Kikuchiûs Disease : √“¬ß“πºŸâªÉ

90 «“√ “√»Ÿπ¬å°“√»÷°…“·æ∑¬»“ µ√å§≈‘π‘° ‚√ß欓∫“≈æ√–ª°‡°≈â“
ªï∑’Ë 23 ©∫—∫∑’Ë 2 ‡¡.¬. - ¡‘.¬. 2549
√“¬ß“πºŸªâ «É ¬
Kikuchiûs Disease : √“¬ß“πºŸâªÉ«¬Àπ÷Ëß√“¬∑’Ë¡“
¥â«¬µàÕ¡πÈ”‡À≈◊Õß∑’˧Ղµ
«— ¥‘Ï ‡®’¬¡®‘µ æ.∫.*
Abstract
Kikuchiûs Disease Present with Cervical Lymphadenopathy : A Case Report
Sawat Jaemjit M.D.*
* Department Otolaryngology Maharat Naknon Ratchasima Hospital, Nakhonrachasima
province, Thailand.
J Prapokklao Hosp Clin Med Educat Center 2006;23:90-94.
Kikuchiûs disease, also known as Kikuchi-Fujimoto disease or histiocytic necrotizing
lymphadenitis that is a rare disease of cervical lymphadenitis. It mostly affects young Asian
women and is being increasingly recognized in worldwide. It resolves spontaneously, usually
over a period of several weeks to 3 months, rarely to 6 months. Cervical lymphadenopathy is
the most prominent symptom and should be differentiated from lymphoproliferative, autoimmune
and postinfectious diseases. A 37-year-old Thai woman with history of a left cervical mass
for 6 month was persented with Kikuchiûs disease at Nakornratchasima regional hospital.
∫∑π”
æ∫„π‡æ»À≠‘ß¡“°°«à“‡æ»™“¬ „π™à«ßÕ“¬ÿª≈“¬¬’Ë ‘∫
ªï∂÷ßµâπÕ“¬ÿ “¡ ‘∫ªï3 Õ“°“√· ¥ß¡“¥â«¬µàÕ¡πÈ”‡À≈◊Õß
∫√‘‡«≥§Õ‚µ ¡’ ‰¢â ÕàÕπ‡æ≈’¬ πÈ”Àπ—°≈¥ ª«¥µ“¡¢âÕ
¡â“¡‚µ ÕÕ°º◊Ëπ °“√¥”‡π‘π‚√§À“¬‰¥â‡Õß ‚¥¬„™â√–¬–
‡«≈“ 2-3 —ª¥“Àå ‰¡à‡°‘π 6 ‡¥◊Õπ Õ“°“√µàÕ¡πÈ”‡À≈◊Õß
∫√‘‡«≥§Õ‚µ¡—°®–‡ªìπÕ“°“√‡¥àπ ´÷Ëß∑”„ÀâµâÕß«‘π‘®©—¬
·¬°‚√§ÕÕ°®“°‚√§„π°≈ÿ à ¡ lymphoproliferative,
autoimmune, ·≈– postinfections
Kikuchiûs disease ‡ªìπ‚√§∑’√Ë ®âŸ °— ¥’„π°≈ÿ¡à 欓∏‘
·æ∑¬å·µà ”À√—∫∑“ß‚ µ »Õ π“ ‘° ¡’√“¬ß“πºŸâªÉ«¬
