Kimura's Disease Involving Thoracic and Abdominal Lymph Nodes in a Hemodialysis Patient
A 45-year-old man was admitted for evaluation of a series of painless, firm, movable neck masses. He had a history of tuberculous pleurisy 25 years prior to this complaint. He was also a carrier of hepatitis B virus surface antigen. He denied experiencing asthma, urticaria, or any other allergic reactions. He had received maintenance hemodialysis for 3 years, for end-stage renal disease resulting from chronic glomerulonephritis. Hemodialysis was performed 3 times weekly for 4 hours per session, using polysulfone dialysis columns. In the preceding 4 months, the patient had discovered masses in his neck. These masses had gradually increased in size. The patient had no history of fever, cold sweating, or weight loss. During the physical examination, firm and movable masses, measuring up to 3×3×2 cm (the largest one) were found. These masses were palpable with no tenderness, and were located primarily in the right anterior triangle of the neck. Although there were also several palpable masses in both the axillary and inguinal areas, no hepatosplenomegaly was detected. No warm sensations or erythema manifested on the overlying skin. Stool examinations, including ova and parasite evaluations, were negative. Laboratory findings included a hemoglobin level of 7.3 g/dL, platelet count of 200×109/L, and a white blood cell (WBC) count of 6.2 × 109/L: the differential WBC count revealed 68.9% segmented neutrophils, 10.2% lymphocytes, 8.4% monocytes, 12.1% eosinophils, and 0.4% basophils. Serum total IgE level was 261.0 IU/mL. The blood urea nitrogen and serum creatinine level were 56 mg/dL and 4.8 mg/dL. Neoplastic disease appeared to be the most likely differential diagnosis. Fine needle aspiration cytology of the neck mass revealed findings of nonspecific reactive lymphadenitis. A computed tomography (CT) scan of the neck and chest revealed masses adjacent to both sternocleidomastoid muscles, numerous lymph nodes of varying size in both axillary areas, and over lymph nodes of over 1 cm in size in the paratracheal, subcarinal, and intrapulmonary areas (). A CT scan of the abdomen and pelvis displayed multiple lymph nodes of varying size, which were enhanced in the hepatic hilum, peripancreatic area, celiac axis, and paraaortic area (the largest was 4.5 cm) (). A tumor scan using Gallium-67 demonstrated more noticeable increased uptake lesions in the left lower cervical, left axillary, paraaortic, right iliac, and both inguinal lymph nodes (). The findings from fine needle aspiration cytology were inconclusive with regard to diagnosis, thus an open biopsy was recommended. An excisional biopsy of neck masses and inguinal lymph nodes was performed. Results of histopathological examinations of the neck mass and lymph nodes revealed dense infiltration of eosinophils, lymphocytes, and histiocytes, along with many small vessels, mild fibrosis, and results consistent with KD, with no evidence of malignant lymphoma ().\nThereafter, the patient has received no specific treatment, as his symptoms, with the exception of the mass, were clinically unremarkable. After two months, physical examination revealed no neck masses, and a follow-up abdominal CT scan showed that the numerous lymph nodes of varying size had subsided spontaneously (). Until now, the patient has been progressing well on maintenance hemodialysis.