A 56-year-old Iranian woman presented with a one-month history of low-grade fever with generalized malaise, loss of weight, and loss of appetite, and she had noticed swelling of neck glands for the similar duration. She denied any joint pains, increased hair loss, or oral ulcers. She did not have chronic cough, sore throat, or ear discharge. The patient denied any alteration of bowel habits or melena. She denied any past history and contact history of tuberculosis or any high-risk sex behaviours. Her past medical history was significant for hypertension and dyslipidemia. One month prior to this presentation, she was seen by a rheumatologist with inflammatory bilateral knee joint arthritis. Her investigations were significant for thrombocytopenia of 109 x 109/L (150-400 x 109/L). There was no involvement of other cell lines. In the workup for the ANA, rheumatoid factor and anti-CCP were negative.
On examination, she was febrile. She was neither pale nor icteric. She had firm, tender discrete lymphadenopathy, the largest measuring 2 cm, in the right upper cervical region. Respiratory and cardiovascular system examinations were normal. Abdominal examination was normal without evidence of organomegaly.
Neck ultrasonography revealed multiple cervical lymph nodes in the cervical region, the largest of which was 24 mm in size in the right submandibular, as well as numerous lymphadenopathies were seen in the right axillary region. Her blood investigations are summarized in Table 1.
The patient was treated with a course of oral antibiotics considering the possibility of bacterial lymphadenopathy (co-amoxiclav and metronidazole). No improvement in symptomatology was observed over 7-day course of antibiotics, and in addition, she was noted to have a generalized urticarial skin rash.
She underwent excision biopsy of the cervical lymph node. Histopathology revealed areas of necrosis, infiltrated with nuclear dust, paucity of granulocytes, and surrounding tissue showing mononuclear cells and reported as "benign acute necrotizing lymphadenitis" which was compatible with Kikuchi's disease. She made an uneventful recovery with normalization of hematological and biochemical parameters without a specific treatment over a period of few weeks.
One year later, she was seen in the hospital with low-grade fever, malaise, loss of appetite, and loss of weight with cervical lymphadenopathy, and repeat biopsy of the cervical lymph nodes revealed similar histopathology compatible with Kikuchi's disease. She was managed conservatively, and the patient made a full recovery. Currently, she is asymptomatic and under follow-up.