Esophageal Candidiasis


Article Author:
Kyle Robertson


Article Editor:
Dhruv Mehta


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/30/2019 8:49:38 PM

Introduction

The most prevalent cause of infectious esophagitis is esophageal candidiasis. Of patients that have infectious esophagitis, 88% are from Candida albicans, 10% are from herpes simplex virus, and 2% are from cytomegalovirus. Patients with esophageal candidiasis may have a wide range of symptoms or may be asymptomatic. Most common symptoms being dysphagia, odynophagia, and retrosternal pain. Candida infections of the esophagus are considered opportunistic infections and are seen most commonly in immunosuppressed patients. Candida can be part of the normal oral flora. When host defense mechanisms are impaired, this allows for a proliferation of candida on the esophageal mucosa forming adherent plaques. Esophageal candidiasis can is treatable with various forms of oral and intravenous antifungal medications.[1][2]

Etiology

By far the highest risk factor for developing esophageal candidiasis is impaired cell-mediated immunity. Immunosuppressed patients at risk for esophageal candidiasis include HIV positive and AIDS patients, chemotherapy patients, patients with radiation to the neck region, antibiotic therapy, patients on chronic systemic or topical inhaled corticosteroids, diabetes mellitus, adrenal insufficiency, and advanced age.[1][2]

Epidemiology

Studies have not shown a predominance of esophageal candida in either sex. Increasing age, HIV infection and the use of corticosteroids have been found to correlate with candidal esophagitis.  The median age of a person with esophageal candidiasis is 55.5 years. Several studies have shown esophageal candidiasis incidence rates ranging from 0.32 to 5.2% in the general population. There is a 9.8% prevalence in HIV-positive patients. Prevalence of esophageal candidiasis in HIV-infected patients appears to be decreasing due to the effectiveness of highly active antiretroviral therapy (HARRT). However, incidence in non-HIV patients appears to be increasing, possibly due to comorbidities such as diabetes mellitus or from medications such as antibiotics and corticosteroids. Some studies show that smoking tobacco also correlates with developing esophageal candidiasis.[2][3][4]

Pathophysiology

Candida albicans can be part of the normal oral flora. Due to impaired cell-mediated immunity, esophageal epithelial layer is susceptible to infection and colonization by candida. The candida proliferates and adheres to the esophageal mucosa forming white-yellow plaques. The plaques can be seen on upper endoscopy and do not wash from the mucosa with water irrigation. These plaques can be found diffusely throughout the entire esophagus or localized in the upper, mid, or distal esophagus.[2]

Histopathology

Histologic confirmation of candida in the esophagus is the gold standard for diagnosis. Hematoxylin and eosin stain of biopsies or brushing of esophageal candidiasis almost always show pseudohyphae which is diagnostic for esophageal candidiasis. The mucosa involved may exhibit desquamated parakeratosis which characteristically has groups of squamous cells that have detached or are in the process of detaching from the main squamous-lined tissue. This finding is not however specific to esophageal candidiasis. Pathology may demonstrate acute inflammation and/or intraepithelial lymphocytosis.[2]

History and Physical

Patients with esophageal candidiasis can have a multitude of complaints; however, patients are often asymptomatic. The most common symptoms associated with esophageal candidiasis are dysphagia, odynophagia, and retrosternal chest pain. Other symptoms include abdominal pain, heartburn, weight loss, diarrhea, nausea, vomiting, melena.[1][2]

Evaluation

Diagnosing esophageal candidiasis is via upper endoscopic evaluation. Visualizing the candida on the esophageal mucosa as white plaques or exudates confirms the diagnosis.  Plaques and exudates are adherent to the mucosa and do not wash off with water irrigation. There may also be mucosal breaks or ulcerations. Biopsies or brushings of the plaques can undergo testing for histologic confirmation of the infection.[1]

