Prevalence of esophageal Candida colonization in a Danish population: special reference to esophageal symptoms, benign esophageal disorders, and pulmonary disease

White Esophagus: The Result of Polypharmacy

Candida esophagitis can occur in immunocompetent patients through impairment of host defense mechanisms including salivation, esophageal motility, acidic pH, and innate immunity. Commonly prescribed medications inhibit these mechanisms, and polypharmacy has been shown to have an additive effect on promoting Candida infection. We present the case of an immunocompetent patient who was chronically prescribed multiple medications associated with Candida esophagitis but experienced infection only after the addition of oral delayed-release budesonide, which has not previously been associated with Candida esophagitis.

Predictors of esophageal candidiasis among patients attending endoscopy unit in a tertiary hospital, Tanzania: a retrospective cross-sectional study

Background

Esophageal candidiasis is a common disease among patients with impaired cell mediated immunity. In the current study, we report esophageal candidiasis among patients with various co-morbidities attending the endoscopic unit at the Bugando Medical Centre.

Methods

This retrospective study was conducted from June to September 2015. All data of the patients who attended the endoscopic unit between 2009 and 2014 were retrieved and analyzed.

Results

A total of 622 patients who underwent oesophagogastroduodenoscopy were analyzed. A slight majority 334/622(53.7%) of patients were female. Out of 622 patients; 35(5.6%) had esophageal candidiasis. Decrease in age (OR 1.1, 95%CI; 1.0–1.1), female sex (OR 3.8, 95%CI; 1.1–13.1), drinking alcohol (OR 17.1, 95%CI; 4.9–58.9), smoking (OR 8.3, 95%CI; 1.7–41.0), antibiotic use (OR 5.7, 95%CI; 2.0–16.4), positive HIV status (OR 10.3, 95%CI; 4.6–6.0) and presence of peptic ulcer disease (OR 13.2, 95%CI; 3.5–49.0) independently predicted esophageal candidiasis.

Conclusion

Patients with a history of drinking alcohol, smoking, use of antibiotics and those with chronic diseases such as peptic ulcers were at high risk of developing esophageal candidiasis. Further studies are needed to identify Candida spp. and their anti-fungal susceptibility for proper management of esophageal candidiasis in HIV and non-HIV individuals.

Esophageal Stricture Secondary to Candidiasis in a Child with Glycogen Storage Disease 1b

Esophageal candidiasis is commonly seen in immunocompromised patients; however, candida esophagitis induced stricture is a very rare complication. We report the first case of esophageal stricture secondary to candidiasis in a glycogen storage disease (GSD) 1b child. The patient was diagnosed with GSD type 1b by liver biopsy. No mutation was found in the G6PC gene, but SLC37A4 gene sequencing revealed a compound heterozygous mutation (p.R28H and p.W107X, which was a novel mutation). The patient's absolute neutrophil count was continuously under 1,000/µL when he was over 6 years of age. He was admitted frequently for recurrent fever and infection, and frequently received intravenous antibiotics, antifungal agents. He complained of persistent dysphagia beginning at age 7 years. Esophageal stricture and multiple whitish patches were observed by endoscopy and endoscopic biopsy revealed numerous fungal hyphae consistent with candida esophagitis. He received esophageal balloon dilatation four times, and his symptoms improved.

Acid suppression therapy as a risk factor for Candida esophagitis

BACKGROUND/AIM

As the prevalence of reflux esophagitis increases, so does the use of gastric acid suppressants. This study aimed to document the prevalence of Candida esophagitis (CE) at a single Korean university hospital over the last 5 years and to evaluate its risk factors.

METHODS

To investigate the prevalence of CE, we conducted a retrospective analysis of 55,314 individuals who underwent a screening esophagogastroduodenoscopy as part of a health check-up between January 2006 and December 2010 at Kyung Hee University Hospital in Seoul, Korea. A total of 250 patients who were treated for CE between January 2008 and August 2011 and 500 age- and sex-matched non-CE patients were enrolled in this study. The rates of recent gastric acid suppression therapy and other well-known risk factors in the two groups were compared.

RESULTS

The prevalence of CE was 0.35 % and increased each year (linear-by-linear association, P = 0.001). Univariate analysis showed that gastric acid suppression therapy, malignancy, DM and steroid therapy were related to CE. Multivariate analysis also showed that gastric acid suppression therapy (OR 5.11, 95 % CI 2.92-8.93 and P < 0.001), malignancy (OR 18.68, 95 % CI 6.37-54.75 and P < 0.001), DM (OR 2.67, 95 % CI 1.70-4.21 and P < 0.001) and steroids therapy (OR 6.74, 95 % CI 1.37-33.05 and P = 0.019) were related to CE.

CONCLUSIONS

The prevalence of CE in Korea is increasing. Also, our results indicate that acid suppression therapy is a meaningful risk factor for CE.

