Is it safe to perform a transesophageal echocardiogram (TEE) on a patient with candidiasis?

Safety of Transesophageal Echocardiography in Patients with Candidiasis

Transesophageal echocardiography (TEE) should be avoided in patients with active esophageal candidiasis due to the risk of mucosal trauma and potential complications, but can be performed safely after appropriate antifungal treatment. 1, 2

Understanding Candidiasis and TEE Risks

Types of Candidiasis Relevant to TEE

• Esophageal candidiasis: Direct contraindication for TEE due to:

  • White mucosal plaque-like lesions and exudates adherent to the esophageal mucosa
  • Risk of mucosal trauma during probe insertion
  • Potential for worsening infection or creating portals for systemic spread

• Candidemia/Systemic candidiasis: Not a contraindication for TEE, and may actually be an indication for the procedure to rule out endocarditis

Risk Assessment for TEE in Candidiasis

High-Risk Scenarios (Avoid TEE)

• Active esophageal candidiasis with visible plaques
• Untreated oropharyngeal candidiasis with extension to esophagus
• Necrotizing esophageal candidiasis

Appropriate Scenarios for TEE

• Candidemia requiring evaluation for endocarditis
• After successful treatment of esophageal candidiasis
• Systemic candidiasis without esophageal involvement

Clinical Decision Algorithm

1. Determine type of candidiasis:

   • Esophageal involvement? → Treat before TEE
   • Systemic/bloodstream only? → Proceed with TEE with appropriate precautions

2. For suspected esophageal candidiasis:

   • Confirm diagnosis (endoscopy may be needed)
   • Complete antifungal treatment course
   • Verify resolution of esophageal lesions before TEE

3. For candidemia without known esophageal involvement:

   • TEE is actually indicated to evaluate for Candida infective endocarditis (CIE)
   • Studies show 4.2-5.9% of candidemic patients have endocarditis 3
   • TEE has significantly higher sensitivity than TTE for detecting vegetations

Evidence-Based Recommendations

For Patients with Esophageal Candidiasis:

• Treat with appropriate systemic antifungals before TEE
• Consider alternative imaging if TEE urgently needed:
  • Transthoracic echocardiography (TTE), though less sensitive 4
  • Cardiac CT or MRI in specific situations 4

For Patients with Candidemia:

• TEE is recommended to rule out endocarditis 3
• The American Heart Association guidelines support TEE for evaluation of suspected endocarditis, particularly in high-risk patients 4

Special Considerations

Immunocompromised Patients

• Higher risk of both esophageal candidiasis and candidemia
• May need more aggressive antifungal treatment before TEE
• Consider prophylactic antifungals before TEE if high risk

Alternative Approaches When TEE is Contraindicated

• TTE with ultrasound-enhancing agents may provide necessary information 4
• Contrast-enhanced CT and MRI have emerged as alternatives for specific indications 4

Common Pitfalls to Avoid

1. Performing TEE without assessing for esophageal candidiasis in high-risk patients
2. Delaying necessary TEE in candidemic patients due to unfounded concerns
3. Failing to provide adequate antifungal treatment before TEE in patients with esophageal involvement
4. Not recognizing that candidemia itself is an indication for TEE to rule out endocarditis

Remember that while esophageal candidiasis is a contraindication for immediate TEE, systemic candidiasis without esophageal involvement actually represents an indication for TEE to evaluate for possible endocarditis.