Treatment / Management

Treatment of esophageal candidiasis involves the use of antifungal therapy. Unlike oropharyngeal candidiasis, esophageal candidiasis should always have therapy with systemic agents and not topical agents. The most commonly used medication to treat esophageal candidiasis is oral fluconazole 200 to 400 mg per day for 14 to 21 days.  If patients cannot tolerate oral intake, then intravenous Fluconazole 400 mg daily can be used and then deescalated to oral Fluconazole when the patient can tolerate oral medications. Fluconazole 100 to 200 mg three times per week can be used to suppress recurrent esophageal candidiasis. Micafungin 150 mg IV daily has been shown to be non-inferior to fluconazole at 200 mg daily. Itraconazole 200 mg per day orally or Voriconazole 200 mg twice daily for 14 to 21 days are other treatment options. Amphotericin B deoxycholate 0.3 to 0.7 mg/kg daily can be used in patients with refractory candida esophagitis, but it has serious medication side effects and should be avoided if possible. Posaconazole 400 mg twice daily has been effective in refractory esophageal candidiasis as well. [5][6][7] Since esophageal candidiasis is an opportunistic infection and most often seen in immunocompromised persons, the cause of the immunosuppression should be diagnosed and treated as well.[8][9][10]

Differential Diagnosis

Other common causes of esophagitis are as follows: cytomegalovirus, herpes simplex virus, eosinophilic esophagitis, pill-induced esophagitis, gastroesophageal reflux disease, radiation esophagitis. Uncommon causes of esophagitis are bacterial esophagitis from Lactobacillus, B-hemolytic streptococci, Cryptosporidium, Pneumocystis carinii, Mycobacterium avium complex, Nocardia, Mycobacterium tuberculosis, Leishmania donovani.[1][11][12]

Prognosis

There are no specific papers discussing prognosis of esophageal candidiasis. It is usually treated successfully with antifungal agents. Resistant and refractory infections can occur and may require alternative agents for treatment or long term antifungal prophylaxis to reduce recurrence.[7]

Complications

Esophageal candidiasis complications include esophageal ulcerations with potential for esophageal perforation and upper gastrointestinal bleeding, weight loss, malnourishment, sepsis, candidemia, esophageal stricture, fistula formation into a bronchial tree.[13][14][15][2]

Consultations

Since upper endoscopy is a requirement for tissue sampling or brushing of the candida plaques in the esophagus, a gastroenterologist or general surgeon would be required to perform the procedure. A pathologist will make the diagnosis of esophageal candidiasis through histologic staining. Infectious disease specialists may be needed to help with treating refractory or recurrent esophageal candidiasis. Infectious disease physicians can also manage the patient's treatment for concomitant HIV which is causing their immunosuppression. Hematology/oncology specialists may also be consulted to manage patients with immunosuppression or manage chemotherapy medications which are causing immunosuppression.

Deterrence and Patient Education

Since candida is a normal oral flora which proliferates in immunocompromised states of health, one way of decreasing risk of esophageal candidiasis is to improve health conditions that can cause immunosuppression. Decreasing the use of antibiotics, systemic steroids, and the proper use of inhaled steroids can also be used to limit the risk of esophageal candidiasis. Prophylactic fluconazole may be necessary for patients that have recurrent infections.[2]

Enhancing Healthcare Team Outcomes

There may be some coordinated care between physicians in regards to interprofessional communications when it comes to dealing with esophageal candidiasis. A gastroenterologist or general surgeon may perform the upper endoscopy required for biopsies and brushings of the esophagus. A pathologist will confirm the diagnosis through histology. Most healthcare professionals feel comfortable treating esophageal candidiasis. If patients have recurrent infections or infections refractory to treatment, then an infectious disease specialist may help. Pharmacists can also help with dosing guidelines. Also, coordinating care with other specialists may be important when managing the causes of immunosuppression.


  • Image 7391 Not availableImage 7391 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Esophageal Candidiasis - Questions

Take a quiz of the questions on this article.

Take Quiz
A 17-year-old female with HIV presents with a major complaint of painful swallowing (odynophagia) and retrosternal chest pain. On physical examination, oral thrush was found. She is admitted for presumed candida esophagitis. Which of the following is not an acceptable treatment option?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the drug of choice for esophageal candidiasis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 25-year-old female with AIDS and a CD4 count of 75 complains of dysphagia. Exam shows oral thrush. What is the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is a finding on microscopy in esophageal candidiasis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which patient is at highest risk for developing esophageal candidiasis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What species of Candida is most commonly found in esophageal candidiasis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 58-year-old female presents for diagnostic esophagogastroduodenoscopy with the chief complaint of dysphagia and odynophagia. She has a past medical history of hypertension, type 2 diabetes mellitus, hyperlipidemia, hypothyroidism, gastroesophageal reflux disease, intravenous drug use, and alcohol use disorder. During the upper endoscopy, there are white plaques in the distal and mid esophagus with underlying mucosal inflammation. The plaques do not wash off with water irrigation. It is decided to take biopsies and brushings of the plaques and mucosa. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Esophageal Candidiasis - References

