Digestive Endoscopy (2005) 17, 257–258 Blackwell Science, LtdOxford, UKDENDigestive Endoscopy0915-56352005 Blackwell Publishing Asia Pty LtdJuly 2005173257258Case report DIMINUTIVE COLONIC TUBERCULOSISWC ONG Et al. Correspondence: Wai Choung Ong, Asian Institute of Gastroenterol- ogy, 6-3-661, Somajiguda, Hyderabad 500 082, India. Email: ongkywks@singnet.com.sg Received 22 November 2004; accepted 17 January 2005. CASE REPORT COLONIC TUBERCULOSIS MIMICKING A DIMINUTIVE SESSILE POLYP WAI CHOUNG ONG, RAMJI CHEEMALAKONDA, ANURADHA SEKARAN AND NAGESHWAR REDDY Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India A 47-year-old male patient presented with abdominal discomfort and loose stools. Colonoscopic examination revealed a diminutive sessile polyp on the hepatic flexure. Histological assessment revealed a caseating granuloma with giant epitheloid cell formation consistent with tuberculosis. Early diagnosis and treatment with antitubercular treatment circumvents the morbidity of the disease. Key words: colonoscopy, early diagnosis, gastrointestinal, tuberculosis. INTRODUCTION Patients presenting with a change in bowel habit frequently have colonoscopic examination performed. Diminutive poly- poidal lesions (< 5 mm) are often considered incidental when noted. It is impossible to accurately predict the histopathol- ogy of such lesions by observation alone; histological assess- ments commonly reveal adenomas or hyperplastic polyps. We report a finding of early colonic tuberculosis mimicking a diminutive polyp. CASE REPORT A 47-year-old man presented with a 3-week history of abdominal discomfort and loose stools. There was a history of low-grade fever of 4 weeks duration. There was no weight loss. Physical examination was unremarkable. Colonoscopic examination revealed a diminutive bi-lobed sessile polyp measuring 3 mm on the hepatic flexure (Fig. 1). The terminal ileum was normal in appearance. The lesion was completely removed via biopsy. Histology revealed two granulomas with central necrosis (Fig. 2), surrounded by epitheloid and giant cells (Fig. 3) located within the submucosa. These histological features typically exemplify colonic tuberculosis. The stain for acid- fast bacilli was negative. DISCUSSION Tuberculosis is experiencing a resurgence in developed coun- tries largely due to human immunodeficiency virus (HIV) infection and migration. Gastrointestinal tuberculosis com- monly involves the colon and ileocecal region; uncommon involvements of the esophagus, 1 duodenum 2 and small bowel 3 in isolation have been reported. Isolated tubercular disease of the small bowel may be diagnosed via capsule endoscopy. 3 An abnormal chest X-ray is usually the first clue to this disease; however, this occurs in only a minority of patients seen with intestinal tuberculosis. Approximately 15–20% of patients with gastrointestinal tuberculosis have concomi- tantly active pulmonary tuberculosis. 4 An abnormal chest X- ray was found in only 14% of patients strongly suspected of having intestinal tuberculosis. 5 Endoscopic diagnosis of colonic tuberculosis represents a challenge. The typical lesion has been described as transverse or circumferential ulcers, deformed ileocecal valve and nod- ular mucosa with areas of ulceration. Case reports have described findings of aphthoid ulcers and multiple erosions, 6 multiple fibrous bands, polypoidal lesions, segmental tuber- culosis and lesions simulating carcinoma, 7 colonic strictures, 8 diffuse pancolitis, 9 strictures with nodules and ulceration, mucosal nodules with or without pseudopolypoid folds 10 and Fig. 1. Endoscopic appearance of ‘diminutive’ colonic tuberculosis.