Fungal Peptic Ulcer Disease in an Immunocompetent Patient

Abstract

The lifetime prevalence of peptic ulcer disease (PUD) is 5-10%. While PUD is most commonly associated with Helicobacter pylori infection or the use of nonsteroidal anti-inflammatory drugs (NSAIDs), less common causes of PUD should be considered in the differential diagnosis. Peptic ulcer diseaes secondary to Candida in immunocompetent patients is uncommon. We describe a case of endoscopic and histologic resolution of peptic ulcer disease related to Candida infection in a healthy, immunocompetent woman. A 50 year-old woman presented with a three month history of post-prandial abdominal cramping, vomiting and seven pound weight loss. There was no history of HIV (human immunodeficiency virus) or diabetes. She denied NSAID use and alcohol consumption and was not taking corticosteroids. Outpatient esophagogastroduodenoscopy (EGD) revealed a 1 cm, non-bleeding, irregular shaped, deep and clean-based ulcer at the pylorus. Histopathology of the biopsies taken revealed an ulcer with necroinflammatory debris and fungal organisms, consistent with Candida species. Periodic acid-Schiff (PAS) fungal stain noted scattered yeast colonizing the fibrinous debris. After a three week course of fluconazole, her symptoms resolved. Repeat EGD revealed ulcer healing. Repeat biopsies of the pylorus were negative for any evidence of fungal organisms. Fungal PUD is more common in the esophagus compared to anywhere else in the GI tract. Gastric candida was found in 0.24% of patients in a large study consisting of outpatient setting. While treatment guidelines have not been established, antifungals and proton-pump inhibitiors have been shown to help resolve this condition.2689_A Figure 1. Endoscopy before resolution. Fungal ulcer at the pylorus.2689_B Figure 2. Periodic acid-Schiff showing fungal elements.2689_C Figure 3. Endoscopy showing resolution of fungal ulcer at pylorus.