Clinical Diagnosis

Clinical diagnosis : Infectious Colitis and suspected Ileitis suspect.

Macroscopic: Received  two specimens in formalin each labeled with the patient’s name and hospital number.
I. Colon: 4 pieces samples of biopsy tissue samples, white in colour, 0.3-0.5 cm in diameter. 1 file stained and mounted.
II. Ileum: 2 pieces samples of biopsy tissue samples, white in colour, measuring 0.3 cm in diameter. 1 file stained and mounted.

Microscopic :Colonic specimens consist of four oedematous colonic mucosa tissues with mild to dense infiltration of inflammatory mononuclear cells and polymorphonuclear cells (PMNs). Basal plasmacytosis and crypt distortion were present. Acid-fast bacilli (AFB) smear positive.

The specimens consist of two illeal mucosa tissues with dense infiltration of inflammatory mononuclear cells, slight infiltration of eosinophils and neutrophils. Partial villous atrophy. Few glands showed mild dysplasia. A lymphoid follicle with caseous necrosis surrounded by epithelioid cells was also present found. Acid-fast bacilli (AFB) smear positive.

Conclusion : Colon
• Chronic crypt destructive colitis/Ulcerative coilitis.
• AFB smear positive
• No malignancy was detected
Ileum
• Chronic ileocaecal tuberculosis with mild dysplasia
• AFB smear positive
• No malignancy was detected

Well done.