Which part of the esophagus is typically affected in esophageal candidiasis?

Esophageal Candidiasis: Affected Parts of the Esophagus

Esophageal candidiasis typically affects the entire esophagus, but most commonly presents with characteristic whitish plaques throughout the esophageal mucosa, with no specific predilection for any particular segment of the esophagus. 1

Endoscopic Findings and Distribution

• Esophageal candidiasis presents with distinctive endoscopic findings including adherent whitish plaques or nummular lesions that cannot be washed away with water irrigation 1
• These characteristic lesions may be found throughout the esophagus without specific predilection for any particular segment
• As the infection progresses, the plaques may develop into superficial ulcerations of the esophageal mucosa, with punctate bleeding when scraped 1

Clinical Presentation

• Cardinal symptoms include:

  • Retrosternal burning pain or discomfort
  • Odynophagia (pain on swallowing)
  • Dysphagia (difficulty swallowing)
  • Fever may be present in some cases 2, 1

• Some patients may develop compensatory behaviors:

  • Food avoidance, particularly difficult-to-swallow textures
  • Drinking large volumes of water with meals 1

Diagnosis

• Definitive diagnosis requires:

  • Endoscopic visualization of characteristic white plaques
  • Histopathologic demonstration of Candida yeast forms in tissue
  • Culture confirmation of Candida species 2, 1

• The white mucosal plaques are adherent to the mucosa and cannot be washed off with water irrigation, distinguishing them from other conditions 1, 3

Risk Factors and High-Risk Populations

Esophageal candidiasis is most commonly seen in:

• Immunocompromised patients, particularly those with:

  • HIV/AIDS (especially with CD4+ T lymphocyte counts <200 cells/µL)
  • Patients receiving immunosuppressive medications 2, 1

• Other risk factors include:

  • Recent antibiotic use
  • Local or systemic steroid use
  • Malignancy
  • Proton pump inhibitor use
  • Advanced age
  • Chronic alcohol use
  • Chronic kidney disease
  • Esophageal motility disorders (which can lead to stasis) 1, 3

Complications

Although rare, complications can include:

• Esophageal strictures due to chronic inflammation, tissue damage, fibrosis, and scarring 4
• Necrotizing esophageal candidiasis
• Fistula formation
• Sepsis in severe cases 3

Clinical Significance

Esophageal candidiasis serves as an important clinical marker of immune suppression and can be an AIDS-defining illness in HIV patients 1. The introduction of antiretroviral therapy has led to a dramatic decline in the prevalence of esophageal candidiasis among HIV patients 2, 1.

Treatment

• Systemic antifungal therapy is required for effective treatment
• Fluconazole (200-400 mg daily for 14-21 days) is the preferred first-line agent 2, 1
• Itraconazole solution for 14-21 days is an effective alternative but less well tolerated 2
• Caspofungin and voriconazole are effective but experience is limited and fluconazole remains the preferred agent 2

Understanding the distribution pattern of esophageal candidiasis is important for proper endoscopic examination and diagnosis, as the infection can affect any part of the esophagus rather than being limited to specific segments.