The Unusual Occurrence of Esophageal Pseudodiverticulosis Associated with Monilial Candidiasis and Esophageal Stricture

Abstract

Purpose: Intramural pseudodiverticulosis of the esophagus is an uncommon benign disorder and was first described by Mendel et al. in 1960. The condition usually presents with mild dysphagia which is usually intermittent and slowly progressive. Few cases of esophageal pseudodiverticulosis have been reported in literature. About 50% of these cases are associated with stricture formation. Case Presentation: A 58-year-old woman presented to our emergency department with dysphagia, non bloody vomiting and weight loss of about 30 pounds over the prior 3 months to admission. She denied abdominal pain, or irregular bowel habits. Her medical comorbidities included HIV/AIDS, depression and asthma. Physical examination apart from revealing a cachectic middle aged woman was otherwise unremarkable. An upper endoscopy performed two days after admission revealed severe stenosis in the esophagus 18 cm from the incisors. The stenosis could not be traversed with a regular upper endoscope. A marked area of whitish plagues, inflammation and ulceration were noted above the stenotic segment. Biopsies revealed severe active esophagitis associated with numerous fungal forms consistent with Candida species. She was subsequently treated with fluconazole and double dose PPI. A barium swallow obtained on the 7th day of admission revealed distal esophageal stricture; however, pseudodiverticulosis was not seen at this time. A repeat upper endoscopy revealed multiple small red openings protruding from the esophageal lumen (pseudodiverticulosis) in the previously noted stenotic segment. This time; however, we were able to gently traverse the previously seen stenosis suggesting improvement of stenosis. An esophageal dilation was, therefore, not necessary. Her dysphagia improved and she was able to tolerate solid chopped diet. Discussion: Esophageal intramural pseudodiverticulosis is a rare condition characterized by multiple flask-shaped outpouchings in the esophageal wall representing dilated excretory ducts of submucosal glands. Dysphagia is the leading symptom. On endoscopy, minute openings in the esophageal wall, and sometimes a segmental Candida esophagitis or a benign stenosis not originating from an erosive reflux esophagitis are found. Treatment aims at ameliorating symptoms. When dysphagia due to esophageal stricture develops, dilatation is the treatment of choice. Reflux or Candida esophagitis must be treated as well. In conclusion, we present a rare case of esophageal pseudodiverticulosis associated with esophageal stenosis and monilial candidiasis.