Massive Submucosal Esophageal Tear from Meat Impaction in Candida Esophagitis

Abstract

Candida species are commensal organisms of different mucous membranes in healthy individuals with the esophagus being a common site of colonization. Candida esophagitis involves the superficial mucosa and transmural invasive candida infection is rare even in immunocompromised patients. Here we report a 49 year-old male who presented with hematemesis after a piece of steak was stuck in his esophagus. He was found on upper endoscopy to have deep esophageal tears, extensive ulcerations and whitish plaque. Biopsies were positive for candida esophagitis and he was subsequently diagnosed with HIV. The patient is a 49 year-old male with history of hypertension that presents with a food impaction in his esophagus after eating steak. He tried to relieve the impaction with self-induced vomiting without relief followed by multiple episodes of hematemesis associated with dysphagia, odynophagia, and severe chest pain. He reports being in usual state of health prior to that incident. He is not on chronic steroids, PPI, or anticoagulant and denies any history of NSAIDs or alcohol abuse. Physical examination was negative for any icteric sclera, palpable crepitus over chest wall or neck, or abdominal findings. CT chest showed no radiopaque foreign body or pneumomediastinum. On emergent EGD the findings were two large submucosal esophageal tears extending 27 to 37 cm from the incisors, diffuse whitish plaques covering the upper esophagus extending to the distal esophagus, and ulcerations of esophageal mucosa but no obvious perforation or food bolus in the esophagus. He was admitted under CT surgery and was kept NPO, on IVF, IV antibiotics and antifungal. Tissue biopsy of the esophagus revealed acute and chronic esophagitis, abundant candida and bacteria. He was positive on HIV screening with a viral load 12,214 and absolute CD4 count 169. A barium esophagram revealed no contrast extravasation. Candida esophagitis is known to occur in immunocompromised hosts but severe complications (i.e perforation, fistula) with esophageal candidiasis are rare and have been mainly reported in diabetic patients with renal transplantations and patients with hematologic malignancy. Unlike eosinophilic esophagitis, food impaction is not often seen in candida esophagitis. The unique highlights of this case are the absence of any prior esophageal or constitutional symptoms and the extent of esophageal mucosal injury sustained from the food impaction in the setting of esophageal candidiasis.Figure 1Figure 2Figure 3