Case report Necrotizing cervical lymphadenopathy caused by Kikuchi–Fujimoto disease 1 M J BENNIE, MRCP, FRCR, 2 K M BOWLES, MRCP and 1 S C RANKIN, MRCP, FRCR 1 Department of Radiology, Guy’s and St Thomas NHS Trust, Guy’s Hospital, London SE1 9RT and 2 Department of Haematology, Addenbrookes Hospital, Cambridge, UK A 22-year-old female presented with fever and tender right sided neck lumps. She reported generalized neck pain and was unable to fully flex, extend or rotate her neck. Initially only one lump was palpable which increased in size over a 2 week period before other lymph nodes lower down in the cervical chain became enlarged. Her General Practitioner had initially treated her with antibiotics for a presumed upper respiratory tract infection, with some improvement in her symptoms, but the nodes persisted. On direct questioning she denied weight loss and night sweats. There was no history of tuberculosis (TB) or TB contacts. She was born in the Indian subcontinent and had had a BCG as a child. She had no other medical problems. On examination a small BCG scar was present over the left shoulder. There was an enlarged node in the upper cervical region on the right measuring 2 cm in diameter with smaller glands approximately 1–2 cm in diameter in the posterior triangle of the neck. No other nodes were palpable. The right tonsil was enlarged. The cardiovascu- lar, respiratory and abdominal examination was normal. On investigation she was found to be leukopenic with a white blood count of 3.3610 9 /l and lymphopenic with lymphocytes of 1.09610 9 /l. Her haemoglobin was 11.2 g dl 21 , erythrocyte sedimentation rate (ESR) 57, Paul Bunnel test negative, blood cultures negative, throat cultures negative and Heaf test grade 2. Chest radiograph was normal. A CT scan of the neck during the infusion of intravenous contrast showed exten- sive right cervical adenopathy extending from the angle of the jaw downwards displacing the right submandibular salivary gland anteriorly. The nodes showed non-uniform enhancement with central low attenuation necrotic areas (Figure 1). Some nodes enhanced more uniformly (Figure 2). There was no evidence of inflammatory changes within the subcutaneous tissues or skin. In view of the CT appearances, the patient’s age and origin, the initial radiological diagno- sis suggested was TB (Figure 3). A fine needle aspiration of the largest of the right cervical lymph nodes showed a cellular aspirate with a mixed population of mature and immature lymphoid cells suggestive of reactive lymphadenopathy. There was no evidence of granulomata. The acid–alkali fast bacilli (AAFB) and bacterial culture was negative. An excision biopsy of the largest lymph node was performed 6 weeks later and the histological features made the diagnosis of Kikuchi disease. The patient went on to make a spontaneous and complete recovery and remained well on review in clinic 4 months later. Discussion Kikuchi disease is a form of necrotizing lymphadenitis with characteristic histological appearances, which was first described in 1972 independently by Kikuchi and Fujimoto [1, 2]. Although first descriptions were in people of Asian origin the disease has now been reported in individuals of all races. Its true incidence is unknown. An increased incidence in females is reported with a female to Address correspondence to Dr M J Bennie, Department of Radiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UZ. Received 12 February 2002 and accepted 7 March 2002. Figure 1. Contrast enhanced CT scan of the neck showing enlarged right cervical lymph nodes with central areas of low attenuation necrosis. The British Journal of Radiology, 76 (2003), 656–658 E 2003 The British Institute of Radiology DOI: 10.1259/bjr/67899714 656 The British Journal of Radiology, September 2003
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