Symptoms of Esophageal Candidiasis
Dysphagia and odynophagia are the cardinal symptoms of esophageal candidiasis, with patients commonly complaining of difficulty swallowing and pain on swallowing. 1
Primary Symptoms
- Dysphagia (difficulty swallowing) - Most common presentation in adults 1, 2
- Odynophagia (painful swallowing) - Highly characteristic symptom 1, 3
- Retrosternal chest pain - Can occur with or without swallowing 1, 2
Additional Symptoms
- Food impaction - Especially in severe cases with stricture formation 4
- Food avoidance behavior - Patients may avoid difficult-to-swallow textures like bread and meat 1
- Drinking large volumes of water with meals - Compensatory behavior 1
- Weight loss - Particularly in severe cases with stricture formation 4
Symptom Presentation Patterns
Symptomatic Presentation
Many patients with esophageal candidiasis present with clear symptoms, particularly those with extensive disease. The severity of symptoms often correlates with the extent of esophageal involvement, with more extensive disease causing more pronounced symptoms 1.
Asymptomatic Presentation
Some patients with esophageal candidiasis may be asymptomatic, particularly those with limited disease 1, 3. This is more common in:
- Early disease
- Immunocompromised patients who may have blunted inflammatory responses
- Patients with concurrent medications that reduce pain perception
Risk Factors Associated with Symptom Development
Patients with the following conditions are more likely to develop symptomatic esophageal candidiasis:
- HIV/AIDS (particularly with low CD4 counts) 5, 6
- Diabetes 2
- Recent antibiotic use 1
- Local or systemic steroid use 1
- Immunosuppression from any cause 1
- Malignancy 1
- Proton pump inhibitor use 1
- Advanced age 1
- Chronic alcohol use 1
- Chronic kidney disease 1
- Esophageal motility disorders (leading to stasis) 1, 2
Endoscopic Correlation with Symptoms
Endoscopically, esophageal candidiasis presents with characteristic white nummular lesions or plaques that adhere to the mucosa and cannot be washed away with water irrigation 1, 2. In severe cases, these plaques may carpet the entire esophagus, which typically correlates with more severe symptoms 1.
Complications and Advanced Symptoms
In cases where esophageal candidiasis progresses without treatment, patients may develop:
- Esophageal strictures - Leading to worsening dysphagia and food impaction 4
- Malnutrition - Due to reduced oral intake 4
- Significant weight loss - Reported as >30 lbs in severe cases 4
- Rarely, necrotizing esophagitis, fistula formation, or sepsis 2
Clinical Pitfalls and Considerations
Oral thrush association: While often associated with esophageal candidiasis, oral thrush may be absent in up to 25% of cases, so its absence does not rule out esophageal involvement 5, 3
Differential diagnosis: Symptoms of esophageal candidiasis can mimic other conditions including:
- Other infectious esophagitis (HSV, CMV)
- Eosinophilic esophagitis
- Gastroesophageal reflux disease
- Medication-induced esophagitis 2
White spots without symptoms: Isolated white spots at the esophageal opening without dysphagia or odynophagia may not require immediate intervention and can be observed, particularly in immunocompetent patients 7
Age-specific presentations: In pediatric patients with eosinophilic esophagitis (which can mimic candidiasis), symptom presentation varies by age, with younger children showing more non-specific symptoms and older children presenting with more classic dysphagia 1
Early recognition of these symptoms is crucial for timely diagnosis and treatment, which typically involves systemic antifungal therapy with fluconazole (200-400 mg daily for 14-21 days) 1, 6.