‡ªìπ§√—Èß·√°‡¡◊ËÕªï æ.». 2528 ‚¥¬ Gleeson ·≈–§≥–4
Kikuchiûs disease À√◊Õ Kikuchi-Fujimoto
disease À√◊Õ histiocytic necrotizing lymphadenitis
‡ªì π ‚√§∑’ Ë æ ∫‰¥â π â Õ ¬‚¥¬¡’ ° “√√“¬ß“π‡ªì π §√— È ß ·√°
æ√âÕ¡°—π∑’ªË √–‡∑»≠’ªË πÉÿ ªï æ.».1972 ‚¥¬‡ªìπ√“¬ß“π
¢Õß Kikuchi1 °—∫√“¬ß“π¢Õß Fujimoto ·≈–§≥–2
√“¬ß“πºŸâªÉ«¬ à«π„À≠à®–Õ¬Ÿà „π∑«’ª‡Õ‡™’¬ ‡™àπ ≠’˪ÿÉπ
‡°“À≈’ ŒàÕß°ß ªí®®ÿ∫—π ¡’√“¬ß“πæ∫°√–®“¬∑—Ë«‚≈°
“‡Àµÿ¢Õß‚√§¬—߉¡à∑√“∫·πà™—¥ ·µà¡’°“√ —ππ‘…∞“π«à“
¿“«–µ‘¥‡™◊ÈÕ parasite, bacteria, EBV À√◊Õ‚√§„π°≈ÿà¡
autoimmune Õ“®®–‡ªìπªí®®—¬∑’Ë∑”„À⇰‘¥‚√§‰¥â ¡—°
* °≈ÿà¡ß“π‚ µ »Õ π“ ‘°«‘∑¬“ ‚√ß欓∫“≈¡À“√“™π§√√“™ ’¡“ ®—ßÀ«—¥π§√√“™ ’¡“
Vol. 23 No. 2 Apr. - Jun. 2006
J Prapokklao Hosp Clin Med Educat Center 91
µàÕ¡“‡√‘Ë¡¡’√“¬ß“π°“√µ√«®æ∫‚√§‡æ‘Ë¡¢÷Èπ¡“‡√◊ËÕ¬ Ê histiocytes admixed with cellular debris and nuclear
”À√— ∫ ª√–‡∑»‰∑¬¡’ √ “¬ß“πºŸ â ª É « ¬ 1 √“¬‚¥¬ dust. ¥—ß√Ÿª
Fooanant S. ·≈–§≥–5 ‡π◊ÕË ß®“°ºŸªâ «É ¬∑’‡Ë ªìπ‚√§π’¡È °— ‰¥â
√—∫°“√«‘π‘®©—¬‚√§®“°°“√µ—¥µàÕ¡πÈ”‡À≈◊Õß (lymph
node biopsy) ∫√‘‡«≥§Õ‡æ◊ËÕµ√«®™‘Èπ‡π◊ÈÕ ¥—ßπ—Èπ·æ∑¬å
®÷ߧ«√µ√–Àπ—°·≈–√–≈÷°∂÷ß‚√§π’È ‰«â¥â«¬·¡â®–‡ªìπ‚√§∑’Ë
æ∫‰¥âπâÕ¬°Áµ“¡ √“¬ß“π©∫—∫π’È®÷ߢÕ𔇠πÕ√“¬ß“π
ºŸªâ «É ¬1 √“¬∑’¡Ë “¥â«¬Õ“°“√µàÕ¡πÈ”‡À≈◊Õß∫√‘‡«≥§Õ‚µ·≈–
‰¥â√—∫°“√«‘π‘®©—¬‡ªìπ Kikuchiûs disease
√“¬ß“πºŸªâ «É ¬
ºŸâªÉ«¬À≠‘߉∑¬Õ“¬ÿ 37 ªï Õ“™’æ√—∫®â“ß ∑’ËÕ¬Ÿà
®—ßÀ«—¥π§√√“™ ’¡“ ‰¥â‡¢â“√—∫°“√µ√«®√—°…“∑’Ë·ºπ° ÀŸ
§Õ ®¡Ÿ° ‚√ß欓∫“≈¡À“√“™ ®—ßÀ«—¥π§√√“™ ’¡“
‡¡◊ËÕ‡¥◊Õπ°ÿ¡¿“æ—π∏å æ.». 2548 ¥â«¬Õ“°“√¡’°âÕπ∑’˧Õ
¢â“ߴ⓬¡“ª√–¡“≥ 6 ‡¥◊Õπ ºŸâªÉ«¬‰¡à¡’Õ“°“√‡®Á∫
∫√‘‡«≥°âÕπ ‰¡à¡’ ‰¢â πÈ”Àπ—°§ß∑’Ë ‰¡à¡’Õ“°“√√à«¡Õ◊Ëπ Ê
µ√«®√à“ß°“¬æ∫°âÕπ¢π“¥
‡ âπºà“π»Ÿπ¬å°≈“ß 1.5 ‡´πµ‘‡¡µ√ ∑’Ë∫√‘‡«≥
posterior triangle ¢Õߧեâ“π´â“¬°âÕπ¡’≈—°…≥– firm,
