S3422 Candida Esophagitis and Heavy Alcohol Consumption

Abstract

INTRODUCTION: Candida esophagitis (CE), a common infection in the immunocompromised, also affects immunocompetent patients. Several retrospective and case control studies of patients without human immunodeficiency virus (HIV) infection and diagnosed with CE have observed its association with different risk factors, such as diabetes mellitus, malignancy, corticosteroids and antibiotic therapy. In this case, we examine heavy alcohol consumption as an independent risk factor for CE, and the need to consider it to prevent or treat CE and its potential complications. CASE DESCRIPTION/METHODS: 50 year old male with a history of alcohol abuse presents with 2 days of severe epigastric abdominal pain with hematemesis and melena. He reports binge drinking 2 liters of whiskey every 1-2 weeks, with his last drink 2 days prior to admission. He occasionally takes ibuprofen for back pain. On examination, his abdomen was soft, but tender in the epigastrium. Blood work showed normocytic anemia, anion gap metabolic acidosis and lactic acidosis, and was negative for HIV, elevated pancreatic enzymes and diabetes mellitus. Computed tomography showed thickening of the esophageal wall. Endoscopy revealed candida esophagitis in the middle and distal third of the esophagus, and a Mallory-Weiss tear at the gastroesophageal junction. The patient was discharged on a course of proton pump inhibitor and antifungal agent, and counseled on alcohol avoidance. DISCUSSION: CE results from colonization of the esophagus by Candida species, followed by invasion of the epithelium. Candida is known to colonize the esophagus even in healthy adults and normally exists in a complex symbiotic relationship with the host and commensal bacteria. However, colonization and virulence can be promoted by exposure to factors that alter esophageal microbiota and damage the mucosa. Heavy alcohol consumption has been linked to increased oropharyngeal colonization by Candida, and has been revealed as a major risk factor for CE. Candida species exacerbate inflammation and delay healing of mucosal lesions. This further promotes Candida colonization and leads to a vicious inflammatory cycle, with studies showing increased risk of ulcer perforation. Physicians should be wary of heavy alcohol consumption as a potential risk factor for the development of CE in immunocompetent patients. Alcohol avoidance and early treatment of CE can break the cycle of inflammation perpetuated by Candida colonization and reduce morbidity and mortality.Figure 1.: Endoscopic image of middle third of esophagus revealing numerous whitish plaques consistent with diagnosis of Candida Esophagitis.