Thrombosis of temporal artery and renal vein in Kimura-disease-related nephrotic syndrome

A rarely described Kimura's disease of the breast

Kimura's disease is a rare chronic inflammatory disease of unknown aetiology. The majority of cases are reported in middle-aged Asian males and rarely seen in other ethnicities. Patients classically present with chronic single or multiple painless subcutaneous masses, lymphadenopathies, hypereosinophilia and elevated serum immunoglobulin E. The disease usually affects the head and neck area, however, rare involvement of other locations such as axilla, upper limbs, popliteal region and abdomen has been reported. Here, we report a rarely encountered Kimura's disease of the breast and axillary lymph nodes in a middle-aged female. In this report, we will describe the main clinical, radiological and pathological features to raise the awareness about this indolent disease.

Clinical, Pathological, Laboratory Characteristics, and Treatment Regimens of Kimura Disease and Their Relationships With Tumor Size and Recurrence

Objective: As of date, Kimura disease (KD) has an unclear etiology, no accepted diagnostic standard, and no definite treatment regimen. In this study, clinical and pathological laboratory characteristics and treatment regimens of patients with KD with different tumor sizes and status of tumor recurrence were analyzed. This was performed to identify the factors, which determine tumor size and recurrence, and to identify effective treatment methods for patients with KD.

Methods: A total of 33 hospitalized patients with a definite diagnosis of KD were enrolled in this study.

Results: There were 15 patients (45.5%) with a maximum tumor diameter of <3 cm. There were no statistically significant differences in age, gender, clinical symptoms, lesion sites, laboratory indicators, and treatment regimens among patients with a maximum tumor diameter <3 cm or ≥3 cm (P > 0.05). Among the 25 patients who completed the follow-up, there were 18 patients (72%) who had a recurrence of KD. There were no statistically significant differences in age, gender, clinical symptoms, the maximum tumor diameter, lesion sites, laboratory indicators, and initial treatment regimens between patients with or without the recurrence of KD (P > 0.05). There was a statistically significant difference in systolic blood pressure (SBP) between patients with or without the recurrence of KD (P < 0.05). All patients who received only surgical treatment had disease recurrence, 33.3% of patients who received prednisone therapy had no disease recurrence, and 37.5% of patients who received combination therapy showed recurrence.

Conclusion: The current study summarized clinical manifestations, pathological features, laboratory indicators, and treatment regimens of patients with KD. There were no significant differences in these aspects among patients with different tumor sizes, and there was no significant difference in these aspects except in the SBP between patients with or without the recurrence of KD, indicating that SBP is a significant clinical factor affecting disease recurrence in patients. Combination therapy with prednisone was found to be superior to surgical treatment.

Kimura's disease: effects of age on clinical presentation

BACKGROUND

Kimura's disease (KD) is known to be dominant among young Asian men, but it can also occur in middle- and advanced-aged people. The clinical characteristics of KD, especially by age, are not well known.

AIM

This study was performed to investigate the effects of age on the clinical characteristics of KD.

DESIGN

We conducted a case series study.

METHODS

All case studies of patients diagnosed with KD were collected via a PubMed search of studies published until August 2018. The data were analyzed by age group.

RESULTS

In total, 215 studies were reviewed (238 patients; mean age of 36 years). The male:female ratio was 4:1 overall, 17:1 in patients aged <20 years, 4:1 in patients aged 20-39 years and 2:1 in patients aged ≥40 years (P = 0.01). The percentage of patients with pruritus was 15.4% overall, 3.8% in patients aged <20 years, 15.5% in patients aged 20-39 years and 21.7% in patients aged ≥40 years (P = 0.02). The time to diagnosis was 5.3 years overall, 3.2 years in patients aged <20 years, 4.7 years in patients aged 20-39 years and 7.1 years in patients aged ≥40 years (P < 0.01).

CONCLUSIONS

The proportion of female patients affected the incidence of pruritus, and the time to diagnosis increased as the patients' age increased. There were no significant age-related differences in region/race, complications, multiplicity, laterality, anatomical distribution, maximum size, eosinophil count, immunoglobulin E level, initial treatment, recurrence or outcomes. This may be useful information for the diagnosis of KD.

