Paratuberculosis-associated lesions in 116 naturally infected adult cows, with or without clinical signs, were classified histopathologically. Tissue samples obtained focused on gut-associated lymphoid tissue. Lesions were divided into five categories. Focal lesions (n=68 cases), consisted of small granulomas in the ileal and jejunal lymph nodes or the ileocaecal lymphoid tissue. In the multifocal type (n=13 cases), small granulomas or scattered giant cells appeared in some intestinal villi, as well as in the lymph nodes. Diffuse multibacillary lesions (n=15 cases), associated with severe granulomatous enteritis affecting different intestinal locations and lymph nodes, were formed by macrophages containing large numbers of acid-fast bacilli. In diffuse lymphocytic lesions (n=3 cases), lymphocytes were the main inflammatory cells, with some macrophages or giant cells containing few if any mycobacteria. In diffuse intermediate forms (n=17 cases), the infiltrate was formed by abundant lymphocytes and macrophages, and mycobacteria were present to varying degrees related to the number of macrophages. Clinical signs and gross lesions were mainly associated with diffuse forms. Thickening of the intestinal wall, which was the most common macroscopical finding, was related to the degree of submucosal change. Mycobacterium avium subsp. paratuberculosis was identified by culture or PCR in all cows with diffuse lesions, and in 55.5 and 37% of those with multifocal or focal forms, respectively. The importance of sampling the ileal and caudal jejunal lymph nodes to find histological lesions of paratuberculosis in cattle is emphasized.