Candidiasis of the Small Bowel Causing Gastrointestinal Bleed

Abstract

Purpose: Recognize small bowel Candidiasis as a rare cause of gastrointestinal bleed. Case Report: A 31-year-old woman with a history of juvenile idiopathic arthritis, not on chronic immunosuppression, was initially admitted to an outside hospital with acute malaise, arthralgias and rash complicated by the development of ARDS, requiring transfer to our hospital for further workup and management. Upon presentation, she was diagnosed with Adult-onset Still's disease and was treated with high doses of IV methylprednisolone. On hospital day #7, she developed hemoccult negative watery diarrhea of unclear etiology. The infectious workup, including cultures, was negative. Despite aggressive ICU management including multiple broad spectrum antibiotics, she remained critically ill with multi-organ dysfunction and was eventually initiated on Anakinra for treatment of her rheumatologic condition. She did experience overall clinical improvement, but her loose stools persisted. On hospital day #20, she developed melena and, subsequently, transfusion-dependent anemia. An esophagogastroduodenoscopy revealed a diffusely edematous and erythematous small bowel with active oozing of blood from the duodenum extending into the mid-jejunum. This mucosal appearance was also noted in the terminal ileum on colonoscopy. Biopsies from throughout the small bowel were positive for fungus, suggestive of Candida. Gastric and colonic biopsies were negative for fungus. IV fluconazole was initiated with subsequent improvement in her melena and anemia. Discussion: Small bowel Candidiasis has been recognized as a rare cause of watery diarrhea in immunocompromised patients. Rare case reports have documented small bowel fungal infections leading to gastrointestinal bleeding. In a 1992 autopsy study of 890 patients with malignant disease, Prescott et al. described 14 cases of small bowel fungal infections (Candida or Aspergillus spp), with only three Candidal infections associated with melena. Only one case of fungal infection was confined solely to the small intestine. Unlike previously described cases of melena caused by small bowel Candidiasis, our case demonstrates that small bowel Candidiasis can occur in the absence of underlying malignancy or extraintestinal Candidal infection. Though rare, small bowel Candidiasis should be considered in severely immunocompromised, acutely ill, hospitalized patients who develop clinically significant gastrointestinal bleeding even in the absence of underlying malignancy. Prompt recognition of this uncommon disease along with initiation of anti-fungal therapy is necessary to limit further bleeding and prevent potential complications such as small bowel perforation.