movable, not tender, smooth surface µ√«®
√à“ß°“¬„π‚æ√ß®¡Ÿ°
À≈—ß‚æ√ß®¡Ÿ° „π™àÕߪ“° ™àÕß§Õ ·≈–°≈àÕß
‡ ’¬ß ‰¡àæ∫§«“¡º‘¥ª°µ‘Õ◊Ëπ Ê
º≈µ√«®∑“ßÀâÕߪؑ∫µ— °‘ “√ CBC æ∫ Hct 39.6%
WBC 10,000 (NE 65%, LY 21 %, MO 7 %) Plt 362,000
·≈– Anti HIV - ve À≈—ß®“°ºŸâªÉ«¬‰¥â√—∫¬“ªØ‘™’«π–
cloxacillin 500 mg. «—π≈– 4 §√—Èß π“π 2 —ª¥“Àå æ∫«à“
°âÕπ‰¡à¬ÿ∫≈ß ®÷߇¢â“√—∫°“√ºà“µ—¥°âÕπ (excision biopsy)
‡æ◊ËÕµ√«®∑“ß欓∏‘«‘∑¬“ °âÕπµàÕ¡πÈ”‡À≈◊Õß¡’≈—°…≥–
∑“ß®ÿ≈欓∏‘«‘∑¬“ §◊Õ
The lymph node architecture is partially
maintained and residual follicles show reactive
germinal centers. Geographic large areas of necrosis
is seen. The necrosis consists of nuclear fragments
surrounded by large accumulations of palely staining
°“√«‘π‘®©—¬§◊Õ acute necrotizing histiocytic
lymphadenitis À√◊Õ Kikuchiûs disease ¿“¬À≈—ß®“°
ºà“µ—¥°âÕπ·≈–µ√«®µ‘¥µ“¡ºŸâªÉ«¬π“π 6 ‡¥◊Õπ (®π∂÷ß
¢≥–π’È) æ∫«à“≈—°…≥–∫“¥·º≈À“¬‡ªìπª°µ‘¥’ ‰¡à¡’°âÕπ
·≈–ºŸâªÉ«¬‰¡à¡’Õ“°“√º‘¥ª°µ‘·µàÕ¬à“ß„¥
«‘®“√≥å
Kikuchiûs disease ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬„π∑«’ª
‡Õ‡™’¬„πÕ—µ√“‡æ»À≠‘ßµàՇ滙“¬‚¥¬ª√–¡“≥ 3-4: 16
‚¥¬¡—°®–æ∫„π™à«ßÕ“¬ÿª≈“¬¬’Ë ‘∫ªï∂÷ßµâπÕ“¬ÿÀâ“ ‘∫ªï
(Õ“¬ÿ‡©≈’ˬ 30 ªï) æ∫¡“°„πª√–‡∑»≠’˪ÿÉπ·≈–‡ªìπ
ª√–‡∑»·√°∑’Ë¡’√“¬ß“πæ∫ºŸâªÉ«¬ µàÕ¡“®÷ß¡’√“¬ß“π
°“√µ√«®æ∫‚√§™π‘¥π’È„πª√–‡∑»Õ◊Ëπ Ê ∑—Ë«‚≈°
“‡Àµÿ¢Õß°“√‡°‘¥‚√§¬—߉¡à∑√“∫·πà™¥— ‰¡àæ∫
«à“æ—π∏ÿ°√√¡À√◊Õ ¿“æ·«¥≈âÕ¡‡ªìπªí®®—¬„À⇰‘¥‚√§∑’Ë
™—¥‡®π·µà¡’¢âÕ —ππ‘∞“π«à“Õ“®¡’ “‡Àµÿ®“°°“√µ‘¥‡™◊ÈÕ
µà“ß Ê7 ‡™àπ ¿“«–°“√µ‘¥‡™◊ÈÕ®“°‰«√— ( rubella virus,
paramyxovirus ·≈–parainfluenza virus ) À√◊Õ °“√
µ‘¥‡™◊ÈÕ®“°ª“√“ ‘µ (toxoplasma) ·≈–°“√µ‘¥‡™◊ÈÕ®“°
·∫§∑’‡√’¬ (Yersinia enterocolitica)3,7
Õ“°“√·≈–Õ“°“√· ¥ß ¡“°°«à“À√◊Õ‡∑à“°—∫
