This case report describes a rare case of multiple sites of Kimura's disease occurring along multiple peripheral nerves in the same patient. A 25-year-old man presented with asymptomatic swellings on his left elbow and arm. Imaging and histological analysis revealed lesions on the medial cutaneous nerve of the forearm, median nerve, and anterior interosseous nerve, consistent with Kimura's disease involving multiple peripheral nerve sites. This is an unusual presentation, as most literature describes Kimura's disease affecting a single nerve or site.

1. Multiple Sites of Kimura’s Disease Occuring Along
Multiple Peripheral Nerves in the Same Patient:
A Case Report
Kumaran Rasappan, Vaikunthan Rajaratnam,
Chin Teck Yew, Lang Tee Ung

2. Introduction
 There can be multiple differential diagnosis for asymptomatic
swellings in the limbs
 Radiological imaging guide identification of the lump
 However, radiological diagnosis may not always be accurate
 We report a case of an asymptomatic swelling in a patient
who’s histological diagnosis differed from radiological
diagnosis

3. History
 25 year old Chinese male
 Noticed swelling over
medial aspect of left elbow
incidentally
 4 months duration
 Noted it getting slightly
bigger over the last month
 Asymptomatic
Examination
 2 x lumps over anterior medial
aspect of elbow and distal arm
 Non tender, firm, deep
 Slightly mobile transversely but
not mobile longitudinally
 Tinnel’s negative
 Completely asympthomatic

4. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
_treeclimber_stock-d3hfvaj.png
• (1.5 x 1.0 x 2 cm) Lump
• Close relation to the
medial cutaneous nerve
of forearm
Axial Saggital
Coronal

5. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
_treeclimber_stock-d3hfvaj.png
• (3.5 x 0.7 x 1.5 cm) Lump
• Following the course of
the median nerve
Axial Saggital
Coronal

6. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
_treeclimber_stock-d3hfvaj.png
• (1.3 x 1.3 x 2.6cm) Lump
• Close relation to the median nerve and/or
anterior interosseous nerve
Axial Coronal

7. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
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Compatible with multiple peripheral nerve sheath tumours

8. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
_treeclimber_stock-d3hfvaj.png

9. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
_treeclimber_stock-d3hfvaj.png

10. Source:
http://img05.deviantart.net/3a9f/i/2
011/148/e/8/hanging_right_arm_by
_treeclimber_stock-d3hfvaj.png

11. Histological Images
Preserved nodal
architecture with
reactive follicular
hyperplasia
Intermediate power

12. Histological Images
Germinal centre
hyperplasia
Intermediate power

13. Histological Images
Interfollicular
eosinophilia
Intermediate power

14. Histological Images
Eosinophilic
mirco abscess
with folliculolysis
and necrosis
Intermediate power

15. Histological Images
Intermediate power
The findings are representative of Kimura's Disease

16. Kimura’s disease / Eosinophilic
Lymphogranuloma
 First described in 1937 in the Chinese literature by HT Kimm and C Szeto
 Definitive histological description published in 1948 by Kimura et al
 Endemic in Asia (China and Japan) but rare
 Only about 200 cases reported since 1948
 M/F sex ratio 7 : 3.5
 Peak age incidence is during 3rd
decade
 DDx: Angiolymphoid hyperplasia
with eosinophilia

17. Clinical presentation of Kimura’s Disease
 Usual location: Head and Neck
 Accompanied by satellite adenopathies with hypertrophy of salivary glands
 Nodules can be pruritic or painful but the overlying skin is normal
 Extra membranous glomerulonephritis is found in half of pts
 Cutaneous eosinophilic vasculitis has been described
 Epitrochlear, axillary, inguinal and popliteal lesion have been described
 Eyes, ears, sperm ducts and nerves
very rarely affected

18. Our Case
 EMBASE, PubMed, CINAHL and Google Scholar were used
 Only 4 cases involving the peripheral nerves were found
 2 case reports describe involvement of the superficial radial nerve
 1 case report describes involvement of the median nerve
 1 case report describes involvement of the ulnar nerve
 No case reports of Anterior Interosseous Nerve or medial cutaneous
nerve of forearm
 No case reports of multiple peripheral nerve involvement in the same
patient
 First such finding of 3 locations of
Kimura’s Disease in 3 different peripheral
nerves in the same patient.

19. Take Home Message
 MRI for multiple unknown lumps in limb
 Take MRI report only as a guide
 Benign Peripheral Nerve Sheath Tumour
(BPNST) vs Kimura’s Disease

20. BPNST vs Kimura’s Lymph Node
Source: http://www.columbianeurosurgery.org/conditions/neurofibroma/

21. References
 Song KS, Woo DE. Kimura’s disease involving the peripheral nerve of the arm in a child:
a case report. Journal of Pediatric Orthopaedics B. 2015 Jan 1;24(1):63-6.
 Vermaak PV, Lyons CB, Harley OJ. Kimura’s disease affecting the superficial branch of
the radial nerve. Journal of Hand Surgery (European Volume). 2014 Feb 1;39(2):208-9.
 Lee YS, Ang HK, Ooi LL, Wong CY. Kimura's disease involving the median nerve: a case
report. Annals of the Academy of Medicine, Singapore. 1995 May;24(3):462-4.
 Martorell M, Pérez-Vallés A, García-García JA, Calabuig C, Aguilella L. Angiolymphoid
hyperplasia with eosinophilia involving the cubital nerve. Acta neuropathologica. 2004
Apr 1;107(4):372-6.
 Larroche C, Bletry O. Kimura's disease. Orphanet encyclopedia, February. 2005 Feb.

22. THANK YOU