kimura 's disease ( kd ) is a rare benign disorder of unknown etiology , and is observed primarily in young asian men .
kd may the result of an allergic or chronic inflammatory response , preferentially occurring in the head and neck .
the clinical symptoms are usually manifest either as painless unilateral lymphadenopathy , predominantly in the head or neck region , or elevated serum immunoglobulin ( ig ) e and eosinophilia1,2 ) .
kd lesions usually precede or coincide with the development of renal disease2,8 ) . early diagnosis and recognition of kd
may spare both patient and doctor from the need for unnecessary invasive diagnostic procedures . in the present case ,
the patient exhibited an unusual case of kd , occurring during hemodialysis , involving the thoracic and abdominal lymph nodes , which resolved itself spontaneously , and nearly completely , after two months .
a 45-year - old man was admitted for evaluation of a series of painless , firm , movable neck masses .
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 no history of fever , cold sweating , or weight loss . during the physical examination ,
firm and movable masses , measuring up to 332 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 .
laboratory findings included a hemoglobin level of 7.3 g / dl , platelet count of 20010/l , and a white blood cell ( wbc ) count of 6.2  10/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 .
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 ( figure 1a ) .
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 ) ( figure 1b ) .
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 ( figure 2 ) .
the findings from fine needle aspiration cytology were inconclusive with regard to diagnosis , thus an open biopsy was recommended .
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 ( figure 3 ) .
thereafter , 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 ( figure 4 ) .
although its etiology remains unknown , it has been tentatively suggested that kd is the result of an aberrant allergic or chronic inflammatory response to viral , bacterial or parasitic infection3 - 5 ) .
kd usually manifests as a tumor - like lesion , showing a predilection for head and neck sites .
systemic manifestations of kd are characterized by elevated serum ige , eosinophilia , and renal diseases , including focal segmental glomerulosclerosis , iga nephropathy , minimal change disease , membranous nephropathy , and igm nephropathy6 - 8 ) .
clinical symptoms of kd normally precede or coincide with the development of renal disease2,8 ) .
neck masses that were incidentally detected in end - stage renal disease patients were first considered in terms of differential diagnoses , possibly as neoplastic disease or infection , such as tuberculosis , in asian patients .
clinically , kd may often be confused with malignant lymphoma or other metastatic cancers9 ) .
consequently , a patient with kd is often unnecessarily evaluated for symptoms of far more serious diseases10 ) .
it is difficult to diagnose kd without a tissue biopsy , and fine needle aspiration cytology has only limited value in such cases . in the present case ,
, we were also unable to differentiate these lesions from malignant lymphoma or metastasis . unlike most cases , our patient exhibited multiple lymphadenopathy , including thoracic , abdominal , neck , axillary , and inguinal lymph nodes .
histopathological analyses of the neck mass and lymph nodes revealed no signs of malignant lymphoma .
in contrast , alhe occurs in all racial groups , showing a slight predominance in females11 ) .
regional lymphadenopathy , serum eosinophilia , and elevated ige levels are rare in cases of alhe .
kd typically manifests several histologic features , such as predominant eosinophilic infiltration with follicular hyperplasia , fibrocollagenous change , and vascular proliferation . however , vascular proliferation is more significant in alhe . in alhe
, vessels are aggregated and lined by plump cuboidal , or occasional hobnail , endothelial cells , with frequent cytologic atypia and vacuolization .
however , these angiomatoid features are never observed in cases of kd12 ) . in our case , we observed no vessels lined by plump cuboidal endothelial cells suggesting alhe , and there were characteristic and distinctive clinical features suggesting kd .
we have no evidence that would explain this relationship between kd and end - stage renal disease in our patient .
the treatment of kd involves one of three major approaches : surgical excision , irradiation , or steroid therapy .
our patient had no complaints or symptoms , with the exception of the aforementioned palpable masses .
thus , the patient has received conservative treatment while undergoing regular checkups . in conclusion , a high index of suspicion regarding kd
the early diagnosis and recognition of kd may spare both patient and doctor from the need for unnecessary invasive diagnostic procedures . to our knowledge , this is the first case of kd occurring during hemodialysis , involving thoracic and abdominal lymph nodes , which resolved itself both spontaneously , and nearly completely , after two months .
 we report the first observed case of kimura 's disease occurring during hemodialysis , involving the thoracic and abdominal lymph nodes , which spontaneously resolved nearly completely after two months . 
 early diagnosis and recognition of kimura 's disease may spare both the patient and doctor from the need for unnecessary invasive diagnostic procedures . 
 therefore , we emphasize that we need to have a high index of suspicion regarding kimura 's disease . 
INTRODUCTION
CASE REPORT
DISCUSSION