Kimura's disease in soft palate with clinical and histopathological presentation: A case report

lNTRODUCTlON

Kimura’s disease affects the deep cervical tissues with benign inflammation and involves the head,neck, and salivary gland lymph nodes. The oral cavity is sometimes involved. There are no reports on tumors occurring in the soft palate. This condition was first reported by Kim and Szeto[1] in 1937 and further characterized in 1948 by Kimura[2]. Young Asian men (especially in China and Japan) are most commonly affected and the peak age of onset is in the 30s[3]. The most common laboratory findings are elevated serum immunoglobulin E (IgE) levels accompanied by eosinophilia[3,4]. In this report we review a rare case of Kimura’s disease in the upper jaw in an elderly woman.

CASE PRESENTATlON

The tumor developed over a period of 4 mo and was still growing slowly. The patient did not present with any pain or any sensory loss in the affected area. She did report discomfort in the upper jaw while eating, which impaired her diet. She denied trauma at the site.

游客的滿意度評價分為四個方面，即動物園核心吸引物、娛樂吸引物、游覽服務和基礎(chǔ)設(shè)施，具體包含15個項目。每個項目評分標準1～5分五個等級，1分最低，5分最高。數(shù)據(jù)統(tǒng)計顯示，游客滿意度總平均得分為3.09，處于中等水平。游客滿意度得分最高的前三項是歡樂主題樂園、加勒比水世界和安全防護措施，而非核心吸引物。說明游客對歡樂和安全的關(guān)注。游客滿意度得分最低的四項是園內(nèi)商品價格、園內(nèi)商品種類、導覽信息和服務態(tài)度，均低于3分，均屬于游覽服務范疇，這說明游覽服務沒有跟上大多數(shù)游客的需求，難以達到人性化和舒適性的服務，也沒有實現(xiàn)動物園自身的增值服務。

Chief complaints

The patient was admitted to our hospital with a growing mass in her upper jaw.

History of present illness

The case in our report was a 63-year-old woman farmer of the Han race who is 1.6-m in height and 40-kg in weight.

History of past illness

Her medical history revealed chronic nephritis, bilateral submandibular lymphadenectomy and weight loss. No other comorbidities or relevant diseases were observed in her family.

Physical examination

Physical examination discovered a red, intact mass that involved nearly the entire soft palate. The tumor exhibited bilateral symmetry in the upper jaw (Figure 1A and B). The patient’s oral hygiene was poor,with missing teeth in regions 31-32, 35-36, 38, 45-46, and 48.

Laboratory examinations

The absolute value of eosinophils was 2.94 × 10

/L, and the percentage of eosinophils was 39.50%. Blood tests indicated elevated peripheral blood eosinophilia. Renal function was normal without eosinophilia.

Imaging examinations

the Natural Science Foundation of Changsha City, No. kq2007076.

Preoperative diagnosis

A biopsy of the mass was performed after the patient was referred to our group, and the lesion was diagnosed as a benign tumor. We recommended cervical lymph node puncture and partial surgical excision of the lesion. Cervical lymph node biopsy by puncture showed visible lymphocytes. With the help of the Davis' opener, we removed part of the tumor located in the left soft palate. After complete hemostasis, the wound was packed with gauze and wrapped under pressure (Figure 1C and D).Multiple biopsies were performed during surgery, and examined after immediate sectioning.

The present case illustrates a characteristic description of Kimura’s disease and expands the phenotypic spectrum of the rare disease. The findings in our report also highlight the main differences between Kimura’s disease and angiolymphoid hyperplasia with eosinophilia.

Histopathology and immunohistochemical findings

The results of histology and immunohistochemistry were consistent with angiomatosis with an inflammatory pseudotumor and many eosinophil cells. We found no evidence of malignancy. Final histopathologic examination diagnosed angiomatosis with inflammatory cells (Figure 3).

FlNAL DlAGNOSlS

High serum IgE levels often a feature of Kimura’s disease[10]. Reports have suggested that normal and moderately elevated levels of IgE may have prognostic significance and help predict the aggressiveness of the tumor[6]. Our patient failed to show elevated serum IgE levels and she was disease free for more than four months after surgery; consistent with low IgE levels associcating with less agressive disease.

