S6038 Beyond the Gut: “Fighting With the Red Soldiers”

Introduction: Eosinophilic gastrointestinal diseases (EGIDs) are chronic, immune-mediated conditions characterized by eosinophilic infiltration of the gastrointestinal (GI) tract in the absence of known secondary causes such as infections, medications, or systemic disorders. We present an interesting case from India of eosinophilic gastroenteritis (EoGE) with serosal involvement & eosinophilic ascites (EA) in a patient with autoimmune thyroiditis & vitiligo, highlighting the importance of early recognition & diagnosis. Case Description/Methods: A 37-year-old woman presented with poor appetite, gastroesophageal reflux disease, intermittent dysphagia & vomiting. She suffered from hypothyroidism, vitiligo & atypical interstitial pneumonia. She had been using herbal medication for vitiligo. Physical examination revealed a tender abdomen & ascites. Laboratory evaluation showed a leukocyte count 19,900/mm³, with 54% eosinophils. Parasitic diseases & malignancy were tested negative. Abdominal imaging revealed moderate ascites, thickening of the stomach & small bowel walls & a near-complete pyloro-duodenal obstruction. Ascitic fluid analysis showed high protein content and 80% eosinophils. Bone marrow biopsy confirmed eosinophilia without malignancy. Endoscopy revealed mild duodenal edema & rectal ulcers. Biopsies demonstrated moderate-to-dense eosinophilic infiltration & mucosal changes throughout the GI tract, consistent with eosinophilic gastroenteritis. The patient was treated with budesonide & a proton pump inhibitor (PPI), resulting in rapid symptom relief. Azathioprine was added for maintenance therapy & steroids were tapered off. On follow-up, she remained symptom free & ascites had resolved. Three years later, she presented with dysphagia. Endoscopy revealed esophageal rings in the distal esophagus & duodenal erosions. Biopsies showed chronic non-specific inflammation. The laboratory tests were normal. Her symptoms improved with a short course of corticosteroids & dietary modifications. Discussion: This case underscores the importance of maintaining a high index of suspicion in patients with unexplained GI symptoms, peripheral eosinophilia & eosinophilic ascitic fluid. A multidisciplinary approach including imaging, endoscopy & histopathology is crucial for timely diagnosis, especially in regions like India, where the pattern of disease is shifting from infectious to autoimmune etiologies. Individualized immunosuppressive strategies & long-term surveillance are crucial to manage chronic and relapsing course of EoGE.