Clinical presentation

A 76 year old woman presented with a two month history of increasingly frequent bowel motions and weight loss. She had a history of diverticular disease diagnosed on barium enema 10 years previously. Physical examination was unremarkable. Blood tests showed normocytic anaemia and neutrophilia. Flexible sigmoidoscopy showed severe inflammation with histological changes of mild active chronic colitis, with crypt abscesses. Her diarrhoea responded well to intravenous steroids and oral mesalazine.

She was readmitted two months later with acute exacerbation confirmed on sigmoidoscopy. Computed tomography showed sigmoid diverticular disease and no lymphadenopathy. She was managed with antibiotics, an increased dose of steroids, and mesalazine enemas. Colonoscopy confirmed chronic pancolitis with a normal terminal ileum and some rectal sparing. Azathioprine was commenced but stopped after four weeks because of severe parotitis. She improved gradually and was discharged after six weeks but was readmitted seven months later with colonic perforation requiring emergency subtotal colectomy.

Question

Figures 1 and 2 show the histology from the resected specimen. Is this the typical appearance of ulcerative colitis or is there another possible diagnosis?

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Figure 1

 Haematoxilin and eosin stain of the colon showing diffuse infiltration of the lamina propria by a monomorphic population of lymphoid cells.

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Figure 2

 Staining of the same sample for CD3 expression, confirming T cell phenotype.

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