Côrte-Real, R

Meliço-Silvestre, AA

Oliveira, JF

Rabadão, EM

Saraiva da Cunha, JG

Repositório Institucional dos Hospitais da Universidade de Coimbra

Letters to the Editor I09 References I. Jacobson MA, O'Donnell JJ, Porteous D, Brodie HR, Feigal D, Mills J. Retinal and gastrointestinal disease due to cytomegalovirus in patients with the acquired immune deficiency syndrome : prevalence, natural history, and response to ganciclovir therapy. Q ff Med I988; 67: 473-486. 2. Wilcox CM, Diehl DL, Cello JP, Margaretten W, Jacobson MA. Cytomegalovirus esophagitis n patients with AIDS. Ann Intern Med I99o; II3:589-593 3. Connolly GM, Hawkins, D, Harcourt-Webster JN, Parsons PA, Husain OAN, Gazzard BG. Oesophageal symptoms, their causes, treatment, and prognosis in patients with the acquired immunodeficiency syndrome. Gut I989; 3o: Io33-ro39. Kikuchi's disease associated with Epstein-Barr virus infection Accepted for publication 2 January I992 Sir, Kikuchi's disease (KD) is a cause of benign lymphadenitis known to have a worldwide distribution, reports of nearly 450 cases having been published. 1 We did not know, however, of any case in Portugal until a 15-year-old caucasian boy presented to us with pyrexia of unknown origin (PUO) and liver dysfunction. The patient gave a 4 weeks' history of daily fever (39-40 °C), enlarged cervical lymph nodes, night sweats, chills, malaise, anorexia nd a 4 kg loss of weight. He had complained of a sore throat during the first week and had developed a skin rash after a I-day course of amoxicillin. He denied any other symptoms. His epidemiological history was unremarkable. On examination he had an axillary temperature of 39 °C and a single 3 c rux4  cm, non-tender cervical lymph node and a few small supraclavicular nodes on the left side. His physical examination was otherwise unremarkable. Laboratory investigation showed leucopenia (3"45 x IO9/1) with relative lympho- cytosis (I'7 x Io9/1), ESR of 86 mm/h  (Westergren), serum lactate dehydrogenase (LDH) IZ87 IU/1 (n = I60-33o IU/1), serum alanine aminotransferase of I78 IU/1 (n = 0--29 IU/1) and aspartate aminotransferase of i2I  IU/1 (n = 0-25 IU/1). All blood, urine stool and bone marrow bacterial cultures were negative. Acid-fast bacilli were not found in sputum, bone marrow, urine and gastric washings. His Mantoux test was negative. Bone marrow aspirate and biopsy, autoimmune studies, chest roentgenography and abdominal ultrasonography were unremarkable. Rose Bengal and Paul-Bunnell tests were negative. No yersinia antibodies were detected and toxoplasma nd cytomegalovirus IgM and IgG titres were not raised. However, IgM VCA antibody to Epstein-Barr virus (EBV) was detected. During the first week in the ward the patient maintained a fever (39-40 °C), with progressive weight loss (5 kg), increased serum aminotransferases and LDH,  sustained leucopenia and relative lymphocytosis. In the second week, a biopsy of a supraclavicular lymph node showed extensive necrosis within the cortical and paracortical reas, with karyorrhectic debris and no neutrophil polymorphonuclear leucocytes. No tubercle bacilli were seen. The specimen was reported to show benign necrotising lymphadenitis, consistent with Kikuchi's disease. Treatment with naproxen (25o mg b.d.), resulted in prompt lysis of the fever. Four weeks later, when he was discharged, he was apyrexial, regaining weight and had resolving cervical adenopathy. His serum aminotransferase values were improving. At a 6 month follow-up he was well, had no adenopathy and his aminotransferases were normal. Kikuchi's disease is probably misdiagnosed in our country, and therefore, the clinical manifestations of this benign lymphadenitis should be more widely known and lymph node biopsy more readily performed. Kikuchi's disease with abnormal iver I Io Letters to the Editor function tests 1-4 and PUO 3-5 has been described recently. We suggest, as Bailey et al.fl and Pearl and Strauchen ~ have done, that KD must be considered a potential cause of PUO. Our patient's illness resolved following treatment with naproxen which is as Kapadia et al. 4 described, but why this drug is effective is not understood. The aetiology of the disease remains uncertain but an association with yersinia, 4,6 toxoplasma, 7 herpes virus 6, ~ EBV, 8 and more recently human immunodeficiency virus 9 and parvovirus B 191 infections has been suggested. Like Rivano et al., s we found an association with the Epstein-Barr virus. Department of Infectious Diseases, University Hospital and School of Medicine, Coimbra, Portugal Eduardo M. Rabaddo* Joaquim F. Oliveira Saraiva da Cunha Rui Cdrte-Real Antdnio A. Melifo-Silvestre * Address correspondence to: Dr E.M. Rabadfio, Clinica de Doenqas Infecciosas, Hospital da Universidade, 3049 Coimbra Codex, Portugal. References I. Meyer O, Ribard P, Belmatoug Net al. Trois cas de lymphad~nite de Kikuchi au cours du lupus eryth6mateux syst6mique. R61e du parvovirus BI9. Ann Mdd Intern 1991 ; I42(4): 259-264. 2. Ohta A, Matsumoto Y, Ohta, T et al. Still's disease associated with necrotizing lymphadenitis (Kikuchi's disease): report of 3 cases. J Rheumatol 1988; 15: 981-983. 3. Bailey EM, Klein NC, Cunha AB. Kikuchi's disease with liver dysfunction presenting as fever of unknown origin (letter). Lancet 1989; ii: 986. 4- Kapadia V, Robinson BA, Helen HB. Kikuchi's disease presenting as fever of unknown origin (letter). Lancet 1989; ii: 1519-I52O. 5. Pearl D, Strauchen JA. Kikuchi's disease as a cause of fever of unknown origin (letter). N EnglJ Med I989; 3zo(17): II47-II48. 6. Feller AC, Lennert K, Stein H et al. Immunohistology and etiology of histiocytic necrotizing lymphadenitis: report of three instructive cases. Histopathology I983; 7: 825-839. 7. Kikuchi M, Yoshizumi T, Nakamura H. Necrotizing lymphadenitis: possible acute toxoplasmic nfection. Virchows Arch (A) 1977; 376: 247-253. 8. Rivano MT, Falini B, Stein Het  al. Histiocytic necrotizing lymphadenitis without granulocytic infiltration (Kikuchi's lymphadenitis). Morphological and immunohisto- chemical study of eight cases. Histopathology I987; I I :  1oi3-Io27. 9. Pileri SA, Sabattini E, Costigliola P et al. Kikuchi's lymphadenitis and HIV infection. AIDS I99I ; 5(4): 459-46I. Gemel la  morb i l l o rum endocard i t i s  in an intravenous drug abuser Accepted for publication I9 December ~991 Sir, Gemella species rarely cause infective endocarditis. We wish to report a case of endocarditis caused by Gemella morbillorum. There appear to be only two previous reports of endocarditis caused by G. morbillorum, formerly Streptococcus morbillorum in the U.K. 1 Streptococcus morbillorum was recently transferred to the genus Gemella as a result of DNA homology studiesfl A i9-year-old male intravenous drug abuser presented in October 199o with a 2 weeks' history of malaise, night sweats and intermittent fever. He had started injecting heroin at the age of I4 years. Since then, he had been on various drug rehabilitation schemes, all unsuccessful. In the months before his admission to hospital, he had been 

Kikuchi's disease associated with Epstein-Barr virus infection

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