1738 Refractory Candida Esophagitis in an Immunocompetent Patient: A Rare Presentation

Abstract

INTRODUCTION: Candida esophagitis is an invasive fungal infection of the esophagus classically caused by Candida albicans. It is usually considered an opportunistic fungal infection affecting those who are immunocompromised. Recently however, there has been an increased incidence of the infection in immunocompetent patients. Here present a case of refractory candida esophagitis in an immunocompetent female. CASE DESCRIPTION/METHODS: The patient is an 83-year-old immunocompetent female with a past medical history of congestive heart failure, hypertension, hyperlipidemia, diabetes mellitus, venous insufficiency, obstructive sleep apnea, fibromyalgia, and degenerative joint who presented to the clinic with a 5-month history of dysphagia and odynophagia. She was recently diagnosed with candida esophagitis through esophagogastroduodenoscopy (EGD) and biopsy and was treated with fluconazole with temporary resolution of symptoms. We performed a repeat EGD which showed diffuse whitish mucosal patches consistent with severe candida esophagitis of the entire esophagus (Figure 1). Biopsies stained with GMS special stain confirmed the diagnosis. Due to the patient’s previous resistance to fluconazole, the patient was referred to an infectious disease specialist who placed the patient on a Nystatin swish and swallow for 14 days with a subsequent course of fluconazole. One-month post-treatment, a follow-up EGD was performed and showed significant improvement with few scattered specks of whitish mucosal exudates in the entire esophagus consistent with mild candidiasis (Figure 2). One month later at follow-up, the patient reported complete resolution of symptoms. DISCUSSION: Candida esophagitis was thought to be a disease of the immunocompromised (i.e. AIDS patients) but, has shown to be on the rise in immunocompetent patients. Several studies showed that diabetes, old age, corticosteroid use, and antibiotic therapy are all major risk factors for development of the infection in this population. It is usually an easily treatable condition through the use of fluconazole, an antifungal agent that is usually seen with great success. However, there have been reports of resistance to the drug and a possible explanation of this is its widespread use leading to growth of fluconazole-resistant strains such as non-albicans candida strains. Species identification and fluconazole susceptibility testing may aid in adjustment of treatment protocols for those with recurrence of candida esophagitis.