a healthy 35-year - old woman presented with a history of a painless , slow - growing nodule in the left eye caruncle over the previous 2 months ( fig . the lesion was not fixed to the underlying tissue , was freely mobile , and had a firm consistency . eversion of the upper and lower eyelids revealed that the lesion was confined to the caruncle without extension to the fornix or palpebral conjunctiva . the visual acuity was 20 / 20 and ocular movement was in the normal range . the ocular examination was otherwise unremarkable . on physical examination , there was no regional lymphadenopathy . the venereal disease research laboratory test , erythrocyte sedimentation rate , serum angiotensin converting enzyme level , and chest radiograph were all normal . the serum ige level was not elevated . she had no prior significant medical history ; however , she declined additional work - up . one week following presentation , the patient underwent an excisional biopsy of the left eye to confirm the diagnosis . a 1.3  0.5  0.3 cm sized nodule was removed and subsequently sent for histopathologic examination . gross examination of the mass revealed a smooth , firm nodule ; infiltration to the underlying tissues was not detected . microscopic examination with hematoxylin - eosin staining showed follicular lymphoid hyperplasia with germinal center and perifollicular fibrosis ( fig . 2 ) . higher magnification revealed an eosinophil infiltrate with proliferation of vascular channels , especially the capillaries ( fig . vascular channels were lined by normal - appearing flat , spindle - shaped endothelial cells ( fig . immunohistochemical staining for cd20 and cd3 showed t - cells surrounding well - formed lymphoid follicles with germinal centers containing b - cells ( fig . 5a and 5b ) . on the basis of these histopathologic findings , we established a diagnosis of kimura disease . at the last follow - up 6 months after surgery , the patient had no evidence of a recurrence . the caruncle is a modified cutaneous tissue containing fine hair , sebaceous glands , sweat glands , and goblet cells . although this large array of tissue elements can give rise to a wide variety of lesions , caruncular tumors are uncommon . kimura disease typically presents as firm , painless , pruritic , single - to - multiple subcutaneous nodules . kimura disease has a predilection for the skin of the pre - auricular , parotid , and submandibular regions . kimura disease of the orbit and ocular adnexa is uncommon , but well - documented by buggage et al . . the orbit , especially in the superior orbital space , may be a preferred site for kimura disease . the disease was first described in chinese literature as an eosinophilic hyperplastic lymphograuloma and was later characterized by kimura et al . in 1948 . hundreds of cases under a variety of names have been reported in asia , including china , japan , and indonesia . kimura disease occurs mainly in asian males , presenting as large ( > 2 cm ) subcutaneous papules or nodules , elevated blood eosinophilia ( up to 54% ) , hypergammaglobulinemia ( ige ) , regional lymphadenopathy , and salivary gland involvement . the patient described herein was female and had a normal peripheral blood eosinophil count and serum ige level . allergic reactions , infections , and autoimmune reactions with an aberrant immune response have been suggested . because of the non - specific presentation of kimura disease , strict histopathologic examination is crucial to confirming the diagnosis . histopathologically , kimura disease is characterized by an inflammatory infiltrate with prominent collections of eosinophils and scattered lymphoid follicles , increased fibrocollagenous tissue , and vascular proliferation , with vessels lined by normal endothelial cells . the differential diagnosis of kimura disease is broad and includes angiolymphoid hyperplasia with eosinophilia ( alhe ) , hodgkin lymphoma , langerhans cell histiocytosis , lymphadenopathy of a drug reaction , and parasitic lymphadenitis . however , distinguishing kimura disease from neoplasms is not difficult when reed - sternberg cells , atypical lymphocytes , and langerhans cells are identified . a positive history of drug use , and seropositivity for parasitic infections can be helpful for differentiating diagnoses . kimura disease and alhe were often confused in a number of early reports . over the years , the clinical features of kimura disease overlap significantly with those of alhe . clinically , both present as relatively asymptomatic soft tissue swellings in the head and neck . however , there are characteristic and distinctive clinicopathological features between the two diseases . in brief , the solitary lesions are usually in the deep subcutaneous tissues , and are frequently associated with regional lymphadenopathy and salivary gland involvement . by contrast , alhe occurs in all racial groups with a slight female predilection . patients present with small , superficial dermal papulonodules , which are frequently erythematous , accompanied by bleeding , pruritis , and tumor growth . regional lymphadenopathy , serum eosinophilia , and elevated ige levels kimura disease and alhe can be differentiated on a histopathological basis , especially with their vascular endothelial morphology . kimura disease is a chronic allergic or autoimmune inflammatory disorder , whereas alhe is a neoplasm of blood vessels . histopathologically , the most important diagnostic feature of alhe is the appearance of endothelial cells , which have a vesicular nucleus , abundant cytoplasm , and an oval - to - cuboidal shape . the histopathologic examination of the surgical specimen revealed flat , spindle - shaped endothelial cells which had normal - appearing nuclei and cytoplasm ; findings which are consistent with kimura disease . interestingly , kimura disease is associated with renal disease , which may develop before or concurrently with disease progression . .   demonstrated ige in the renal glomeruli of a patient with kimura disease who manifested nephritic syndrome . excision is the most widely used therapy and oral or intralesional steroids , radiation , and chemotherapy can also be used . we treated the patient with complete excision and recurrence has not been detected through the 6-month follow - up visit . there is a tendency for caruncular lesions to have inconsistencies between clinical and histopathologic diagnosis , which can be as high as 50% . our patient is a further unusual example of the confounding nature of the caruncular lesions . despite its rarity , kimura disease caruncular lesions are rare and diverse , making clinical diagnosis difficult . with a strict histopathologic examination of excised tissue
a 35-year - old woman presented with history of a painless , slow - growing nodule in a left eye caruncle over the last 2 months . 
 the visual acuity was 20 / 20 and the ocular movements were in the normal range . the venereal disease research laboratory test , erythrocyte sedimentation rate , serum angiotensin converting enzyme level , and chest radiograph were all normal . 
 an excisional biopsy was done to confirm the diagnosis . a 1.3  0.5  0.3 cm sized nodule was extracted and sent for histopathologic examination . 
 hematoxylin - eosin staining showed follicular hyperplasia with perifollicular fibrosis , an eosinophil infiltrate , and proliferation of capillary vessels . 
 the capillaries were lined by normal - appearing , flat , spindle - shaped endothelial cells . on the basis of these histopathologic findings , 
 the diagnosis of kimura disease in a caruncle was established . 
 this is the first report describing kimura disease localized to a caruncle . 
 kimura disease should be suspected and included in the differential diagnosis of a caruncular mass lesion .