Kimura's disease: clinical and imaging parameters for the prediction of disease recurrence

Kimura Disease: A Detailed Analysis of Clinical and Radiological Manifestations in a Retrospective Case Series

Background

Kimura disease (KD) is a rare chronic inflammatory disease that affects mainly young Asian men and is characterized by painless subcutaneous masses, lymphadenopathy, and elevated serum IgE levels. Despite its benign nature, KD poses a diagnostic and therapeutic challenge due to its rarity and clinical variability.

Objective

This study aimed to provide a comprehensive analysis of the clinical and radiological features of KD in a retrospective case series, to assess treatment outcomes, and to discuss the implications for diagnosis and management.

Methods

We retrospectively analyzed four histologically confirmed cases of KD admitted to Zhejiang Provincial People's Hospital from January 2018 to October 2023. Clinical and radiological data were retrospectively analyzed, and imaging findings were analyzed by two neuroradiologists to determine lesion characteristics and contrast enhancement patterns.

Results

Our findings showed that the patients were predominantly male, with a mean age of 43 years and an age range of 13-71 years. All patients presented with painless subcutaneous masses and three of them had peripheral blood eosinophilia and elevated serum IgE levels. Radiographically, the lesions were predominantly ill-defined with heterogeneous enhancement, accompanied by subcutaneous fat atrophy. Complete surgical excision and oral corticosteroids were effective treatments, and no recurrence was noted during follow-up.

Conclusion

KD should be considered in the differential diagnosis of painless subcutaneous masses in the head and neck region, especially in the presence of eosinophilia and elevated IgE levels. Our findings contribute to the understanding of KD's clinical and radiological spectrum and highlight the need for long-term follow-up due to the risk of recurrence.

Kimura Disease: A case report with bilateral upper lid masses and a right parotid mass

A 38-year-old male presented with bilateral upper eyelid masses and a right parotid mass. Nineteen years before the consultation, the patient experienced swelling at both upper eyelids. Formerly diagnosed by an ophthalmologist, corticosteroid, an anti-inflammatory medication, was prescribed for the patient, which resulted in partial resolution of the lid swelling. However, he was lost to follow-up, and progressive enlargement of the lids was observed with the development of a right parotid mass. The visual acuity of the patient was classified as counting fingers, three feet bilaterally. A detailed examination was difficult owing to the obstructive nature of the masses. However, ocular structures appeared intact. An excisional biopsy with a reconstruction of bilateral upper lids was performed. Histopathologic findings revealed a lymphoproliferative lesion suggestive of Kimura disease (KD). The patient was subsequently referred to rheumatology for management, where they started a regimen of oral steroids and antihistamines.

Case report: Kimura's disease with minimal degenerative glomerulopathy without eosinophil infiltration responds to mycophenolate mofetil treatment

Kimura's disease (KD) is a rare chronic progressive immune inflammatory disease. The etiology is unknown and manifests as a chronic inflammatory process, which is more common in young Asian men. The clinical manifestations are painless subcutaneous swelling of the head and neck and periauricular lymphadenopathy, which is slow growing and has a benign course. KD may involve the kidney, and pathological examination revealed eosinophil infiltration in the renal tissue. Proteinuria has been reported in 12-16% of KD cases, and about 60-70% of KD patients will develop nephrotic proteinuria. KD is easily confused with nephrotic syndrome, because KD does not have specific clinical manifestations, laboratory and imaging, and early misdiagnosis is easy. We report a case of KD that was biopsy-proven to have minimal lesion glomerulopathy after ~11 years. In this report, we describe a clinical case of KD with nephrotic syndrome, but there's no eosinophil infiltration in the kidneys. The clinical manifestations of KD recurrence were bilateral eyelid edema, bilateral lower limb swelling, and massive proteinuria in response to mycophenolate mofetil treatment (1.5 g).

Kimura disease in children: A report of 11 cases and review of the literature

INTRODUCTION

Kimura disease (KD), also known as eosinophilic hyperplastic lymphoid granuloma, is a rare benign chronic inflammatory condition, which is featured with the painless progressive mass located in the subcutaneous area of the head and neck region, elevated peripheral blood eosinophils, and raised serum immunoglobulin E (IgE) levels. KD is uncommon in clinical practice, especially with low incidence in children, so it often leads to misdiagnosis or missed diagnosis in pediatric patients.

