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A 64-year-old woman was admitted to the hospital with complaints of recurrent non-intensive abdominal pain without watery diarrhea; she also complained of hand tremors and dizziness. The patient had a medical history of chronic primary adrenal insufficiency for 22 years. She was on steroid replacement therapy (hydrocortisone, fludrocortisone) at the time of presentation. Physical examination was unremarkable. Laboratory test results showed only a low level serum iron (4.1 micromole/L); others (including hemoglobin, C-reactive protein) were within normal limits. Human immunodeficiency virus serology and fecal culture were negative. Upper gastrointestinal (GI) endoscopy revealed atrophic gastritis features. Colonoscopy examination showed normal ileum mucosa with local erythematous spots of mucosa in the ascending colon (▶Video 1, ▶Fig. 1); a biopsy was performed simultaneously. Histopathological examination of the biopsy demonstrated an increased number of intraepithelial lymphocytes and normal crypt architecture with no clearly thickened subepithelial collagen layer. In addition, subepithelial multinucleated giant cells were present (▶Fig. 2 a, b). No true granulomas, foreign material, or microorganisms were seen. Special stains for fungi and acid-fast bacilli were negative. An atypical form of microscopic colitis with giant cells was confirmed. Microscopic colitis with giant cells is a rare atypical form of microscopic colitis characterized by the presence of multinucleated giant cells in an otherwise classic microscopic colitis without endoscopic and radiological abnormalities; its reported incidence is less than 3.7 to 4.1 cases per 105 person-years [1]. Giant cell colitis was first described by Libbrecht et al. in 2002 [2]. The exact etiology of microscopic colitis is unknown, but a luminal factor triggering an abnormal reaction in predisposed patients has been implicated [3]. We electronically searched the PubMed database (January 2002– January 2020) for the key words “microscopic colitis with giant cells” and found only 14 messages.

Visible or invisible atypical form of microscopic colitis with giant cells: for the endoscopist, that is the question