Photo Quiz - January 2019

A 55/male farmer was admitted with vague abdominal pain of 3 months duration with weight loss of 5 kg. He denied diarrhea, vomiting or fever. He had no known co-morbidities. Four months earlier he was admitted elsewhere and underwent hemicolectomy for perforative peritonitis , HPE for which was not collected since discharge from that center. Current evaluation showed diffuse wall thickening and enhancement of ileo-colic anastomosis and descending colon on CECT Abdomen (fig-1) and colonoscopic findings s/o Crohn’s disease(fig 2). A biopsy was taken from rectal ulcer which was suggestive of infective colitis (fig 3).

Figure 1: CECT abdomen, Figure 2: Colonoscopy findings, Figure 3: H&E stains of rectal ulcer

What is your diagnosis? View Answer

Answer

Rectal ulcer slide was re-looked again with PAS stain high power and showed ulcerated rectal mucosa with acute and chronic inflammatory cells along with Entamoeba histolytica trophozoites (arrow) showing eccentric small round nuclei and abundant cytoplasm showing phagocytosed RBCs.

Review of the HPE report of earlier hemicolectomy also revealed trophozoites of Amoeba on PAS stain.

The patient was treated with 14 days metronidazole and discharged on parmomycin.

One should always exclude infectious causes of colitis like amoebiasis, campylobacter and TB before labeling patients as IBD.

Final diagnosis: Amoebic colitis caused by Entamoeba histolytica

Case provided by: Dr Kalpesh Sukhwani (ID), Dr Pramod Kadam (Gen Surg), Dr Anirudha Puntambekar (Patho), Dr Taher Chharchhodawala (Patho), Dr Shilajit Bhattacharya (Patho)