The impact of systemic fungal infection in patients with perforated oesophagus

INTRODUCTION

Perforated oesophagus is a surgical emergency with significant morbidity and mortality. Systemic fungal infection represents a poor response to the magnitude of the insult, which adds significantly to the risk of morbidity and mortality in these patients. We reviewed our experience with this group of patients over a six-year period in a tertiary referral centre.

METHODS

A retrospective clinical review was conducted of patients who were admitted following a ruptured oesophagus over a period of six years (January 2002 - January 2008).

RESULTS

We had 27 admissions (18 men and 9 women) following an isolated perforated oesophagus to our unit. The median patient age was 65 years (range: 22-87 years). The majority (n=24, 89%) presented with spontaneous perforations (Boerhaave's syndrome) and three (11%) were iatrogenic. Fungal organisms, predominantly Candida albicans, were positively cultured in pleural or blood samples in 16 (59%) of the 27 patients. Fourteen patients grew yeasts within the first seven days while two showed a delayed growth after ten days. Overall mortality was 5 out of 27 patients (19%). There was no mortality among the group that did not grow yeasts in their blood/pleural fluid while mortality was 31% (5/16) in the group with systemic fungal infection (p<0.001). A positive fungal culture was also associated with increase ventilation time, intensive care unit stay and inpatient hospital stay but not an increased rate of complications.

CONCLUSIONS

Systemic fungal infection in patients with a ruptured oesophagus affects a significant proportion of these patients and carries a poor prognosis despite advanced critical care interventions. It may represent a general marker of poor host response to a major insult but can add to mortality and morbidity. It is worth considering adding antifungal therapy empirically at an early stage to antimicrobials in patients with an established diagnosis of a perforated oesophagus.

Candida esophagitis complicated by an esophago-airway fistula: report of a case

Candida esophagitis rarely involves life-threatening complications, such as necrosis, perforation, or fistula formation between the esophagus and the airway. We herein report a case of Candida esophagitis complicated by esophagobronchial and esophagopulmonary fistulas. The patient in our study was a 70-year-old man with a 3-month history of dysphagia. Based on endoscopy and histological findings, he was diagnosed with a coinfection of Candida spp. and herpes simplex virus. Antifungal and antiviral therapy was administered without success. The esophagopulmonary fistula formation and a lung abscess were identified 7 months later. The patient was deemed intolerable to an esophagectomy due to his poor general condition, thus necessitating a two-stage operation. A cervical esophagostomy and a tube drainage of the thoracic esophagus were followed by an esophageal bypass using the pedicled jejunum via an antethoracic route. Although the lung abscess resolved, the inflammation of the esophagus persisted. A fistula between the esophagus and the left main bronchus eventually formed postoperatively and the patient died due to respiratory failure.

Candida esophageal perforation and esophagopleural fistula: a case report

Introduction

Esophageal perforation is a rare disease, which can lead to significant morbidity and mortality. Its clinical presentation can mimic other disease processes and, therefore, it can be easily misdiagnosed. Candida infection of the esophagus is an extremely rare cause of esophageal perforation.

Case presentation

We report the youngest pediatric case in the medical literature of spontaneous esophageal perforation and an esophagopleural fistula due to Candida infection.

Conclusion

A high index of suspicion, especially in the presence of Candida empyema and the absence of disseminated infection, should raise the possibility of esophageal perforation with esophagopleural fistula formation. This can lead to early diagnosis and surgical intervention, which would decrease the high mortality rate of this rare condition.

Fatal Esophageal Perforation Caused by Invasive Candidiasis

Instrumental lesions, spontaneous rupture, and trauma cause most esophageal perforations. Transmural fungal infection is extremely rare, although Candida may be detected in as many as 25% of normal esophagus. In this report we present a case of fatal esophageal perforation due to transmural Candida infection in a 76-year-old woman. The patient died from septic shock and multiorgan failure, despite esophageal resection and systemic antifungal therapy. Pathogenetic aspects and treatment strategies are discussed.

Predisposing factors and clinical symptoms in HIV-negative patients with Candida oesophagitis: are they always present?

Candida oesophagitis (CO) is scarce among immunocompetent patients. This study aimed at evaluating predisposing factors, clinical symptoms and endoscopic findings in this group. We retrospectively reviewed 55 patients diagnosed as CO endoscopically (whitish plaques) and cytologically (fungal mycelia on brush cytology). Carcinoma, diabetes, acid suppression, steroids, gastric surgery and oesophageal motility disorders were considered as predisposing factors. Twenty of 55 patients lacked any predisposing factor for CO. These patients were more frequently asymptomatic (8/20) when compared with those with known predisposing factors (5/35) (p = 0.031). Moreover, dysphagia was more prevalent in the latter group (24/35 vs. 8/20; p = 0.039). Endoscopic findings correlated with the presence of neither predisposing factors nor symptoms (Wilcoxon p > 0.05). Thus, CO can be discovered in patients without apparent predisposing risk factors and clinical symptoms. Further studies are needed to elucidate the mechanisms of transition from colonisation to infection.