√â Õ ¬≈– 80 3,6,7,8,9 ¢ÕߺŸ â ª É « ¬¡— ° ®–¡“æ∫·æ∑¬å ¥ â « ¬
Õ“°“√µàÕ¡πÈ”‡À≈◊Õß∑’˧Ղµ ‰¡à¡’Õ“°“√‡®Á∫∑’Ë°âÕπ8
À√◊Õ‡®Á∫πâÕ¬ (mild tender)3 ‚¥¬ºŸâªÉ«¬∑’Ë¡’°âÕπµàÕ¡πÈ”
‡À≈◊Õß∑’˧Ղµ¡—°æ∫∑’Ë∫√‘‡«≥ posterior triangle √âÕ¬≈–
65-70 ·≈–æ∫∫√‘‡«≥Õ◊Ëπ Ê ‰¥âπâÕ¬ ‡™àπ axillary node
92 «“√ “√»Ÿπ¬å°“√»÷°…“·æ∑¬»“ µ√å§≈‘π‘° ‚√ß欓∫“≈æ√–ª°‡°≈â“
√âÕ¬≈– 149 À√◊Õ supraclavicular node √âÕ¬≈– 129
„π®”π«ππ’È√âÕ¬≈– 79 ‡ªìπºŸâªÉ«¬∑’Ë¡’°âÕπµàÕ¡πÈ”‡À≈◊Õß
‚µ¢â“߇¥’¬« (unilateral cervical) à«π∑’ˇÀ≈◊Õ√âÕ¬≈– 21
‡ªìπºŸâªÉ«¬∑’Ëæ∫°âÕπ‚µ∑—Èß Õߢâ“ß (bilateral cervical)
¢π“¥¢Õß°âÕπ à«π„À≠àæ∫‰¥âµ—Èß·µà 1-4 ´¡.·µàÕ“®æ∫
°âÕπ‚µ¢π“¥ 5-6 ´¡.‰¥â „π∫“ß√“¬6 πÕ°®“°π’ÈÕ“®æ∫
Õ“°“√Õ◊ËπÊ√à«¡¥â«¬‡™àπ ¡’ ‰¢â µ—∫¡â“¡‚µ ª«¥»’√…–
§≈◊Ëπ‰ â Õ“‡®’¬π º◊Ëπ∑’˺‘«Àπ—ß ª«¥¢âÕ ·≈–Õ◊Ëπ Ê
Kikuchiûs disease ¡’§«“¡ —¡æ—π∏å°—∫‚√§
SLE ‚¥¬Õ“®®–«‘π‘®©—¬‡ªìπ‚√§‰¥âæ√âÕ¡°—πµ—Èß·µà‡√‘Ë¡µâπ
À√◊Õ¿“¬À≈—ß®“°«‘π‘®©—¬‚√§ Kikuchiûs disease ·≈â«
®÷ßµ√«®æ∫‚√§ SLE ´÷ËßÕ“®„™â√–¬–‡«≈“µ—Èß·µà 10 ‡¥◊Õπ
∂÷ß 3 ªï10 ¥—ßπ—Èπ®÷ߧ«√¡’°“√µ‘¥µ“¡°“√√—°…“ºŸâªÉ«¬„π
√–¬–¬“« ·≈–‡ΩÑ“√–«—ß°“√‡°‘¥‚√§ SLE √à«¡¥â«¬
°“√«‘π®‘ ©—¬·¬°‚√§ ‡π◊ÕË ß®“°ºŸªâ «É ¬¡—°®–¡“¥â«¬
Õ“°“√¡’µàÕ¡πÈ”‡À≈◊Õß∑’˧Ղµ °“√«‘π‘®©—¬·¬°‚√§¡—°®–
Õ¬Ÿà „π°≈ÿà¡‚√§¥—ßµàÕ‰ªπ’È
1. °“√µ‘¥‡™◊ÕÈ ( infection) ‡™à𠉫√— ·∫§∑’‡√’¬
ª“√“ ‘µ
2. Autoimmune ‡™àπ SLE
3. Malignant ‡™àπ lymphoma ‡π◊ËÕß®“°
Kikuchiûs disease ¡—°‰¥â√—∫°“√«‘π‘®©—¬‚√§º‘¥‡ªìπ
lymphoma ‰¥â∂÷ß√âÕ¬≈– 408, metastatic carcinoma
°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‰¡à “¡“√∂¬◊π¬—π
°“√«‘π‘®©—¬‰¥â ·µà™à«¬„π°“√«‘π‘®©—¬·¬°‚√§Õ◊Ëπ11 ‡™àπ
SLE ºŸâªÉ«¬¥â«¬‚√§ Kikuchi ª√–¡“≥√âÕ¬≈– 503 ¡—°æ∫
¿“«–‡¡Á¥‡≈◊Õ¥¢“«µË”‡≈Á°πâÕ¬ (mild granulocytopenia)
·≈–Õ“®®–æ∫§à“ ESR ·≈– C- reactive protein Ÿß3
