A Rare Case of Odynophagia as a Result of Radiation and Candida Esophagitis

Abstract

Radiation esophagitis is inflammation of the esophagus caused by radiation therapy. It is characterized by inflammation, edema, erythema and erosion of the esophageal mucosa. Acute radiation esophagitis develops within 3 months, while late onset occurs 3 or more months after radiation. Symptoms of acute radiation esophagitis include dysphagia, odynophagia, and substernal discomfort. We are presenting a young patient who developed dysphagia and odynophagia two weeks after starting radiotherapy and was found to have radiation esophagitis with superimposed candidiasis. A 34-year-old man with a history of thymoma and myasthenia gravis, who underwent thymectomy and resection of pleural metastases was treated with radiotherapy and presented with symptoms of fever, dysphagia, and chest pain 5 days after the last radiation session. He started having intermittent dysphagia two weeks into radiation therapy. The symptoms were temporally related to his radiation sessions, maximal symptoms occurring 1 week after sessions. A week after his last radiation the dysphagia worsened and he developed nausea and chills. He reported odynophagia and pleuritic chest pain on admission and was febrile and tachycardic. Fluids and antibiotics were given and a CT chest was performed to rule out pulmonary emobolism (PE). CT was negative for PE and thymoma recurrence but showed esophagitis. An EGD showed esophagitis with exudative mucosa and leukoplakia, consistent with either radiation or candida esophagitis. Biopsies were taken. When white oral lesions were noted, he was treated empirically for candida esophagitis. Biopsies were positive for Candida. The patient's pain improved with fluconazole. He was discharged with a 14-day course. Radiation esophagitis is a common complication of radiation therapy characterized by progressive fibrosis and degeneration of vessels and smooth muscle. Endoscopically, mucosal friability and damage ranging from small erosions to large ulcers are found. Injury to the esophageal mucosa caused by thoracic radiation can be accompanied by Candida infection. Indeed, esophageal candidiasis has been reported in up to 15% of patients who had thoracic radiation. It is a common opportunistic infection in immunocompromised hosts. The typical endoscopic presentation is characterized by linear, white, mucosal, plaquelike lesions on the esophagus. Generally, candidiasis should be expected in patients with fever and suspected radiation esophagitis.1752_A Figure 1 No Caption available.1752_B Figure 2 No Caption available.