TREATMENT

The discomfort of eating was alleviated, and tumor growth was suppressed. We recommend patient follow-up and close observation.

有效的營銷方式。在開展城市節(jié)慶營銷活動時，可以運用多種營銷方式，如體驗營銷、事件營銷、口碑營銷、網(wǎng)絡(luò)營銷、整合營銷，等等。下面主要探討前兩種營銷方式。

OUTCOME AND FOLLOW-UP

Our patient was under physical examination 6 mo after resection, which resolved without evidence of recurrence of the partially resected area.

DlSCUSSlON

Kim and Szeto initially described the tumor in 1937 and Kimura’s disease was more widely recognized after the 1948 report of a systematic examination by Kimura[2]. This is a rare disease that can present as angiolymphoid hyperplasia accompanied by lymphadenopathy, elevated serum IgE, and eosinophilia observed in the peripheral blood[5]. Kimura’s disease is usually seen in men of Asian extraction in their third decade of life[6]. Kimura’s disease is rare and little reliable information on the incidence of Kimura’s disease is available. The disease is normally associated with deep subcutaneous tissue or with the patient’s salivary glands[5]. However, our patient had a lesion in the soft palate of the upper jaw.The soft palate can also originate the tumor, although two cases of Kimura’s disease have been reported to arise from the hard palate[5,7]. Other organs that can be affected are the kidney[8], orbital structures[9], and there are reports of axillary or inguinal lymph nodes being affected[3].

The eosinophilic inflammation determined our final diagnosis of Kimura’s disease.

Differential diagnosis of this patient required us to consider other lymphatic diseases; angioimmunoblastic T-cell lymphoma, Hodgkin’s lymphoma, parasitic lymphadenitis, Langerhans cell histiocytosis,and, most importantly, angiolymphoid hyperplasia with eosinophilia (ALHE)[3,6]. Kimura’s disease and ALHE are often confused due to both their overlapping clinical and histopathological results.ALHE is more often seen in Western patients in their in the third, fourth, or fifth decades. The small reddish-brown cutaneous nodules of ALHE are more superficial than the lesions seen with Kimura’s disease. The ALHE patients do not present with elevated serum IgE, lymphadenopathy, nor do they have eosinophilia[11]. The basic biological difference is that ALHE is a blood vessel neoplasm while Kimura’s disease is a chronic inflammatory disease[3,12]. Young Asian men are most likely to develop Kimura’s disease that usually manifests as a single or multiple masses located in the subcutaneous tissue and/or in the salivary glands. The lesion is usually asymptomatic. Regional lymph nodes are often involved and serum eosinophilia and elevated IgE are characteristic of the condition. ALHE, by contrast, is usually seen in middle-aged women and presents as multiple small papules or nodules with erythematous and itching. The nephrotic syndromes like membranous glomerulonephritis and mesangioproliferative are more closely related to Kimura’s disease than they are to ALHE. In addition,systemic manifestations, like eosinophilia found with Kimura’s disease, are rarely found in patients with ALHE[13].

The author has read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Kimura’s disease histology is characterized follicular hyperplasia that includes follicles surrounded by large numbers of eosinophils, lymphocytes, and mast cells. The lymphoid follicles are themselves hyperplastic and they include conspicuous germinal centers. We also observed the presence of fibrosis and sclerosis and the presence of vascular proliferation (Figure 3), consistent with a previous report[19].By contrast, ALHE histology includes both abnormal vascular proliferation with diffuse lymphocyte infiltration and eosinophils. The abnormal vasculature is composed of capillaries that are clustered around atypical arterial or venous vessels that are dilated and have a protruded endothelium and exhibit rounded and occasionally angular nuclei. The endothelial cells can contain one or multiple cytoplasmic vacuoles. Lymphoid follicles are rare or absent in most cases. Histological examination found a diffuse inflammatory infiltrate with profuse vascular proliferation, endothelial cells with noticeable vacuoles, an eosinophil infiltrate, and predominant vascular processes. Kimura’s disease has different histological characteristics, with lymphoid follicles and with a greater average number of eosinophils and ALHE does not show cytoplasmic vacuoles[20]. While the literature comparing Kimura’s disease with ALHE is inconclusive, the clinical, epidemiological, and histological characteristic from the present case, and data from relevant publications, show that there are many differences between the two diseases.

