What causes esophageal candidiasis in adults?

Causes of Esophageal Candidiasis in Adults

Esophageal candidiasis is primarily caused by immunocompromised states, with HIV/AIDS being the most significant risk factor, followed by other conditions that impair immune function such as diabetes, malignancy, and immunosuppressive therapy. 1

Primary Risk Factors

Immunocompromised States

• HIV/AIDS: Most common risk factor, especially with CD4+ counts <200 cells/µL 1
• Malignancies: Particularly hematologic malignancies and those requiring chemotherapy 2
• Diabetes mellitus: Impairs immune function and increases susceptibility 2
• Immunosuppressive therapy: Including:
  • Corticosteroids
  • Chemotherapy
  • Radiation therapy
  • Post-transplant immunosuppressants 1, 2

Medication-Related Factors

• Recent antibiotic use: Disrupts normal flora, allowing Candida overgrowth 1
• Proton pump inhibitors: Alter gastric pH, promoting fungal colonization 1
• Systemic steroids: Suppress immune function 2

Esophageal Disorders

• Motility disorders: Achalasia and scleroderma lead to esophageal stasis 1, 2
• Structural abnormalities: Can create environments favorable for Candida colonization 2

Other Contributing Factors

• Advanced age: Associated with decreased immune function 1
• Chronic alcohol use: Impairs immune function and may cause mucosal damage 1
• Chronic kidney disease: Alters immune response 1

Pathophysiology

Candida species (predominantly Candida albicans) are normal commensal organisms in the gastrointestinal tract. Under normal circumstances, they are kept in check by:

1. Intact mucosal barriers
2. Normal bacterial flora
3. Functioning immune system

When these protective mechanisms are compromised, Candida can proliferate and invade the esophageal mucosa, leading to:

• Adherent white plaques
• Mucosal inflammation
• Potential ulceration in severe cases 1, 2

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 significantly reduced its prevalence among HIV patients 1.

Complications

If left untreated, esophageal candidiasis can lead to:

• Severe dysphagia and odynophagia
• Malnutrition and weight loss
• Rare but serious complications including:
  • Necrotizing esophageal candidiasis
  • Esophageal strictures
  • Fistula formation
  • Sepsis 2, 3

Key Diagnostic Considerations

When evaluating patients with suspected esophageal candidiasis, it's important to:

• Identify underlying immunocompromising conditions
• Recognize characteristic symptoms (retrosternal pain, odynophagia, dysphagia)
• Consider concurrent oropharyngeal candidiasis (thrush), which is often present
• Confirm diagnosis with endoscopy showing characteristic white plaques that cannot be washed away 1, 2

Understanding the underlying cause is crucial for both effective treatment and prevention of recurrence in patients with esophageal candidiasis.