Esophageal candidiasis

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Esophageal Candidiasis

Esophageal candidiasis is an opportunistic fungal infection of the esophageal mucosa, most commonly caused by Candida albicans, though non-albicans species (C. glabrata, C. tropicalis, C. krusei, C. parapsilosis) are increasingly implicated, particularly in immunocompromised hosts.

Epidemiology & Risk Factors

Category	Examples
HIV/AIDS	Most common cause; occurs when CD4 < 100–200 cells/µL
Hematologic malignancy	Leukemia, lymphoma, stem cell transplantation
Solid organ transplant	Immunosuppressive therapy
Prolonged corticosteroids	Systemic or inhaled (ICS)
Broad-spectrum antibiotics	Disruption of normal flora
Diabetes mellitus	Impaired host immunity
Esophageal dysmotility	Stasis promoting fungal overgrowth
Malnutrition / elderly	Reduced cellular immunity

Clinical Presentation

Odynophagia (painful swallowing) — hallmark symptom
Dysphagia (difficulty swallowing, especially solids)
Retrosternal chest pain or discomfort
Nausea, reduced oral intake
Oral thrush is present in ~50–70% of cases but its absence does not exclude esophageal involvement
Rarely, patients may be asymptomatic (incidental endoscopic finding)

Diagnosis

Endoscopy (Gold Standard)

Endoscopic findings range from mild to severe:

Early: Few small, raised white plaques on erythematous mucosa
Advanced: Elevated confluent plaques (cottage-cheese-like) with underlying hyperemia and ulceration

The classic endoscopic appearance below is diagnostic in the appropriate clinical context:

Esophageal Candidiasis — Upper GI Endoscopy

Extensive whitish, confluent, cottage-cheese-like plaques covering the esophageal mucosa with areas of underlying erythema — classic esophageal candidiasis (PMC Clinical VQA)

Barium Swallow

Classic "cobblestone" or "shaggy" esophagus appearance (Prevention and Treatment of OIs in Children with HIV, p. 58)

Histopathology / Brushings

KOH preparation, Gram stain, PAS stain: budding yeast with pseudohyphae
Biopsy not always required if clinical/endoscopic picture is classic
Endoscopy also rules out co-infections: HSV, CMV, Mycobacterium avium complex (Prevention and Treatment of OIs in Children with HIV, p. 58)

Grading (Kodsi Classification)

Grade	Endoscopic Findings
I	Few raised white plaques ≤2 mm, no ulceration
II	Multiple raised white plaques >2 mm, no ulceration
III	Confluent linear/nodular plaques, hyperemia, ulceration
IV	Grade III + mucosal friability, narrowing of lumen

Treatment

Per IDSA Management of Candidiasis Guidelines (p. 38):

First-Line

Oral fluconazole 200–400 mg (3–6 mg/kg) daily × 14–21 days (strong recommendation; high-quality evidence)
Systemic antifungal therapy is always required — topical therapy alone is insufficient
A diagnostic trial of antifungal therapy is appropriate before endoscopy in the right clinical setting

If Unable to Tolerate Oral Therapy

IV fluconazole 400 mg (6 mg/kg) daily, OR
Echinocandin:
- Micafungin 150 mg/day
- Caspofungin 70 mg load → 50 mg/day
- Anidulafungin 200 mg/day
De-escalate to oral fluconazole once oral intake is tolerated

Less Preferred Alternative

Amphotericin B deoxycholate 0.3–0.7 mg/kg daily (moderate-quality evidence)

Fluconazole-Refractory Disease

Agent	Dose
Itraconazole solution	200 mg/day × 14–21 days
Voriconazole	200 mg (3 mg/kg) PO/IV BID × 14–21 days
Echinocandin	(doses as above) × 14–21 days
AmB deoxycholate	0.3–0.7 mg/kg/day × 21 days
Posaconazole (suspension)	400 mg BID (weak recommendation)
Posaconazole ER tablets	300 mg/day (weak recommendation)

Recurrent/Chronic Esophagitis

Suppressive therapy: Fluconazole 100–200 mg 3× weekly (strong recommendation; high-quality evidence)

Complications

Esophageal stricture or narrowing (severe Grade IV disease)
Fistula formation (rare)
Fungemia / disseminated candidiasis (rare, primarily in severely immunocompromised or critically ill patients)
Weight loss, malnutrition from impaired oral intake

Special Considerations

HIV patients: ART initiation alongside antifungal therapy; consider chronic suppression if CD4 remains low. Recurrence is common until immune reconstitution occurs.
Inhaled corticosteroid users: Encourage spacer use and mouth rinsing post-inhalation; consider switching to alternative ICS formulations.
Drug interactions: Fluconazole is a potent CYP2C9/CYP3A4 inhibitor — check interactions with anticoagulants, immunosuppressants, and antiretrovirals.
Azole resistance: Non-albicans species (especially C. glabrata) may be intrinsically resistant or develop acquired resistance; susceptibility testing recommended in refractory cases.

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