fujimoto disease &#40;KFD&#41; with cutaneous involvement&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">KFD&#44; also known as histiocytic necrotizing lymphadenitis&#44; was first described by Kikuchi<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> and Fujimoto<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> in 1972&#46; It is a benign and self-limiting disorder characterized by lymphadenopathy associated with low-grade fever and flu-like symptoms&#46; Unilateral and posterior cervical nodes are the commonest to be involved although it can present as generalized lymphadenopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The female to male ratio is more than 4&#58;1&#46; The predominance of reports from Japan&#44; and the fact that many of the patients reported in Europe and the USA have been of Asian descent&#44; may point to a racial or genetic susceptibility&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Its etiology remains uncertain&#46; A viral origin has long been suspected&#59; however&#44; the clinical course of the disease&#44; the disappearance of lesions without any specific treatment&#44; and some similarity with features of systemic lupus erythematosus &#40;SLE&#41; suggests the involvement of autoimmune mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis is confirmed by lymph node biopsy&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Involved lymph nodes characteristically demonstrate architecture partially effaced by confluent paracortical necrotic foci with abundant karyorrhectic debris&#44; surrounded by CD68&#43; and MPO&#43; histiocytes&#44; immunoblasts&#44; CD8&#43; T-cells and CD123&#43; plasmacytoid dendritic cells&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Neutrophils and eosinophils are absent&#46; KFD has been classified into three histological subtypes&#44; and is thought to progress from the proliferative type &#40;expanded paracortex with an increase in histiocytes and plasmacytoid dendritic cells and karyorrhectic nuclear debris&#41; to the necrotizing type &#40;predominance of necrosis&#41;&#44; and finally resolve into the xanthomatous type &#40;predominance of foamy histiocytes&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The skin is the most frequently affected extranodal organ&#44; as cutaneous involvement has been reported in 16-40&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Although some cases of KFD cutaneous lesions mimicking urticarial&#44; morbilliform&#44; rubella-like or drug-eruption-like rashes have been described&#44; cutaneous KFD usually presents as erythematous papules and plaques&#44; predominantly on the face&#44; arms and upper neck&#46; The histopathological findings of skin biopsies might mimic those of discoid lupus erythematosus&#59; however&#44; karyorrhectic debris without neutrophils&#44; and the presence of CD68 and MPO positive cells are characteristic of KFD&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> The skin lesions of KFD resolve after several weeks to months along with the resolution of lymphadenopathy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Misdiagnosing KFD as lymphoma or SLE is not uncommon due to the similarity of clinical and histopathological features of these diseases&#46; Identification of the characteristic histiocytes and abundant karyorrhectic debris instead of malignant lymphoma cells or SLE-pathognomonic haematoxylin bodies would provide the clue for the diagnosis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">As the evidence suggests&#44; it seems that individuals with KFD are more susceptible to SLE<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#59; in particular&#44; KFD can precede&#44; postdate or coincide with the diagnosis of SLE&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Although&#44; the relationship between SLE and KFD remains a matter of debate&#44; regular follow-up is required because SLE may develop several years after the onset of KFD&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">KDF is typically self-limiting&#44; resolving within 1 to 4 months&#44; though a possible recurrence rate of 3 to 4&#37; has been reported&#46; There is no specific treatment for KFD&#44; although analgesics&#44; antipyretics and nonsteroidal anti-inflammatory drugs may be used to alleviate lymph node tenderness and fever&#46; The use of corticosteroids has been recommended in severe extranodal or generalized KFD&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> and if symptoms persist&#44; intravenous immunoglobulins can be prescribed&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our patient presented with leukopenia and positive antinuclear antibodies&#44; however&#44; she did not fulfill the American College of Rheumatology criteria for the diagnosis of SLE&#46; She was given oral ibuprofen daily for three months&#44; lymphadenopathies gradually diminished and the scalp plaque disappeared&#46; After one-year follow up&#44; only few&#44; small and non-specific lymph nodes remain in CTS&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Kikuchi-Fujimoto disease is rare&#46; Clinicians should be aware of this condition as early diagnosis of the disease will avoid unnecessary medical tests and will lessen concerns of the patient and their relatives&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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