MetroHealth Medical Center Cleveland, OH, United States
Nabil El Hage Chehade, MD1, Fahmi Shibli, MD1, Bhavesh Shah, MD2 1Esophageal and Swallowing Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; 2MetroHealth Medical Center, Cleveland, OH
Introduction: Esophageal candidiasis (EC) is the most common type of infectious esophagitis. It frequently occurs in the form of superficial esophagitis. However, severe cases present with deep mucosal breaks, ulceration, pseudodiverticula, and esophageal polyps. We present the case of a severe recurrent EC refractory to standard antifungal therapy.
Case Description/Methods: A 68-year-old-male patient with end-stage renal disease, on hemodialysis, presented with progressive dysphagia for several months’ duration. Prior admissions showed evidence of Candida esophagitis for which the patient completed 3 weeks of oral fluconazole therapy. A barium esophagogram was performed which revealed deep ulceration, pseudo-diverticulosis, and intramural diverticulosis throughout the entire esophagus. There were multiple hyperplastic polyps within the distal esophagus and ulcerations extending to the level of the gastroesophageal junction. Esophagogastroduodenoscopy demonstrated a severely erythematous and ulcerated esophagus with deep friable craters and adherent pus-like material. In the mid-esophagus, the presence of a esophagopleural fistula was suspected. Radial endoscopic ultrasound was then performed and was significant for diffuse esophageal wall thickening confined within the muscularis layer. No fistulous tract was visualized. Cold forceps biopsies were obtained from this area. Histopathology showed acute on chronic esophagitis with marked ulcerations consistent with EC without dysplasia or malignancy. Candida speciation will be obtained during a follow-up endoscopy to test for antifungal resistance.
Discussion: Few cases of ulcerated transmural necrotic candidiasis have been reported and are often associated with serious immunosuppression or comorbidities, mainly end-stage renal disease. Current evidence suggests that frequent relapses of EC is linked to increased antifungal resistance resulting from increased prophylactic use of antifungal drugs, particularly fluconazole.
Figure: (A) Extensive esophageal ulcerations and crater formation in the proximal esophagus; (B) Proximal polyp within the mid-esophagus; (C) Mucosal ulceration and thick white plaque-like lesions in the distal esophagus (C) Endoscopic ultrasound findings of diffuse esophageal thickening confined to the muscularis layer without pleuro-esophageal fistula.
Disclosures:
Nabil El Hage Chehade indicated no relevant financial relationships.
Fahmi Shibli indicated no relevant financial relationships.
Bhavesh Shah indicated no relevant financial relationships.
Nabil El Hage Chehade, MD1, Fahmi Shibli, MD1, Bhavesh Shah, MD2. P2424 - Ulcerated Esophagus: A Case Report of Severe Recurrent Esophageal Candidiasis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
