Candidal Esophagitis: Symptoms, Causes, Diagnosis, and Treatment

Introduction:

Candidiasis is an infection caused by the fungus Candida. The fungus candida usually lives inside the body in the skin and other areas like the throat, stomach, mouth, and vagina. In normal cases, the body's immune system regulates the presence of good and bad organisms inside the body, so the fungus does not cause any problems inside the body. But sometimes, the environment changes in the areas of the throat, esophagus, or mouth, causing an increase in the growth of the fungus. This multiplication of the fungus causes infections like candida esophagitis.

What Is Candidal Esophagitis?

Candidal esophagitis, or esophageal thrush, is a yeast infection caused by the fungus Candida Albicans in the esophagus. The esophagus is a tube that is the connection between the throat and the stomach region. This infection is mostly seen in immunocompromised patients like Human immunodeficiency virus (HIV) patients, patients undergoing chemotherapy, or patients with uncontrolled diabetes. People infected by candida esophagitis often have candidiasis in other regions like the mouth and throat region.

What Causes Candidal Esophagitis?

Candida Albicans mainly cause candidal esophagitis. However, Candidal esophagitis can also be seen in underlying conditions like herpes simplex virus, cytomegalovirus, medication-induced esophagitis, radiation-induced esophageal injury, gastroesophageal reflux disease, and inflammatory conditions like eosinophilic esophagitis.

What Are the Symptoms of Candidal Esophagitis?

The hallmark symptom of Candidal esophagitis is pain during swallowing (odynophagia). Other symptoms seen in candida esophagitis are:

• Soreness or redness is seen inside the esophagus area.

• White patchy areas are present in the lining of the esophagus that can bleed when they are scraped.

• Feeling a cotton-like sensation inside the mouth.

• Nausea and vomiting.

• Diarrhea.

• Pain during swallowing and eating.

• Abdominal pain.

• Dark-colored stool containing blood (melena).

• Weight loss.

• Retrosternal chest pain (pain that occurs inside the chest).

In some cases, Candida esophagitis can also be asymptomatic.

Who Is at More Risk for Candida Esophagitis?

People who get infected by candida esophagitis have a weak immune system, like people affected by HIV/AIDS or people with blood cancers. When a person has a weak immune system, their body won't be able to fight infections, causing an increase in the growth of the fungus. The other underlying conditions that increase the risk for candida esophagitis are:

• Smoking.

• People who wear dentures.

• A dry mouth condition or medications that cause dry mouth.

• People who take inhaled corticosteroids or antibiotics for asthma.

• Conditions like diabetes. In uncontrolled diabetic patients, increased sugar levels are present in their saliva. This sugar in the saliva allows the fungus to flourish, causing the infection.

• Blood cancer.

• Immunocompromised patients like Human immunodeficiency virus (HIV) positive or acquired immunodeficiency syndrome (AIDS) patients.

• Chemotherapy (drug treatment to stop the growing cancer cells) patients.

• Patients who are undergoing radiation to the neck region.

• Adrenal insufficiency (condition when adrenal glands are damaged and do not produce enough steroid hormones).

• Old age.

What Are the Complications Caused by Candida Esophagitis?

Candida Esophagitis can cause complications like ulcers in the esophagus, leading to esophageal perforations and bleeding in the upper gastrointestinal tract. Other complications include:

• Malnourishment.

• Weight loss.

• Fistula formation into a bronchial tree.

• Esophageal stricture (abnormal narrowing of the esophagus).

• Candidemia (presence of Candida in the bloodstream).

• Sepsis (life-threatening emergency).

The risk of complications is more seen in people with compromised immune systems. In addition, the thrush could spread to other parts of the body, like the liver, lungs, valves of the heart, and intestines.

How Is Candida Esophagitis Diagnosed?

• The healthcare provider usually examines the inside of the mouth and the throat region.

• Sometimes, a sample will be collected from the throat or mouth region and sent to the laboratory for testing.

• Another procedure done to diagnose candida esophagitis is endoscopy. An endoscope is a lighted tube containing a camera inserted into the throat region through the mouth to examine the esophagus.

• Candida is visualized as white plaque regions by the endoscope.

• The plague usually sticks to the mucosa and does not usually go with water irrigation. Ulcerations or mucosal breaks can also be seen in the esophageal region.

• To histologically confirm the presence of the infection, the plaques are brushed, and biopsies are done.

How Is Candida Esophagitis Treated?

• The first-line treatment for candida esophagitis is antifungal therapy. Unlike oropharyngeal candidiasis, candida esophagitis is treated with systemic medications rather than topical agents.

• The most commonly given antifungal medication is Fluconazole, orally or intravenously. The oral dosage is 200 to 400 mg for about 14 to 21 days.

• Intravenous Fluconazole is given to patients who cannot tolerate oral intake of Fluconazole. The dosage of IV fluconazole is 100 to 200 mg three times every week.

• Other oral treatment options include Itraconazole 200 mg or Voriconazole 200 mg, given twice daily for about 14 to 21 days.

• Other intravenous options include Micafungin which is given 150 mg daily.

• Since candida esophagitis can be caused due to certain underlying conditions like HIV infection, adrenal insufficiency, or chemotherapy, those underlying conditions should be diagnosed and treated to resolve candida esophagitis.

• Amphotericin B medication is the preferred option in pregnant patients with esophageal candidiasis and for people with late-stage HIV.

• The dosage of antifungal medications like Fluconazole or Miconazole is modified for patients with renal insufficiency.

• Even after 72 hours of treatment, if no improvement is noted in immunosuppressed patients, an upper endoscopy must be performed.

• In immunosuppressed patients, long-term antifungal therapy can lead to liver damage. Hence, liver function tests should be regularly done in immunosuppressed patients.

• If esophageal thrush has developed extensively and affected the patient's eating ability, the doctor might recommend nutritional options like high protein shakes or feeding options like gastric tubes.

Can Candida Esophagitis Be Prevented?

Candidiasis can be prevented by maintaining good oral hygiene. Asthmatic patients who use inhaled corticosteroids must brush their teeth and wash their mouths after using them. It is advisable to eat yogurt whenever an antibiotic is taken. In the case of HIV or AIDS patients, antiretroviral therapy medications can help prevent the risk of esophageal candidiasis.

Conclusion:

Candida esophagitis is a fungal infection that occurs in the esophagus. It can cause various symptoms like pain during swallowing, nausea, vomiting, diarrhea, abdominal pain, and retrosternal chest pain. Candida esophagitis is commonly seen in immunocompromised patients with diabetes, HIV patients, patients undergoing chemotherapy, and patients undergoing radiation to the neck. Antifungal medications like Fluconazole are used to treat Candida esophagitis. However, if the infection is left untreated, it can become severe and life-threatening. So, it is important to note the symptoms and seek immediate medical intervention.