S5036 Eosinophilic Gastroenteritis, Ascites, Small Bowel Obstruction, and Urinary Retention: An Atypical Manifestation of Disseminated Coccidioidomycosis

Introduction: Coccidioidomycosis is a fungal infection caused by fungus endemic to the Southwestern United States. Around 40% of cases present with pulmonary symptoms following initial exposure, while others may remain asymptomatic for months to years. Around 1% of infected patients develop disseminated disease which may affect the skin, joints, central nervous system, and can rarely involve the GI tract. Diffuse eosinophilic inflammation of the gastrointestinal and genitourinary tracts is a rare manifestation of disseminated coccidioidomycosis. Case Description/Methods: We present a 57-year-old man with history of uncontrolled type 2 diabetes mellitus who first presented to the Emergency Department with urinary tract infection like symptoms empirically treated with antibiotics as an outpatient. He later presented with 2 days of abdominal pain and urinary retention. Blood count was notable for marked eosinophilia. Imaging showed small bowel obstruction (SBO), ascites, and thickening of the distal esophagus and urinary bladder. Diagnostic paracentesis yielded eosinophilic ascites. Esophagogastroduodenoscopy (EGD) and colonoscopy with biopsies showed eosinophilic inflammation in the esophagus, stomach, duodenum, and large bowel consistent with eosinophilic gastroenteritis (EGE). Prostatic and urinary bladder biopsies also showed diffuse eosinophilic inflammation. Further history revealed the patient had previously lived in Arizona. Imaging of the chest led to discovery of a large cavitary lung lesion in the right upper lobe. Lung biopsy demonstrated fibrosis, inflammation, and necrosis suggesting infectious etiology. Additional testing showed positive Coccidioides antibody titer and lung biopsy culture. SBO spontaneously resolved with supportive therapy. He was treated with Amphotericin B inpatient with improvement in his eosinophilia and was discharged on high-dose Fluconazole. Discussion: This is an atypical presentation of disseminated coccidioidomycosis with extensive eosinophilic infiltration across multiple organ systems manifesting as EGE, SBO, ascites, and urinary retention. Eosinophilia is a well-known immunologic response to certain infections, however, widespread eosinophilic inflammation of the gastrointestinal and genitourinary tracts in the setting of disseminated coccidioidomycosis has rarely been reported. This case emphasizes the importance of considering disseminated fungal infections in the differential diagnosis of unexplained eosinophilia and visceral organ dysfunction, particularly in patients with pertinent geographic exposure and immunocompromised status.