METHODS

The clinical data of 11 pediatric patients with KD in the authors' institution were retrospectively analyzed.

RESULTS

There were 11 pediatric patients with KD enrolled in total, including 9 male patients and 2 female patients (sex ratio 4.5:1). The median age at diagnosis stood at 14 years (range 5-18 years), the initial symptoms in all patients included painless subcutaneous masses and focal swelling, the duration of symptoms ranged from 1 month to 10 years, and the average duration was 24.45 months. Six patients had single lesions, and 5 had multiple lesions. The highest proportion of lesion regions were parotid gland (n = 5, 31.3%) and retroauricular (n = 5, 31.3%), followed by cervical lymph nodes (n = 4, 25%), and others (n = 2,12.5; elbow n = 1; back n = 1). The eosinophil absolute count elevated in all patients, ranging from 0.71×10⁹/L to 10.35 ×10⁹/L (normal range 0.02-0.52×10⁹/L). IgE levels were increased in all 7 patients who underwent serum immunoglobulin examination (normal range <100 IU/mL). Three patients received oral corticosteroid treatment while 2 relapsed. Three patients received surgical resection combined with oral corticosteroid treatment, and no patient relapsed. The other 3 patients received surgery and radiotherapy, surgery combined with corticosteroid and cyclosporin and corticosteroid combined with leflunomide respectively, and no patient relapsed.

CONCLUSION

Base on the study, it is found that Kimura disease is rare and may have the atypical symptoms in pediatric patients, combination therapy is recommended to reduce recurrence, and long-term follow-up should be performed.

Current concepts of Kimura disease: pathophysiology and evolution of treatment

Kimura disease (KD) is a chronic inflammatory disorder that frequently involves the subcutaneous tissue of the head and neck regions. It often manifests as regional lymphadenopathy or salivary gland enlargement in the affected area. The histologic architecture of the lymph nodes in KD patients is preserved, while the affected tissues show follicular hyperplasia and eosinophilic infiltration. No single modality has been adopted as an optimal treatment for KD. This article concentrates on the fundamental features of KD and reviews current approaches to its treatment.

Kimura disease with Allergic Bronchopulmonary Aspergillosis: a case report

Background

Kimura disease (KD) is a rare chronic idiopathic condition of unknown etiology that is prevalent in Asian males. It often causes subcutaneous lumps and enlarged lymph nodes, especially in head and neck region. But KD is also a systemic disease that can involve multiple organs, such as the kidneys and skin.

Case presentation

We report a 62-year-old Chinese man who presented with paroxysmal cough, enlarged inguinal lymph nodes, recurrent skin itching, and elevated IgE antibodies specific to A. fumigatus. After a comprehensive review, the final diagnosis for this patient was KD with Allergic Bronchopulmonary Aspergillosis (ABPA).

Conclusions

The age of onset and the location of the lump involved were not characteristic for the illness. This case report described the patient’s diagnosis and treatment process. This case report serves to arouse the attention of multidisciplinary team to explore the potential relationship between KD and ABPA. It will contribute to preventing the misdiagnosis and missed diagnosis of KD.

Kimura's disease successively affecting multiple body parts: a case-based literature review

Background

Kimura’s disease is a rare, benign, chronic inflammatory disease that presents as painless, solid masses mainly affecting the deep subcutaneous areas of the head and neck, especially the salivary glands, parotid glands and nearby lymph nodes. It is characterized by elevated peripheral blood eosinophil and Immunoglobulin E (IgE) levels.

Case presentation

A 31-year-old Asian male presented with an orbital space-occupying lesion lasting for 1.5 years. Ten years prior, surgical excision of bilateral fossa cubitalis and groin masses was performed, and the pathological examination showed "lymphoproliferative disease". One year later, masses reappeared near the surgical sites; they grew slowly and shrank after glucocorticoid treatment. At this point, admission examinations showed in the peripheral blood an eosinophil proportion of 13.4%, a total IgE level of 26,900.00 IU/mL, prurigo present on the whole body, and multiple palpable masses near the bilateral fossa cubitalis and groin. The left eyeball was exophthalmic. The left elbow mass was excised, and the pathological examination confirmed Kimura’s disease. Oral glucocorticoid therapy is taken and tapering regularly. The eosinophil count returned to normal, the IgE level gradually decreased, the orbital space-occupying lesion and elbow and groin masses shrank significantly, and the whole-body skin prurigo disappeared. Currently, the patient has been in a stable condition for eighteen months.