References

Alsomali MI,Arnold MA,Frankel WL,Graham RP,Hart PA,Lam-Himlin DM,Naini BV,Voltaggio L,Arnold CA, Challenges to     [PubMed]
Walsh TJ,Hamilton SR,Belitsos N, Esophageal candidiasis. Managing an increasingly prevalent infection. Postgraduate medicine. 1988 Aug;     [PubMed]
Klotz SA, Oropharyngeal candidiasis: a new treatment option. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2006 Apr 15;     [PubMed]
Pappas PG,Kauffman CA,Andes DR,Clancy CJ,Marr KA,Ostrosky-Zeichner L,Reboli AC,Schuster MG,Vazquez JA,Walsh TJ,Zaoutis TE,Sobel JD, Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016 Feb 15;     [PubMed]
Skiest DJ,Vazquez JA,Anstead GM,Graybill JR,Reynes J,Ward D,Hare R,Boparai N,Isaacs R, Posaconazole for the treatment of azole-refractory oropharyngeal and esophageal candidiasis in subjects with HIV infection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2007 Feb 15;     [PubMed]
Lake DE,Kunzweiler J,Beer M,Buell DN,Islam MZ, Fluconazole versus amphotericin B in the treatment of esophageal candidiasis in cancer patients. Chemotherapy. 1996 Jul-Aug;     [PubMed]
de Wet NT,Bester AJ,Viljoen JJ,Filho F,Suleiman JM,Ticona E,Llanos EA,Fisco C,Lau W,Buell D, A randomized, double blind, comparative trial of micafungin (FK463) vs. fluconazole for the treatment of oesophageal candidiasis. Alimentary pharmacology     [PubMed]
Rosołowski M,Kierzkiewicz M, Etiology, diagnosis and treatment of infectious esophagitis. Przeglad gastroenterologiczny. 2013;     [PubMed]
Takahashi Y,Nagata N,Shimbo T,Nishijima T,Watanabe K,Aoki T,Sekine K,Okubo H,Watanabe K,Sakurai T,Yokoi C,Kobayakawa M,Yazaki H,Teruya K,Gatanaga H,Kikuchi Y,Mine S,Igari T,Takahashi Y,Mimori A,Oka S,Akiyama J,Uemura N, Long-Term Trends in Esophageal Candidiasis Prevalence and Associated Risk Factors with or without HIV Infection: Lessons from an Endoscopic Study of 80,219 Patients. PloS one. 2015;     [PubMed]
Choi JH,Lee CG,Lim YJ,Kang HW,Lim CY,Choi JS, Prevalence and risk factors of esophageal candidiasis in healthy individuals: a single center experience in Korea. Yonsei medical journal. 2013 Jan 1;     [PubMed]
Antunes C,Mathew G, Esophagitis 2018 Jan;     [PubMed]
Geagea A,Cellier C, Scope of drug-induced, infectious and allergic esophageal injury. Current opinion in gastroenterology. 2008 Jul;     [PubMed]
Ostrosky-Zeichner L,Rex JH,Bennett J,Kullberg BJ, Deeply invasive candidiasis. Infectious disease clinics of North America. 2002 Dec;     [PubMed]
Lee KJ,Choi SJ,Kim WS,Park SS,Moon JS,Ko JS, Esophageal Stricture Secondary to Candidiasis in a Child with Glycogen Storage Disease 1b. Pediatric gastroenterology, hepatology     [PubMed]
Aghdam MR,Sund S, Invasive Esophageal Candidiasis with Chronic Mediastinal Abscess and Fatal Pneumomediastinum. The American journal of case reports. 2016 Jul 8;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Adult Health. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Adult Health, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Adult Health, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Adult Health. When it is time for the CNS-Adult Health board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Adult Health.