Management of Non-Candida White Esophageal Plaques
When white plaques in the esophagus are confirmed NOT to be Candida, obtain endoscopic biopsies with histopathology to establish the correct diagnosis, as the differential includes eosinophilic esophagitis, lymphocytic esophagitis, herpes simplex virus, cytomegalovirus, lichen planus, pemphigus, and Crohn's disease—each requiring distinct treatment approaches.
Diagnostic Approach
Confirm Candida Exclusion
- Histopathologic confirmation is essential to definitively exclude Candida, as diagnosis requires demonstration of characteristic yeast forms in tissue with culture confirmation 1.
- Endoscopic appearance alone cannot accurately predict non-Candida etiologies; specimen acquisition for laboratory study is mandatory 1.
- Obtain multiple biopsies from at least 2 levels, as inflammatory conditions can be patchily distributed 1.
Key Differential Diagnoses for White Plaques
Viral Esophagitis:
- Herpes simplex virus (HSV) and cytomegalovirus (CMV) are common infectious causes in both immunocompromised and immunocompetent patients 1.
- These require endoscopic biopsies with histology, cytology, immunostaining, or culture for definitive diagnosis 1.
- Giant esophageal ulcers warrant endoscopy to differentiate CMV from HIV-associated ulcers and initiate appropriate antiviral therapy 1.
Eosinophilic Esophagitis (EoE):
- Presents with white exudates along with edema, rings, furrows, and strictures on endoscopy 1.
- Requires ≥15 eosinophils per high-power field on biopsy in the absence of other causes 1.
- Treatment involves dietary elimination, proton pump inhibitors, or topical corticosteroids—not antifungals 1.
Lymphocytic Esophagitis:
- Characterized by dense peripapillary lymphocytic infiltrate and spongiosis without significant eosinophils or neutrophils 1.
- May present with white plaques and requires histologic diagnosis 1.
Autoimmune Conditions:
- Lichen planus and pemphigus can cause white plaques with sloughing tissues 1.
- Crohn's disease may involve the esophagus with inflammatory changes 1.
- Sjogren's syndrome can cause esophageal strictures with white changes 1.
Management Algorithm
Step 1: Obtain Tissue Diagnosis
- Perform endoscopy with multiple biopsies (minimum 2 levels) for histopathology 1.
- Request special stains, viral cultures, and immunostaining as clinically indicated 1.
- Brush cytology can provide additional diagnostic yield 2.
Step 2: Treat Based on Confirmed Etiology
If HSV Esophagitis:
- Initiate antiviral therapy (acyclovir or valacyclovir) 1.
If CMV Esophagitis:
- Begin ganciclovir or valganciclovir, particularly for giant ulcers 1.
If EoE:
- Implement dietary elimination therapy, high-dose proton pump inhibitors, or topical corticosteroids 1.
- Monitor for esophageal strictures and motility disorders 1.
If Lymphocytic Esophagitis:
- Consider proton pump inhibitor therapy and address underlying inflammatory conditions 1.
If Autoimmune Etiology:
- Systemic immunosuppression tailored to the specific condition (e.g., corticosteroids for pemphigus, disease-modifying therapy for Crohn's) 1.
Critical Pitfalls to Avoid
- Do not empirically treat with antifungals when Candida has been excluded, as this delays appropriate diagnosis and therapy 1, 3.
- Do not rely on endoscopic appearance alone—white plaques can represent multiple etiologies that require histopathologic differentiation 1.
- Do not assume immunocompetence excludes infectious causes—HSV and CMV esophagitis occur in immunocompetent hosts 1, 3.
- Do not miss concurrent conditions—patients may have multiple simultaneous esophageal pathologies requiring comprehensive biopsy sampling 1.
Special Considerations
Immunocompromised Patients
- Broader differential includes opportunistic infections beyond Candida 1.
- Lower threshold for endoscopy with extensive biopsy sampling 1.
- Consider empiric antiviral therapy while awaiting biopsy results if clinical suspicion is high 1.