πÕ°®“°π—Èπ°“√∑” fine needle aspiration
(FNA) ¢ÕßµàÕ¡πÈ”‡À≈◊Õß Õ“®®–™à«¬„π°“√ π—∫ πÿπ
°“√«‘π‘®©—¬ (suggest) ·µà ‰¡à “¡“√∂„™â „π°“√«‘π‘®©—¬
‚√§‰¥âÕ¬à“߉√ °Áµ“¡≈—°…≥–®”‡æ“– (typical finding)
∑’Ëæ∫‰¥â „π°“√µ√«® fine needle aspiration 3 §◊Õ
lymphocytes (small and atypical), reactive
phagocytic histiocytes, and çintense extracellular
debrisé
ªï∑’Ë 23 ©∫—∫∑’Ë 2 ‡¡.¬. - ¡‘.¬. 2549
”À√—∫ definite diagnosis ¢Õß‚√§ Kikuchiûs
„™â«‘∏’°“√µ—¥°âÕπµàÕ¡πÈ”‡À≈◊Õß (lymph node biopsy)
¡“µ√«®®ÿ≈欓∏‘«‘∑¬“ (histopathology) ´÷Ëß®–æ∫
欓∏‘ ¿“æ histopathology ‰¥â 3 ≈—°…≥– §◊Õ
proliferative, necrotizing ·≈– xanthomatous3,12 ´÷Ëß®–
µâÕßæ∫¢âÕ∫àß™’È (critiria)6 µ“¡≈—°…≥–µàÕ‰ªπ’È
1. patchy irregular areas of eosinophilic
necrosis in the paracortex and/or cortex
2. pronounced fragments of nuclear dust
distributed in an irregular fashion through the area
of necrosis
3. absence of granulocytes and paucity of
plasma cells
4. clusters of plasmacytoid T cells, or
plasmacytoid monocytes, and
5. numerous immunoblasts ( transformed
lymphocytes, predominantly of T cell phenotype).
à«π„À≠ຟâªÉ«¬∑’ˇªìπ‚√§ Kikuchiûs ®–¡’Õ“°“√
¥’¢÷Èπ¿“¬„π 2-3 —ª¥“Àå ·≈–À“¬‰¥â‡Õß (self limited
disease) ‚¥¬√–¬–‡«≈“°“√¥”‡π‘π‚√§‰¡à‡°‘π 6 ‡¥◊Õπ3
·≈–‰¡àµâÕß°“√°“√√—°…“∑’Ë®”‡æ“– À≈—°¢Õß°“√√—°…“
‚√§„™â«‘∏’°“√√—°…“·∫∫ª√–§—∫ª√–§Õß (supportive)
‚¥¬°“√„™â¬“„π°≈ÿà¡ nonsteroidal anti- inflammatory
drug9 ¬°‡«âπ„π√“¬∑’Ë¡’ªí≠À“À√◊Õæ∫√à«¡°—∫‚√§Õ◊Ëπ Ê
‡™àπ SLE ´÷Ëß®–„À⬓„π°≈ÿà¡ corticosteroid6 Õ¬à“߉√
°Áµ“¡¡’ºŸâªÉ«¬∫“ß√“¬∑’Ë¡’Õ“°“√π“π‰ª°«à“π’È ‰¥â ®÷ß¡’
√“¬ß“π∫“ß©∫—∫‡ πÕ„Àℙ⫑∏’ excision biopsy ‡æ◊ËÕ
µ—¥°âÕπ∑’Ë¡’欓∏‘ ¿“æÕÕ° ´÷Ëß®–™à«¬∑”„À⺟âªÉ«¬À“¬
®“°‚√§‰¥â‡√Á«¬‘Ëߢ÷Èπ8,9
