Scientific Letter
Kikuchi-Fujimoto Disease as a Differential Diagnosis for Lymph Nodetuberculosis. The First Case of Kikuchi-Fujimoto Disease in Peru
Enfermedad de Kikuchi-Fujimoto como diagnóstico diferencial de tuberculosis ganglionar. Reporte del primer caso de enfermedad de Kikuchi-Fujimoto en Perú
Jorge Nelson Chung-Ching
Hospital Nacional Arzobispo Loayza, Lima, Peru
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The First Case of Kikuchi-Fujimoto Disease in Peru" "tieneTextoCompleto" => true "saludo" => "To the Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "282" "paginaFinal" => "284" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Jorge Nelson Chung-Ching" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Jorge Nelson" "apellidos" => "Chung-Ching" "email" => array:1 [ 0 => "jorgechung14@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Nacional Arzobispo Loayza, Lima, Peru" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad de Kikuchi-Fujimoto como diagnóstico diferencial de tuberculosis ganglionar. Reporte del primer caso de enfermedad de Kikuchi-Fujimoto en Perú" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2249 "Ancho" => 1500 "Tamanyo" => 1026636 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) BK negative; (B) PAS negative; (C) EBV negative; (D) CD3 partially positive; (E) CD15 negative; (F) CD20 partially positive; (G) CD30 positive in reactive lymphocytes and (H) CD68 positive for histiocytes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis (TB) is a highly prevalent disease in Peru.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> Lymph node involvement presents a particular challenge, as it is often difficult to diagnose, and treatments unsupported by scientific evidence may sometimes be prescribed, given that this entity can be confused with Kikuchi-Fujimoto disease (KFD).</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 7-year-old boy from Lima, in his second year of primary school, who was referred to the respiratory medicine department by his pediatrician for left axillary lymph node enlargement, with no previous history of respiratory symptoms or fever. He had been fully vaccinated according the WHO vaccination schedule, which in Latin America includes Bacillus Calmette-Guérin (BCG). He had no history of previous TB, but his mother reported a possible exposure 6 months before the episode, when she took the child along to a prison to visit a family member who was an inmate there. The family member did not have a diagnosis of TB, but in Peru the high prevalence of this disease among the prison population means that visiting one of these establishments is considered a risk factor.</p><p id="par0015" class="elsevierStylePara elsevierViewall">No respiratory abnormalities were found on examination, but painful lymphadenopathies measuring ±2<span class="elsevierStyleHsp" style=""></span>cm were observed in the region of the left axilla. The rest of the examination was normal and no abnormalities were found on blood tests. Imaging studies revealed increased bronchovascular markings, with no pathological lesions on chest radiograph, and axillary lymphadenopathies measuring 2.2<span class="elsevierStyleHsp" style=""></span>cm on ultrasonography. Sputum tuberculin testing (PPD) and sputum smear were negative for alcohol-acid resistant bacilli. A lymph node biopsy was performed, and the sample was sent for study. The biopsy was not cultured for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>. After receiving the pathology study, which reported chronic, mildly granulomatous lymphadenitis, lymph node tuberculosis was considered as a first option, and admission to a TB program to start treatment was planned. However, as part of a special protocol, polymerase chain reaction (PCR) was performed on the lymph node biopsy for <span class="elsevierStyleItalic">M. tuberculosis</span> with sequence IS6110, with negative results. Samples were sent for immunohistochemistry testing, with the results shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was diagnosed with KFD and did not receive antituberculosis treatment. The clinical picture resolved after 3 weeks of symptomatic treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Tuberculous cervical lymphadenitis is the most common manifestation of TB of the head and neck in our setting, and accounts for 15% of cases of extrapulmonary TB.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Both tuberculous lymphadenitis and KFD are diseases that form part of the differential diagnosis of necrotizing lymphadenopathies.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">2–5</span></a> KFD is a rare disease that consists of histiocytic necrotizing lymphadenitis, and is generally self-limiting with a benign course. It affects mainly younger individuals, and is more common among females than males.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> Although it has been described mostly in Asian populations, cases have been reported worldwide. It generally presents in the form of enlarged, mainly unilateral cervical lymph nodes (70%–90%),<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,6</span></a> accompanied in some cases by fever, fatigue, night sweats, and gastrointestinal and cutaneous changes.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">35,7,8</span></a> Laboratory and imaging data are not characteristic, so diagnosis can be difficult: a lymph node biopsy is required for correct identification, since fine needle aspirates tend to be inconclusive.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Pathogenesis remains unclear to date, but some authors have suggested that both interferon and interleukin-6 (IL-6) or cell apoptosis may play some role, pointing toward viral<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,9,10</span></a> or autoimmune<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">9,11</span></a> etiologies. It seems clear that KFD is an exaggerated T cell-mediated reaction to a variety of mostly infectious stimuli.