Conclusion

Our case provides a novel insight that Kimura’s disease should be involved in the differential diagnosis of inflammatory lesion mass of orbit and also supports systemic regular glucocorticoid as a valuable therapy of such condition, but close follow-up and long-term observation are crucial.

Kimura Disease: A Rare Cause of Head and Neck Tumour in Children- A Case Report

BACKGROUND

Kimura disease is a rare inflammatory condition classically manifested as painless subcutaneous nodules in the head and neck region and associated with regional cervical lymphadenopathy and salivary gland involvement.

OBJECTIVE

The purpose of this report is to illustrate the diagnostic difficulty due to its rarity and non-specific clinical presentation.

CASE PRESENTATION

We present a case of Kimura disease with bilateral eyelid swelling, parotid involvement, and cervical lymphadenopathy in a young boy. Computed Tomography (CT) showed ill-defined enhancing masses in both upper eyelids with lacrimal gland infiltration, multiple nodular lesions in both parotid glands, and bilateral enlargement of cervical nodes. After several multidisciplinary discussions and trials of medications, Kimura's disease was finally confirmed by histology examination.

CONCLUSION

In conclusion, a rare disease such as Kimura must be considered earlier if the patient is not responding to the treatment.

Eosinophilic interstitial nephritis and cardiac insufficiency in Kimura's disease: a case report

Background

Kimura’s disease (KD) is a rare chronic inflammatory disease and the etiology remains uncharacterized. The typical manifestations are painless lymph node or subcutaneous masses. There is currently no report of prominent renal interstitial injury and cardiac insufficiency in KD.

Case presentation

A 45-year-old man was referred to our hospital with dark urine, subcutaneous masses in forehead and right retroauricular, multiple lymphadenopathy and unexplained cardiac insufficiency. Renal biopsy demonstrated eosinophilic interstitial nephritis. Laboratory tests revealed eosinophilia and a high level of serum IgE. A biopsy of cervical lymph node was performed and KD was diagnosed. Treatment with oral prednisone resulted in a decrease of eosinophil, serum IgE, improvement of cardiac function, and regression of the subcutaneous mass.

Conclusions

We describe an extremely rare KD case presenting with eosinophilic interstitial nephritis, cardiac insufficiency and significant response to prednisone. The clinicians should improve the disease awareness and find optimal treatment.

Kimura Disease: A Case Series and Systematic Review of Clinico-radiological Features

Kimura disease is a rare chronic inflammatory disorder mostly reported in males in second to third decades from south-east Asia. Head and neck is the most commonly involved region. The usual presentation is painless facial swelling with salivary gland involvement and regional lymphadenopathy. The diagnosis can be suspected on imaging but needs to be proven on histopathology. We describe three histopathology proven cases of Kimura disease and emphasize the specific clinic-radiological findings which can help in early identification of the condition and its differentiation from other diseases with similar presentation. Gray scale Ultrasound, contrast-enhanced ultrasound, and contrast-enhanced Magnetic Resonance Imaging (CE-MRI) were done in all patients and Computed Tomography (CT) was done in one. The salient imaging features were ill-defined solid mass in the subcutaneous location of the facial region which was heteroechoic on Gray scale Ultrasound, heterogeneously hyperintense on T2W MRI and without much diffusion restriction. There was involvement of salivary glands with ipsilateral cervical adenopathy. The lesion showed avid contrast enhancement on contrast-enhanced ultrasound and CE-MRI. We also present a systematic literature review of clinico-radiological features in Kimura disease in the head and neck. The articles with histopathologically proven cases and satisfactory description of imaging findings were included and we have compared the findings in our cases with published literature. In addition, we have included examples of radiological mimics of this disease. Certain imaging findings are highly suggestive and can aid in early diagnosis of Kimura disease which helps in early initiation of treatment with better patient prognosis.

