Esophageal Candidiasis

Background

• Esophageal candidiasis refers to the infection of the esophagus with any yeast species of the Candida genus.
• Candida albicans causes the majority of cases but infection with nonalbicans Candida spp. is also reported.
• Most cases occur in patients with impaired cell-mediated immunity such as:
  • HIV infection, typically patients with CD4+ T cell counts < 100 cells/mm³
  • recipients of solid-organ or bone marrow transplantation
  • chemotherapy-induced immunosuppression, particularly neutropenia
• Esophageal candidiasis often co-occurs with oral candidiasis (thrush).
• Symptoms associated with esophageal candidiasis include dysphagia or odynophagia and retrosternal pain.
• Systemic symptoms such as fever are often absent.

Evaluation

• Diagnosis is usually made clinically based on the presence of compatible symptoms and oral candidiasis.
• Endoscopy and biopsy can be considered for patients who do not respond to empiric therapy or have atypical symptoms.
• Gross findings consistent with esophageal candidiasis on endoscopy include whitish mucosal plaques.
• Culture, typically from esophageal brushings, allows for identification of the candidal species causing disease and susceptibility testing but does not distinguish colonization from infection.
• Biopsy provides definitive diagnosis and may show yeast with pseudohyphae and detached esophageal epithelium.

Management

• Use a systemic antifungal when treating patients with esophageal candidiasis.
• Fluconazole 200-400 mg/day orally is the recommended first-line option (Strong recommendation).
• For patients who cannot tolerate oral therapy, alternate options include IV fluconazole or an echinocandin (such as micafungin) (Strong recommendation).
• Options for fluconazole refractory disease include itraconazole, posaconazole, voriconazole, or micafungin (Strong recommendation).
• Suppressive therapy with fluconazole 100-200 mg orally 3 times weekly is recommended for patients with recurrent disease (Strong recommendation).