The clinicopathological characteristics of Kimura disease in Chinese patients

INTRODUCTION

Kimura disease (KD) is a rare idiopathic inflammatory disorder of unknown etiology. Unusual presentations of KD might cause diagnostic difficulty or be misdiagnosed as malignancy if clinical suspicion is insufficiently high. Here, we aimed to determine the clinicopathological features of Chinese KD patients to reveal further insights into the natural history and treatment of this disease.

METHOD

The clinical data of 46 cases of KD diagnosed at Peking Union Medical College Hospital from January 1980 to December 2018 were analyzed retrospectively through case record review.

RESULTS

Of 46 cases, 40 were male and six were female. The age at onset ranged from 2 to 56 years (median 27 years). All patients presented with either single (26.1%) or multi-focal (73.9%) subcutaneous masses. Twenty-nine (63.0%) cases presented with head and neck subcutaneous masses, and 9 cases (19.6%) involved different parts of the body. Parotid, submandibular, and lacrimal gland involvement occurred in 17 (37.0%), 3 (6.5%), and 2 cases (4.3%), respectively. Nephrotic syndrome was present in three cases (6.5%), and thromboembolism was present in five cases (10.9%). During follow-up, thirteen patients (13/28, 46.4%) relapsed over 1-13 years (median 8.5 years). The recurrence rate in patients receiving corticosteroids, surgery, and combined surgery and radiotherapy was 30.8%, 66.7%, and 50.0%, respectively. One patient was diagnosed with T cell lymphoma 1 year after diagnosis of KD.

CONCLUSIONS

KD is characterized by subcutaneous masses but it is also a systemic disease. Given the high rate of recurrence and reported association with lymphoma, patients require careful long-term follow-up.Key Points• Kimura disease (KD) is a rare inflammatory disorder of unknown etiology that is endemic in Asia.• Clinicians must regard and manage KD as a systemic disease.• There is no consensus on optimal treatments and further studies are necessary to improve outcomes.• Given the high rate of recurrence and reported association with lymphoma, patients require careful long-term follow-up.

Concurrent Kimura disease and lupus nephritis: A case report

BACKGROUND

Kimura disease is a rare chronic inflammatory disorder with peripheral eosinophilia and elevated serum IgE and is also frequently complicated by nephropathy.

METHODS

We report a rare case of Kimura disease concomitant with lupus nephritis in a 72-year old male patient with recurrent unexplained lymphadenopathy, renal lesions, and immunologic abnormalities.

RESULTS

The patient was successfully managed with gamma immunoglobulin, intravenous pulse methylprednisolone therapy, hydroxychloroquine, and prednisone.

CONCLUSION

This is the first report of a case of Kimura disease concomitant with lupus nephritis and highlights the importance of considering lupus nephritis as a possible concurrent disease in patients with Kimura disease that have immunologic abnormalities.

Pulmonary embolism as the initial clinical presentation of Kimura disease: case report and literature review

Pulmonary embolism is clinically critical in that if misdiagnosed or delayed, the mortality is very high. The recognition of its risk factor or underlying disease is important for prevention of recurrence. Kimura disease is a rare, chronic inflammatory disease, which is seldom associated with thrombosis. We reported a 47-year-old male case presenting with pleural pain and dyspnoea and was found to have pulmonary embolism. After successful management of pulmonary embolism, he was noticed to have eosinophilia and lymphadenopathy. Pathologic examination of a resected lymph node has confirmed the diagnosis of Kimura disease. The patient was treated with corticosteroid and cyclosporine A, with a significant improvement of the symptoms and signs of Kimura disease and no recurrence of any thromboembolism. Associated literatures were reviewed to explore the pathogenesis underlying the thrombotic event in Kimura disease cases. It is suggested that hypereosinophilia may play a key role in thrombosis formation. The control of hypereosinophilia may contribute to the prevention of thrombosis and its recurrence in patients with Kimura disease.

Paradoxical brain embolism associated with Kimura disease mimics watershed infarction

Kimura disease (KD) is an uncommon chronic inflammatory disease presenting as subcutaneous lymphadenopathy with eosinophilia. To date, only a single case of brain embolism caused by fibroblastic endocarditis associated with KD has been reported. Watershed infarction was seen in patients with episodes of severe hypotension or cardiac surgery. We here report a young case of KD who developed ischemic stroke and showed multiple small infarcts in the border zones between the territories of major cerebral arteries, mimicking watershed infarction. Transesophageal echocardiography revealed patent foramen ovale and atrial septal aneurysm. Concurrently, deep venous thrombus in the femoral vein was found on duplex ultrasonography. Our case supports the notion that paradoxical brain embolism associated with KD can cause multiple small embolisms and mimic watershed infarction.

