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With great interest we read the tutorial by Forbes (Gut 2005;54:1156). We would like to stress that the count of CD4 lymphocytes (and possibly immunoglobulins) might be quite helpful in the differential diagnosis of chronic inflammatory bowel disease and tuberculosis, as evidenced by the following case report.
A 35 year old Iranian patient presented to our clinic with chronic diarrhoea, intermittent abdominal pain, and a 10 kg weight loss over the last four months. The right lower abdomen was slightly tender at physical examination. Routine laboratory tests revealed hypochromic microcytic anaemia, an elevated erythrocyte sedimentation rate (88 mm in the first hour), and a low serum albumin of 25 g/l (normal range 35–50). Multiple ulcers with signs of scarring were detected by colonoscopy in the distal ascending colon (fig 1A).
Histological examination of biopsy specimens disclosed granulomatous disease of the ascending colon (fig 1B) but normal mucosa in the more distal colon and rectum. Despite a normal peripheral leucocyte count, peripheral CD4 lymphocytes had decreased to 17/µl (normal range 400–1800).
Human immunodeficiency virus infection was excluded. However, the tuberculin test was positive, and Ziehl-Neelsen staining demonstrated acid fast bacilli in colonic biopsies (fig 1C). The left lung showed some pleural scarring on chest x ray. Ultrasound revealed slight pericardial effusion as well as some ascites. Antituberculotic chemotherapy was initiated, and non-resistant Mycobacterium tuberculosis was finally cultured from colonic biopsies. Now, five years later, the patient is well, and peripheral CD4 lymphocyte count has normalised.
Conflict of interest: None declared.