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,7,8,12</span></a> The course is usually benign, and it resolves in a few months without specific treatment, although some more severe cases have occasionally been reported.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,7,13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Histological findings correspond to 3 disease stages (proliferative, necrotizing and xanthomatous), representing progressive pathological changes.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> The typical immunophenotype of this disease consists a predominance of CD8+ cells over CD4+ T cells. Consistent immunohistochemistry results shows CD68 and CD3+, CD20+/− and CD30−. Histiocytes expressing myeloperoxidase and CD68 are characteristic of this disease.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Chest radiograph must be obtained from all patients to rule out the possibility of other causes such as neoplasms or TB. Multislice spiral tomography is of particular use in locating the most accessible lymph node for biopsy and for determining the extent of the disease.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In Peru, a country with a very high prevalence of TB, lymph node involvement is found in a good number of cases. Lymph node biopsy studies are included in diagnostic protocols, and epidemiological factors and other laboratory findings are taken into consideration. However, antituberculosis treatment is sometimes prescribed without hard scientific evidence and before the other etiological options, which would include KFD, have been explored. We therefore hold that is important to include this disease in the differential diagnosis of lymphadenopathies, particularly for lymph node TB, and appropriate studies must be conducted to avoid the prescription of costly drugs that might be unnecessary and carry significant risks for the patient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ching JNC. Enfermedad de Kikuchi-Fujimoto como diagnóstico diferencial de tuberculosis ganglionar. Reporte del primer caso de enfermedad de Kikuchi-Fujimoto en Perú. Arch Bronconeumol. 2017;53:282–284.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2249 "Ancho" => 1500 "Tamanyo" => 1026636 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) BK negative; (B) PAS negative; (C) EBV negative; (D) CD3 partially positive; (E) CD15 negative; (F) CD20 partially positive; (G) CD30 positive in reactive lymphocytes and (H) CD68 positive for histiocytes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Norma técnica de salud para la atención integral de las personas afectadas por tuberculosis/Ministerio de Salud. 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Alberto Yuen and Guillermo Ríos of the Laboratory of the Universidad Nacional Mayor de San Marcos, Lima, Peru, for their invaluable support.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000005/v1_201704280925/S1579212917300873/v1_201704280925/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000005/v1_201704280925/S1579212917300873/v1_201704280925/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212917300873?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 3 | 5 |
| 2024 October | 41 | 25 | 66 |
| 2024 September | 66 | 16 | 82 |
| 2024 August | 76 | 46 | 122 |
| 2024 July | 44 | 25 | 69 |
| 2024 June | 87 | 35 | 122 |
| 2024 May | 109 | 31 | 140 |
| 2024 April | 41 | 32 | 73 |
| 2024 March | 40 | 22 | 62 |
| 2024 February | 34 | 19 | 53 |
| 2023 March | 25 | 2 | 27 |
| 2023 February | 82 | 17 | 99 |
| 2023 January | 45 | 27 | 72 |
| 2022 December | 60 | 34 | 94 |
| 2022 November | 70 | 29 | 99 |
| 2022 October | 54 | 42 | 96 |
| 2022 September | 36 | 25 | 61 |
| 2022 August | 46 | 47 | 93 |
| 2022 July | 37 | 35 | 72 |
| 2022 June | 38 | 26 | 64 |
| 2022 May | 50 | 30 | 80 |
| 2022 April | 49 | 49 | 98 |
| 2022 March | 37 | 33 | 70 |
| 2022 February | 60 | 47 | 107 |
| 2022 January | 66 | 40 | 106 |
| 2021 December | 91 | 40 | 131 |
| 2021 November | 62 | 43 | 105 |
| 2021 October | 58 | 43 | 101 |
| 2021 September | 69 | 50 | 119 |
| 2021 August | 47 | 41 | 88 |
| 2021 July | 44 | 31 | 75 |
| 2021 June | 49 | 38 | 87 |
| 2021 May | 39 | 28 | 67 |
| 2021 April | 118 | 90 | 208 |
| 2021 March | 73 | 37 | 110 |
| 2021 February | 71 | 25 | 96 |
| 2021 January | 39 | 14 | 53 |
| 2020 December | 43 | 16 | 59 |
| 2020 November | 59 | 11 | 70 |
| 2020 October | 127 | 13 | 140 |
| 2020 September | 125 | 12 | 137 |
| 2020 August | 92 | 19 | 111 |
| 2020 July | 63 | 22 | 85 |
| 2020 June | 78 | 6 | 84 |
| 2020 May | 53 | 17 | 70 |
| 2020 April | 39 | 26 | 65 |
| 2020 March | 41 | 13 | 54 |
| 2020 February | 51 | 18 | 69 |
| 2020 January | 66 | 20 | 86 |
| 2019 December | 67 | 17 | 84 |
| 2019 November | 46 | 23 | 69 |
| 2019 October | 50 | 15 | 65 |
| 2019 September | 68 | 15 | 83 |
| 2019 August | 42 | 16 | 58 |
| 2019 July | 42 | 20 | 62 |
| 2019 June | 42 | 9 | 51 |
| 2019 May | 40 | 20 | 60 |
| 2019 April | 52 | 20 | 72 |
| 2019 March | 39 | 18 | 57 |
| 2019 February | 20 | 13 | 33 |
| 2019 January | 24 | 17 | 41 |
| 2018 December | 28 | 14 | 42 |
| 2018 November | 36 | 19 | 55 |
| 2018 October | 58 | 14 | 72 |
| 2018 September | 25 | 5 | 30 |
| 2018 May | 12 | 0 | 12 |
| 2018 April | 29 | 5 | 34 |
| 2018 March | 25 | 7 | 32 |
| 2018 February | 40 | 10 | 50 |
| 2018 January | 89 | 3 | 92 |
| 2017 December | 71 | 7 | 78 |
| 2017 November | 23 | 7 | 30 |
| 2017 October | 23 | 10 | 33 |
| 2017 September | 28 | 7 | 35 |
| 2017 August | 29 | 14 | 43 |
| 2017 April | 0 | 1 | 1 |
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