The lymphatic system is an essential part of our body's natural defence system against infections. In this article, Dr Anuj Rastogi shares his experience of diagnosing Kikuchi's illness in a patient with lymphadenopathy.

Swollen lymph nodes

Since all the entry points of our body are enriched with lymphatic supply, it is very common to see enlarged lymph nodes, chiefly in the area of the neck or frequently in the inguinal area of children.  After reaching a peak size between the ages of 5 and 6 years, lymph nodes begin to shrink. When they are 12 to 15 years old, they either return to their normal size or start to act deceptively.

There are 600 glands in our entire body, out of which 300 are in the head and neck region and the remaining 300 are in the lower body. 150 of the 300 lower glands in our body are located in the abdominal region. Amidst the advancement of technology in the ultrasound machine, it became easier to pick mesenteric lymph nodes in the abdomen area. Their size became a matter of concern for parents as well as doctors, despite the fact that they are just a normal variation of mesenteric lymph nodes.

When treating a patient with lymphadenopathy, you should focus on the entire body's examination rather than just the lymph nodes. Even today, most of us begin treating these lymph nodes for tuberculosis either because of their enlargement or the Mantoux (Mx) test. Lymph node Fine Needle Aspiration Cytology (FNAC) is rarely conclusive. Immunohistochemistry in conjunction with lymph node biopsy is the only test that has true validity.

The case

Recently, I came across a child who had high-grade fever that had been intermittent for the previous four months along with left-sided supraclavicular lymph nodes. His Fine Needle Aspiration Cytology (FNAC) test was negative as usual.

He was being treated in the ward of an ENT surgeon when he had a lymph node biopsy, and the results showed central necrosis. After receiving ATT for three weeks, there was no improvement. The patient was then brought to my clinic.

Diagnosis

My analysis revealed that his growth profile was not consistent with tuberculosis. He was a well-cared-for child, and there was no history of tuberculosis in his family. In light of the strong tendency towards Kikuchi disease in the differential diagnosis of central necrosis of lymph nodes, I sent his immunohistochemistry IHC to core diagnostic, which validated the diagnosis of Kikuchi disease by showing histiocytes with CD68 markers.

Treatment

Presently, the child is on a low dose of omnacortil and hydroxychloroquine post the diagnosis of recurrent Kikuchi disease and now he is doing well. His steroid treatment is about to end.

A takeaway message for all doctors

An accurate diagnosis can be attained by taking into account factors such as family history, growth percentile and area epidemiology, which are all extremely significant things to take into account.

Instead of making a diagnosis based just on one element and narrowing our vision, we should explore the other possible causes. Common diseases are indeed prevalent but when things do not go as planned, uncommon diseases also need attention.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising paediatrician from Meerut.