作為地方高校發(fā)展之關(guān)鍵的管理科學化問題——關(guān)于當代教育改革問題的批判性反思之一 …………………… 簡圣宇（4/73）

CONCLUSlON

The carrier mobility has been calculate by the electric field based on the complex Monte Carlo methods[12]. Thus, several approximate analytical expressions have been proposed for this purpose. For low electric fields:

FOOTNOTES

Li W organized the figures and clinical information, wrote the draft of the manuscript.

閃著神秘色彩的藍寶石被斯里蘭卡人視為驅(qū)邪的吉祥物，代表秋高氣爽、藍天白云和五谷豐登，是“靈魂的寶石”。“星光藍寶石”更被視為“命運之石”。

A magnetic resonance imaging (MRI) scan revealed a tumor in the upper jaw with bilateral symmetry and a size of 5 cm × 2 cm (Figure 2A-D). The soft palate was enlarged and the palatine tonsils exhibited swelling to the third degree. The tumor had a high retention of contrast agent although it did not appear to be a hemangioma. The tumor mainly infiltrated the soft tissue, without osseous destruction. There were enlarged cervical lymph nodes on both sides with multiple nodes between 1 and 2 cm in diameter.They were identifiable and symmetrical without suspicion of metastasis. The findings from radiology are consistent with a malignant lymphoma or sarcoma. A subsequent computed tomography (CT) was used to visualize the lesion (Figure 2E and F). Following contrast agent administration, the tumor was not enhanced compared to the adjacent tissues and it appeared hypodense. The cervical vessels appeared normal and had no obvious connection with the tumor. The lymph nodes failed to show characteristics of metastases. The CT results were consistent with a sarcoma or with a malignant lymphoma. Further examination of the patient failed to find evidence of any distant metastatic sites.

Informed written consent was obtained from the patient for publication of this report and accompanying images.

The author declares that there is no conflict of interest to disclose.

While the etiology of Kimura’s disease is still unclear, one hypothesis includes immune system pathogenesis with both Th2 and Tc1 cells involved. There are two recent publications that have reported multiple T-cell alterations that are seen with Kimura’s disease[3,14]. Other researchers[15,16] indicate that certain cytokines play a predominant role as well[17]. Future high-quality and sufficient sample studies should further evaluate these findings. ALHE’s pathogenesis also remains unknown. Some investigators have hypothesized that the damage results from the vascular tumor. Others speculate that they might represent a reaction to injury of vascular tissue; for example, trauma to the skin, persistent viral infection such as with a human T-lymphotropic virus or herpes virus 8, or a hormonal imbalance[18].

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

1.5.1 致死劑量LPS組小鼠生存率及生存時間觀察（n=6）給予致死計量LPS打擊后，每12 h觀測1次，連續(xù)觀察至處理組小鼠全部死亡，統(tǒng)計小鼠存活率及每組小鼠生存時間。

Wu Li 0000-0002-1385-3120.

最簡單的例子,如果未設(shè)置準入門檻,“糧食銀行”運營主體可能會沖破法律和道德的約束,過分追求經(jīng)濟利益導致企業(yè)無法正常運轉(zhuǎn)或破產(chǎn),出現(xiàn)“跑路”情況,加之必要的監(jiān)管缺失以及農(nóng)民法律意識和維權(quán)能力差,損害農(nóng)民利益的現(xiàn)象就有可能出現(xiàn)。這不僅影響到廣大農(nóng)民的收益,更會成為農(nóng)村穩(wěn)定的一大隱患。

Ma YJ

本文的創(chuàng)新點在于：一是在研究匯率預期對跨境資金流動的影響時，不是只考慮單一跨境資金流動項目，而是基于國際收支平衡表，將跨境資金流動的各個項目均作為研究對象，通過實證分析匯率預期對各項目跨境資金流動指標的影響，以全面掌握匯率預期變化對我國跨境資金流動的總體影響。二是在研究匯率預期對跨境資金流動的影響時，將各項目跨境資金流動指標分解為流入端和流出端，完善了匯率預期變化對跨境資金流動的路徑研究。

Filipodia CL

Ma YJ

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