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.

Computerized tomography features and clinicopathological analysis of Kimura disease in head and neck

The aim of the current study was to discuss and analyze computerized tomography (CT) features and clinicopathological characteristics of patients with Kimura disease in head and neck. CT and clinicopathological data of 12 patients with Kimura disease diagnosed between May 2011 and May 2015 were analyzed. The mean age was 43.9 years and the disease course varied from 1 week-20 years. The mean absolute value of eosinophil granulocytes was 1.95×10⁹/l. Multiple nodules were detected in 4 patients with Kimura disease. Main symptoms included multiple enlarged lymph nodes in neck and submaxillary regions. CT imaging of nodular lesions revealed a clear boundary, with moderate to marked homogeneous enhancement. Diffuse mass lesions were observed in 6 patients with Kimura disease. Main symptoms included subcutaneous diffuse soft tissue mass in parotid gland and maxillofacial regions. CT imaging of diffuse mass revealed unclear boundaries, adjacent skin thickness and moderate heterogeneous enhancement. In some cases, the diffuse mass involved soft mass with unclear boundaries. Pathological symptoms of Kimura disease included infiltration of eosinophilia, lymphocytic proliferation, formation of lymphatic follicles and variable degrees of fibrosis and vascular proliferation. Diagnosis of Kimura disease in head and neck regions may be improved based on lesions with clear or unclear boundaries, homogeneous or heterogeneous enhancement, with or without lymphadenectasis and by the presence of peripheral blood eosinophilia. However, a final diagnosis relies on a pathological examination.

Expression of the interleukin-21 and phosphorylated extracellular signal regulated kinase 1/2 in Kimura disease

OBJECTIVE

To investigate the expressions of interleukin (IL)-21 and phosphorylated extracellular signal regulated kinase 1/2 (pERK1/2) in Kimura disease (KD) and to correlate the findings with clinical and prognostic variables.

METHODS

Immunohistochemical analysis of IL-21 and pERK1/2 was performed in 18 cases of KD and five gender- and age-matched control samples. Clinical data were extracted and patients followed up for a mean period of 32.1 months.

RESULTS

After a mean follow-up period of 32.1 months (range 1-102 months), recurrence was diagnosed as the end point for seven patients-that is, a 44% (7/16) cumulative recurrence rate. In comparison with gender- and age-matched controls, patients showed strong in situ expressions of IL-21 and pERK1/2, respectively (p<0.05). Patients with strong IL-21 staining intensity and overexpression of pERK1/2 had a lower recurrence rate than those with moderate staining intensity (p=0.049, p=0.019, respectively). However, differences were not statistically significant by gender, age, eosinophils, location, multiplicity, laterality, size, duration and primary outbreak. pERK1/2 was the independent prognostic factor (p=0.020), while age, gender, eosinophils, multiplicity, laterality, size, duration, primary outbreak and expression of IL-21 were not.

CONCLUSIONS

This study suggests that the IL-21/pERK1/2 pathway is activated in KD, and pERK1/2 might be considered as a potential prognostic indicator in KD.

Kimura's Disease without Peripheral Eosinophilia: An Unusual and Challenging Case Simulating Venous Malformation on Imaging Studies-Case Report and Review of literature

Kimura's Disease (KD) is a rare chronic inflammatory disorder presenting as multiple painless solitary subcutaneous nodules, predominantly in the head and neck region and frequently associated with regional lymphadenopathy and/or salivary gland involvement. Because of painless nature and indolent course, there is usually a delay in the patient's presentation. KD may radiologically mimic other chronic inflammatory conditions like tuberculosis, vascular malformations and neoplasms. Clinical correlation and histological evaluation along with elevated peripheral eosinophil and serum IgE level are considered important for confirmatory diagnosis. We report a case of painless swelling over right submandibular region extending to the right superficial parotid. The haematological reports were within normal limits. Ultrasound (USG), Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiogram (MRA) favoured a diagnosis of venous malformation. However, histopathological examination of excised lesion confirmed a diagnosis of KD. This case proves the possibility of the KD even in the absence of peripheral eosinophilia and/ or elevated serum IgE level, and may mimic venous malformation on imaging studies. Therefore, KD must find a place in the differentials of solitary painless neck swelling even in the absence of peripheral eosinophilia and/or elevated IgE level.

