Case Presentation: A previously healthy 28-year-old female, originally from India, presented with severe perineal pain and recurrent fevers six weeks following a forceps-assisted vaginal delivery complicated by perineal lacerations and hemorrhage. Two weeks post-partum, she presented with vaginal pain despite being afebrile with a normal physical exam. Four weeks later, the pain continued, and she was treated with 10 days of Cefdinir for perineal tenderness. Upon completion of her antibiotics course, she returned to clinic due to recurring fevers and ongoing perineal pain leading to her admission. She was initiated on Cefazolin and Metronidazole and eventually extended to Vancomycin and Meropenem despite normal white blood cell counts and initial infectious work. Pelvic and rectal exam under anesthesia and abdominal/pelvic computed tomography (CT) showed no abscess. Chest x-ray was normal. CT angiography of the abdomen and pelvis showed no active bleeding or fluid collection, no deep vein thrombosis, and stable bilateral pelvic lymphadenopathy; blood cultures showed no growth; and urine cultures grew candida albicans. Despite broad-spectrum antimicrobials, she had persistent fevers up to 39.8°C, and Fluconazole was added to her medication regimen. Rheumatology was consulted for elevated inflammatory markers and a transient malar rash, but autoimmune disease was deemed unlikely. Broad infectious disease evaluation with pelvic magnetic resonance imaging (MRI) and ultrasound, transthoracic echocardiogram, and extensive infectious serologies were unrevealing. Antibiotics were held due to concern for medication-induced fever. Hematology/oncology work-up was unrevealing. Due to continued fevers of unknown origin, positron emission tomography (PET) was completed and demonstrated intensely hypermetabolic multi-station lymphadenopathy suspicious for lymphoma versus systemic inflammatory disorder. Excisional lymph node biopsy confirmed histiocytic necrotizing lymphadenitis, suggestive of Kikuchi-Fujimoto disease. Fevers resolved two days prior to discharge, and she remained afebrile two weeks later during a hospital follow-up.
Discussion: Kikuchi-Fujimoto Disease (KFD) is a rare condition with subacute necrotizing lymphadenopathy and frequently associated fevers, usually affecting young adults of Asian descent. Because its clinical features can mimic rheumatologic, infectious, and malignant conditions, diagnosis is frequently delayed or missed. Previous studies have found correlations with certain viruses, such as EBV; however, presentation post-partum remains rare and infrequently reported, highlighting the importance of considering KFD in the differential for fever of unknown origin in postpartum patients [1].
Conclusions: Although benign and self-limiting, Kikuchi-Fujimoto Disease should be considered in post-partum patients with persistent fevers and a negative infectious workup. Timely recognition is critical to avoid misdiagnosis, prevent unnecessary treatment, and provide reassurance to both clinicians and patients.