Infectious Esophagitis

Candida Esophagitis

Candida is a part of the normal flora in the human gastrointestinal tract. Candida spp., primarily C. albicans, are the most common agents in causing esophagitis. In addition to human immunodeficiency virus (HIV) disease, other factors that predispose to Candida esophagitis include advanced age, frequent antibiotic use, inhaled or ingested corticosteroids, poorly controlled diabetes mellitus, adrenal dysfunction, alcoholism, head and neck radiotherapy, hematologic malignancies, and motility disorders such as achalasia and scleroderma. Routine prophylactic antifungal therapy has reduced the incidence of Candida esophagitis in patients undergoing solid organ/bone marrow transplantation. Odynophagia (painful swallowing) with or without dysphagia is the classic symptom. Although oral thrush may be seen in many patients, absence of it does not exclude the infection. Esophagogastroscopy is diagnostic and is needed in all patients with alarm symptoms (dysphagia, weight loss, and bleeding) and those who do not respond to empiric therapy. Esophagoscopy shows white mucosal plaquelike lesions. Confirmatory biopsy shows the presence of yeast and pseudohyphae with invasion of mucosal cells. Empiric therapy is appropriate in AIDS patients on the basis of patient's history. However, nearly 50% of the patients may not respond because of the high incidence of coinfection with CMV and HSV in particular when the CD4 count is less than 200 cell/mm ³ . The treatment of oropharyngeal candidiasis without AIDS is with antifungal lozenges or solutions of nystatin 600,000 U four times daily or clotrimazole 10 mg five times daily. Fluconazole 200 to 400 mg a day for 2 to 3 weeks is recommended in immunosuppressed patients, as well as those not responding to the previously mentioned empiric therapy. Posaconazole 400 mg twice daily followed by 400 mg once daily is an option in patients who have refractory disease.