[An indolent and fluctuating subcutaneous mass of the skull in a 5-year-old patient: Diagnostic approach and difficulties]

A subcutaneous mass of the skull in children can have many different causes (infectious, tumoral, and inflammatory). We report on the case of a 5-year-old patient with a subcutaneous mass of the skull evolving over several months. The first pathological analysis concluded in Kimura disease. The progression and scarcity of this entity in children led to a second pathological analysis that showed lymphoblastic lymphoma B (LLB). This case reminds us that when there are discrepancies between pathological conclusions and clinical progression of a tumoral process, repeated analysis and immunochemistry are necessary.

Kimura's disease of the right cheek: A case report

Kimura's disease (KD), a chronic inflammatory disease of uncertain etiology, manifests as a painless subcutaneous swelling in the head and neck region that involves major salivary glands and regional lymph nodes. To date, the majority of cases of KD have been documented in Asian males aged 20-30 years. However, the number of reported cases of KD involving the oral and maxillofacial area is limited, and since the masses appear similar to cysts or benign tumors, the establishment of an accurate pre-operative diagnosis is challenging. The accurate diagnosis of KD is considered to require surgical excision followed by histopathological examination. In the current case, a 39-year-old man was admitted to hospital in October 2011 with a swelling evident on his right cheek. Surgical excision was performed, and histopathological observation was carried out. The formation of a lymphoid nodule accompanied by the vigorous proliferation of small blood vessels, eosinophilic infiltration and thickened cell walls were observed. No sign of recurrence of the mass has yet been observed, on the basis of the telephone follow-up interviews. These findings provide a novel insight useful in the diagnosis of KD in the oral and maxillofacial area.

Recurrent Kimura Disease of the Inner Canthus With No Lymphadenopathy

The Kimura disease is a benign rare inflammatory condition of the soft tissue, especially of the head and neck region presenting as painless nodule with or without lymphadenopathy. This condition with unknown etiology is seen mainly in Asian males, in their thirties. The authors' present a 39-year-old man with the Kimura disease in the inner canthus of his OS and no lymphadenopathy. The subcutaneous nodule was excised, and on histopathological study it was confirmed as the Kimura disease. He presented with a larger recurrence after 1 year. It was fixed to the underlying bone. Excision biopsy proved it to be the Kimura disease. To the authors' knowledge, this is the first report of the Kimura disease affecting ocular structures. The Kimura disease, although a rare condition, should be considered in the differential diagnosis of the primary and recurrent masses arising from the inner canthus of the eye.

Kimura's disease involving the peripheral nerve of the arm in a child: a case report

A 7-year-old Korean boy was referred for a nontender mass in the left arm. He had a 5-year history of a poorly defined painless mass on the medial side of the left elbow. The ultrasonogram of the left arm indicated an ill-defined, lobulating solid mass involving the deep soft tissue layer. The fat-suppressed T2-weighted magnetic resonance image showed a poorly marginated, homogeneous high-signal intensity mass. On further follow-up of 1 year and 6 months, the mass showed no change in size and nature. At surgery, a poorly demarcated inflammatory mass was dissected from a branch of the superficial radial nerve and excised completely. There was no recurrence and any dysfunction, except temporary localized hypoesthesia of the medial aspect of the left arm at the 3.6-year follow-up.

Angiolymphoid hyperplasia with eosinophilia: a clinicopathologic study of 9 cases

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare disease characterized by single or multiple angiomatous lesions typically located on the scalp and the face. We present a retrospective analysis of 9 cases of ALHE. The lesions appeared largely as multiple grouped papules or, in some cases, subcutaneous nodules, located mainly on the scalp, particularly around the ear. We also observed lesions in atypical locations, such as areas of the head other than the scalp, and the shoulder, neck, and forearm. At these sites the lesions had an atypical clinical appearance that made diagnosis difficult; this should be borne in mind in patients with single, well-delimited lesions with a vascular appearance and superficial ulceration or crusting. Surgery was the most common treatment in our series, and even though ALHE is considered a benign condition, recurrence was common.