A 45‐year‐old woman was admitted with vomiting. Her medical history was notable for Down syndrome, type 2 diabetes, and moderate aortic stenosis. Four weeks before admission she presented to her physician with a 3‐month history of odynophagia, dysphagia, and a 15‐pound weight loss. Alendronate was discontinued and omeprazole begun. Upper endoscopy demonstrated white exudate coating the entire esophagus and food in the stomach. Esophageal biopsy showed Candida esophagitis. Oral fluconazole was begun, and Candida dubliniensis was cultured. Two days later the patient was admitted with persistent vomiting. Physical examination revealed a murmur of aortic stenosis, and a benign abdomen. No thrush was noted. Laboratory testing was significant for a nHbA1c of 7.3% and negative HIV antibody testing. Intravenous fluconazole was begun. A gastric emptying study showed tracer activity through the esophagus at 60 minutes, with minimal activity in the stomach. A barium esophagram showed esophageal distension with tapering at the lower esophageal sphincter and minimal contrast transit to the stomach consistent with achalasia, subsequently confirmed by esophageal manometry. After a failed trial of botulinum toxin injection, the patient underwent a successful laparoscopic myotomy and fundoplication.
Down syndrome has been associated with enteric nervous system (ENS) abnormalities including esophageal motility disorders, chronic constipation, and Hirschsprung's disease. Primary achalasia is an idiopathic disorder characterized by degeneration of ganglion cells in the myenteric plexus leading to aperistalsis of the distal esophagus and impairment of lower esophageal sphincter relaxation. Esophageal stasis–induced inflammation and ulceration caused by acidic foods, pills, and bacterial fermentation of food predisposes to Candida superinfection. Delayed diagnosis of achalasia is common because of the indolent progression of symptoms, adoption of compensatory mechanisms such as slow eating, and failure of treating physicians to recognize typical symptoms. Endoscopy should be performed in all suspect patients to exclude an infiltrative malignancy causing or complicating the disease. However, up to 40% of patients with achalasia may have normal findings on endoscopy, and most require barium esophagram and/or esophageal manometry for diagnosis.
Hospitalists face challenges diagnosing atypical illness presentations in intellectually disabled patients, as self‐reported history and caretaker observations may be limited. The diagnosis of severe Candida esophagitis prompts consideration of altered immunity as a predisposing condition. This case highlights esophageal stasis as another risk factor for extensive Candida infection and the limited sensitivity of upper endoscopy in diagnosing achalasia.
R. Blair ‐ none
To cite this abstract:Blair R. An Unusual Case of Candida Esophagitis. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 244. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/an-unusual-case-of-candida-esophagitis/. Accessed March 30, 2020.