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Oesophageal candidiasis

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What are the clinical features of oesophageal candidiasis?

The hallmark of oesophageal candidiasis is dysphagia or odynophagia. However, the patients may be asymptomatic too. It often occurs together with oral thrush; however absence of thrush does not preclude a diagnosis of oesophageal candidiasis.

What is the causative organism?

C. albicans is almost always the infecting organism. Symptomatic infections caused by C. glabrata and C. krusei alone have been described

What are the risk factors for oesophageal candidiasis?

  • HIV infection- oesophageal candidiasis is an AIDS defining illness and occurs with CD4 counts less than 200/microL.
  • Haematological and non-haematological malignancies
  • Chemotherapy or use of broad spectrum antibiotics
  • Use of inhaled steroids

Discuss the diagnosis?

Diagnosis is made at endoscopy when white plaque like lesions is noted in the oesophagus. Brushings/biopsy of the lesions reveals presence of candida pseudohypahe

What is the treatment?

  • Systemic antifungal therapy is always required for treatment. Oral fluconazole (200 to 400 mg daily for 14 to 21 days) is the drug of choice due to its lack of toxicity and cost. Symptoms improve within 7 days.
  • For fluconazole-refractory disease, itraconazole solution at a dosage of 200 mg daily, posaconazole suspension at a dosage of 400 mg twice daily, or voriconazole at a dosage of 200 mg twice daily administered intravenously or orally for 14– 21 days is recommended.
  • Intravenous fluconazole at a dosage of 400 mg (6 mg/kg) daily, Amphotericin B at a dosage of 0.3–0.7 mg/kg daily, or an echinocandin (caspofungin, micafungin and anidulafungin) should be used for patients who cannot tolerate oral therapy.
  • Suppressive therapy with fluconazole at a dosage of 100–200 mg 3 times weekly is recommended for recurrent infections

Discuss the role of presumptive treatment?
The presence of oropharyngeal candidiasis and dysphagia or odynophagia is predictive of oesophageal candidiasis. A therapeutic trial with fluconazole for patients with presumed oesophageal candidiasis is a cost-effective alternative to endoscopic examination. If symptoms fail to improve within 7 days of treatment, endoscopy must be performed to exclude other causes of symptoms

Discuss side effects of azole therapy?

Azole therapy can be associated with gastrointestinal upset; prolonged administration can cause hepatotoxicity.
Azoles are teratogenic and are thus contraindicated in pregnancy. Amphotericin B is the recommended treatment for candidiasis in pregnancy.
Pic 1 Oesophageal candidiasis
Pic 1 Oesophageal candidiasis

Ref

  1. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America

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