Prevalence of esophageal candidiasis among patients treated with inhaled fluticasone propionate

OBJECTIVES

Development of oropharyngeal candidiasis is a frequently reported adverse effect of inhaled corticosteroid use, but the prevalence of esophageal candidiasis is unknown. The aim of this study was to estimate the prevalence of esophageal candidiasis among patients treated with an inhaled corticosteroid, fluticasone propionate.

METHODS

Upper GI endoscopy was performed on 49 patients treated with inhaled fluticasone propionate to examine the prevalence of esophageal candidiasis. Of the patients, 36 had bronchial asthma and 13 had chronic obstructive pulmonary disease. To compare the prevalence with control patients, upper GI endoscopy was performed on 700 consecutive patients without malignancy or immunosuppression.

RESULTS

The prevalence of esophageal candidiasis was 37% among patients treated with inhaled fluticasone propionate, whereas only 0.3% of the control patients had the infection. The prevalence was especially high among patients with diabetes mellitus or those who were treated with a high dose of inhaled fluticasone propionate. Moreover, a reduction in the daily dose of inhaled fluticasone propionate eliminated the infection in four of five patients.

CONCLUSIONS

Esophageal candidiasis is a common complication of inhaled corticosteroid use.

Esophageal candidiasis as a complication of inhaled corticosteroids

BACKGROUND

Oropharyngeal candidiasis is a well-described side effect of inhaled corticosteroids. Nevertheless, few cases of esophageal candidiasis have been reported.

OBJECTIVE

To present a patient with esophageal candidiasis associated with inhaled corticosteroids.

METHODS

Case report.

RESULTS

Our patient is a 70-year-old white woman with a 20-year history of intrinsic asthma, well controlled on triamcinolone acetonide 400 micrograms, ipratropium bromide 36 micrograms, and pirbuterol acetate 400 micrograms, each inhaled four times daily. She reported no oral steroid use for > 4 years and that she always rinsed her mouth following triamcinolone acetonide inhalation. The patient had gastritis with peptic ulcer disease in the past and developed worsening dyspeptic pain and heartburn. Following discontinuation of cimetidine and initiation of ranitidine without improvement, esophagogastroduodenoscopy was performed. Several small white patches in the mid and distal esophagus could not be removed with pressure. A biopsy confirmed the diagnosis of candidal esophagitis. Following a 4-week course of fluconazole, the patient was clinically improved and follow-up esophagogastroduodenoscopy was normal. There was no evidence of underlying cellular immunosuppression, malignancy, or diabetes mellitus and no history of recent antibiotic usage. Delayed skin tests revealed 5 x 5 mm induration to dermatophytin. Delayed hypersensitivity to Candida and mumps tests was absent. There was strong in vitro lymphocyte transformation and a positive immediate skin test response to Candida. ELISA for human immunodeficiency virus was negative. T and B cell counts were normal with CD4 = 630/mm3, CD8 = 520/mm3, and absolute B cell = 120/mm3. It is possible that this patient's immediate hypersensitivity response to Candida suppressed her delayed response. Candidal esophagitis is a rare, yet important, complication of inhaled corticosteroid use.

CONCLUSION

Immunocompetent patients on inhaled corticosteroids with medically unresponsive symptoms of esophagitis should be investigated for esophageal candidiasis.

Oral and esophageal disorders

This article focused on the approach to oral and esophageal disorders in patients with AIDS. Most of these disorders respond to various therapeutic regimens. Some of the oral complications can be prevented with dental prophylaxis, whereas recurrent esophageal disease in some patients may require long-term suppressive therapy. As patients with AIDS live longer with lower CD4 counts, gastroenterologists need to become familiar with the approach to and management of the more common lesions of the mouth and esophagus.

Esophageal infections: risk factors, presentation, diagnosis, and treatment

Infections of the esophagus are unusual in the general population and strongly imply immunodeficiency, although immunocompetent individuals are not exempt. HIV infection is predominant among risk factors for infectious esophagitis. For all immunocompromised patients, the most frequently identified esophageal pathogens are Candida, CMV, and HSV. Peculiar to HIV-infected patients are idiopathic esophageal ulcers as well as unusual bacteria and parasites. Patterns of presentation differ with each infecting organism, and clinical features should be used as a guide in achieving a correct diagnosis. For example, a patient with AIDS presenting with esophageal symptoms and thrush, along with abdominal pain, nausea, vomiting, and fever, is unlikely to resolve all symptoms with empiric antifungal therapy alone. Parsimony of diagnosis does not hold among immunodeficient patients in whom concurrent infections are common. Accurate and timely diagnoses are essential as effective treatments are available for particular etiologies. Finally, among immunocompromised patients, all esophageal symptoms are not necessarily due to an infection, and possible diagnoses of pill esophagitis, acid-peptic injury, or structural and functional abnormalities should not be overlooked.