Kimura disease complicated with bowel infarction and multiple arterial thromboses in the extremities

Kimura disease (KD) is a chronic inflammatory disease characterized by slowly growing subcutaneous nodules in the face and the neck region. Although a concomitant hypercoagulable state can accompany KD, massive thromboses in patients with KD have rarely been reported. Here, we report a case of KD complicated with bowel infarction and multiple arterial thromboses in the upper and lower extremities. The patient underwent bowel resection and was successfully treated with corticosteroid and anticoagulation.

Kimura's disease associated with membranous nephropathy with IgG4 and phospholipase A2 receptor-positive staining of the glomerular basement membrane

Kimura's disease is a granulomatous disease of unknown origin that develops in the dermis, subcutaneous tissue and lymph nodes. Kimura's disease is frequently complicated by nephropathy, particularly membranous nephropathy (MN). It has recently been suggested that glomerular immunoglobulin (IgG)4 deposition may play a role in the pathogenesis of idiopathic MN. These IgG4 antibodies are thought to react with antigens, primarily the phospholipase A2 receptor (PLA2R) expressed on the podocyte cell membrane. We herein report a case of Kimura's disease with MN in which a renal biopsy specimen revealed positive staining for anti-IgG4 and anti-PLA2R antibodies.

Selected topics on lymphoid lesions in the head and neck regions

Lymphoid tissue located in the head and neck region include multiple regional lymph node chains as well as mucosa associated lymphoid tissue of the conjunctiva, buccal and nasopharyngeal cavities (Waldeyer's ring), and thyroid and salivary glands. This region is a rich source of antigenic stimuli including infectious agents coming from the outside environment. Many reactive conditions that affect lymphoid tissue in this region may mimic neoplasia. In fact, distinguishing between benign and malignant lymphoid proliferations in the head and neck region is a relatively frequent diagnostic challenge and in many instances, this distinction is not straightforward. It therefore behooves the practicing pathologist to be able to recognize the benign lymphoproliferative disorders that affect this region so as to effectively guide the appropriate clinical management of such patients. Kimura disease, Epstein Barr lymphadenitis, HIV associated salivary gland disease and chronic sialadenitis are benign conditions that not infrequently affect lymphoid tissue in the head and neck region and that share certain overlapping features with malignant lymphoma. In this brief review, we discuss these conditions and highlight clinicopathological features that may help distinguish them from neoplastic lymphoproliferations that may share similar features.

Membranous nephropathy and Kimura's disease manifesting a hip mass. A case report with literature review

We report a case of Kimura's disease with membranous nephropathy. A 15-year-old Japanese boy was referred to our hospital with proteinuria and a subcutaneous mass in the hip. Renal biopsy demonstrated secondary membranous nephropathy (MN) with mild mesangial proliferation and some electron-dense deposits in the mesangium. Laboratory tests revealed eosinophilia and a high level of serum IgE, which are common findings in Kimura's disease. A biopsy of the mass in the hip was performed and Kimura's disease was diagnosed. Treatment with oral prednisolone resulted in a decrease of proteinuria and regression of the subcutaneous mass. Kimura's disease should be included in the differential diagnosis of secondary MN.

Thrombotic storm in Kimura disease

We report herein a patient with Kimura disease who experienced life threatening visceral venous thromboses and a clinical course fitting the description of "thrombotic storm". Kimura disease is an indolent chronic inflammatory disease common in Asians and characterized by angiolymphoid proliferation with ample eosinophil infiltration, peripheral blood eosinophilia and elevated serum immunoglobulin E levels. The clinical course of the disease is thought to be benign. Our patient experienced a major thrombotic event with a thorough evaluation revealing no evidence of inherited thrombophilia or acquired conditions associated with visceral venous thromboembolism. Despite persisting eosinophilia and other manifestations of Kimura disease there have been no recurrent thrombotic events with continuous warfarin therapy over a 4-year period. This case highlights the occurrence of hypercoagulability in association with this unusual eosinophilic disorder.