Fever, Weight Loss, Lymph Nodes—not so Bad

1Elmhurst Hospital Center/ Mount Sinai School of Medicine, Elmhurst, NY

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 384

Case Presentation:

A 13‐year‐old girl with no medical history was admitted with a 1‐month history of intermittent fever, 20‐pound weight loss, fatigue, dry cough, and 2 months of left neck mass, initially painful but now painless. She had no recent travel, no sick contacts, no tuberculosis (TB) exposure. She was followed in our outpatient clinic, where her QuantiFERON was positive but protein purified derivative negative. She had refused imaging and lymph node (LN) biopsy by otorhinolaryngology. On admission, she appeared well, with a 2 × 3 cm, nontender, nonmobile left anterior cervical lymph node, as well as a small left posterior cervical lymph node. No other lymph nodes were enlarged, and there was no hepatosplenomegaly. The rest of the physical examination was normal. Labs revealed pancytopenia, with ANC 1300 and no immature cells, ESR 81, normal AST/ALT, LDH 541, total protein 7.5, and albumin 3.5. Because of suspicion for lymphoma, LN and bone marrow biopsies were ordered. Pathologically, the LN showed necrotizing lymphadenitis diagnostic of Kikuchi disease. The patient was discharged with no treatment and outpatient clinic follow‐up. Three weeks after discharge, she had gained 5 pounds and had no fevers and no lymphadenopathy.

Discussion:

Prolonged fever, weight loss, and persistent lymph nodes have a differential diagnosis of malignancy, viral diseases such as Epstein–Barr virus and HIV, and autoimmune diseases. Our top concern was lymphoma, so we proceeded with the diagnostic tests of lymph node and bone marrow biopsy, leading to the ultimate diagnosis. Kikuchi disease was described in 1972 and is rare in the United States, more common in young women, especially those of Asian descent. Its etiology is unknown, but an autoimmune response of T cells and histiocytes to an infectious agent is hypothesized. Fever and cervical adenopathy in a previously healthy young woman is the most common presentation. Fever is typically low grade for 1 week to more than 1 month. Other features include fatigue, joint pain, rash, arthritis, hepatosplenomegaly, night sweats, nausea, vomiting, diarrhea, and weight loss. Lab findings include leukopenia (20%–30%), high erythrocyte sedimentation rate (usually > 60), anemia, thrombocytopenia, mildly abnormal liver function tests, and high serum lactate dehydrogenase. These symptoms and signs are also common for systemic lupus erythematosus (SLE) and malignancies, so a bone marrow biopsy and SLE markers are often done as well as serologic studies for infectious agents. CT shows perinodal infiltration and homogenous nodal contrast enhancement. Ultrasonography may appear suspicious for malignancy. The diagnosis of Kikuchi is made by LN biopsy. Fine‐needle aspiration can be done, although excisional biopsy is preferred. There is no effective treatment for Kikuchi, but it is self‐limited with an excellent prognosis. It usually resolves within 1–4 months but can recur. Steroids have been shown to be beneficial in patients with severe/ persistent symptoms.

Conclusions:

Kikuchi disease is a rare benign disease that mimics other, more common serious illnesses. The diagnosis is made by LN biopsy. It is rare in the young pediatric age group but should always be considered in the differential diagnosis with cancer, SLE, and TB. There is no effective treatment for this disease, but it is self‐limited and has an excellent prognosis.

Disclosures:

D. Rauch ‐ Baxter, consultant.

To cite this abstract:

Sabe R, Rauch D. Fever, Weight Loss, Lymph Nodes—not so Bad. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 384. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/fever-weight-loss-lymph-nodesnot-so-bad/. Accessed July 23, 2019.

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