°“√°≈—∫‡ªìπ´È” (recurrence of the disease)
æ∫ºŸâªÉ«¬√âÕ¬≈– 3.310,12 °≈—∫¡“‡ªìπ‚√§π’ȴȔՒ°¿“¬„π
√–¬–‡«≈“ 4-7 ªï À≈—ß®“°°“√«‘π‘®©—¬‚√§§√—Èß·√°
‚¥¬„π°≈ÿà¡∑’Ë°≈—∫¡“‡ªìπ‚√§´È”Õ’°√âÕ¬≈– 80 æ∫°âÕπ
µàÕ¡πÈ”‡À≈◊Õ߬ÿ∫À“¬‰¥â‡Õß¿“¬„π 6 ‡¥◊Õπ ‚¥¬‰¡à ‰¥â√—∫
°“√√—°…“„¥ Ê
¡’√“¬ß“πæ∫ºŸâªÉ«¬ Kikuchiûs ‡ ’¬™’«‘µ 2 √“¬
Vol. 23 No. 2 Apr. - Jun. 2006
‚¥¬ºŸâªÉ«¬ 1 √“¬ “‡Àµÿ°“√µ“¬‡π◊ËÕß®“° lupus-like
syndrome13 √“¬∑’Ë 2 “‡Àµÿ°“√µ“¬‡π◊ËÕß®“°À—«„®
≈⡇À≈«·∫∫‡©’¬∫æ≈—π (sudden heart failure)¿“¬
À≈—ß®“°°“√µ—¥°âÕπµàÕ¡πÈ”‡À≈◊Õß∑’˧ա“µ√«®‰¥â‡æ’¬ß
72 ™¡.14
√ÿª
‚√§ Kikuchiûs ‡ªìπ‚√§∑’Ëæ∫‰¥âπâÕ¬·≈–‡ªìπ
‚√§∑’ËÀ“¬‰¥â‡Õß¿“¬„π√–¬–‡«≈“ª√–¡“≥ 6 ‡¥◊Õπ
‡ªìπ‚√§∑’Ë¡’§«“¡ ”§—≠∑’Ë®–µâÕß«‘π‘®©—¬·¬°‚√§Õ◊Ëπ Ê ∑’Ë
‡ªìπÕ—πµ√“¬∑’Ë∑”„À⇰‘¥µàÕ¡πÈ”‡À≈◊Õß∑’˧Ղµ ‡π◊ËÕß®“°
°“√¥”‡π‘π‚√§·≈–°“√√—°…“¡’§«“¡·µ°µà“ß°—π‡ªìπ
Õ¬à“ß¡“°°—∫‚√§Õ◊ËπÊ ‚¥¬°“√∑” excision biopsy „π
√“¬∑’Ë¡’µàÕ¡πÈ”‡À≈◊Õß‚µπ“π°«à“ Õß —ª¥“Àå
Referrences
1. Kikuchi M. Lymphadenitis showing focal
reticulum cell hyperplasia with nuclear debris
and phagocytes : a clinicopathological stuty.
Nippon Ketsueki Gakkai Zasshi 1972;35:
379-80.
2. Fujimoto Y,Kojima Y, Yamaguchi K. Cervical
subacute necrotizing lymphadenitis. Naika
1972;30:920-7.
3. Baumgartner BJ, Helling ER. Kikuchiûs disease:
a case report and review of the literature. ENTJ
2002;81:331-5.
4. Gleeson MJ,Siodlak MZ, Barbatis C, Salama
NY. Kikuchiûs disdase-: a new cause of
cervical lymphadenopathy. J Laryngol Otol
1985;99:935-9.
J Prapokklao Hosp Clin Med Educat Center 93
5. Fooanant S, Sriuthaisiriwong P, Kanchanarak
C, Hanprasertpong J, Chaiwan B.Kikuchiûs
disease presented with lateral neck cellutis,
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