Do you treat for Candida when a biopsy of the gastroesophageal (GE) junction shows chronic reflux with fungal forms?

Treatment of Fungal Forms at the Gastroesophageal Junction with Chronic Reflux

Yes, you should treat Candida when biopsy demonstrates fungal forms at the gastroesophageal junction, as the presence of fungal organisms invading tissue indicates active infection requiring systemic antifungal therapy, regardless of whether symptoms are present. 1

Clinical Reasoning for Treatment

The key distinction is between colonization versus tissue invasion. When biopsy confirms fungal forms (yeasts and pseudohyphae) invading mucosal cells, this represents true esophageal candidiasis requiring treatment, not mere colonization. 2

Risk Factor Assessment in Your Patient

Your patient has chronic reflux at the GE junction, which creates several conditions favoring candidal infection:

• Mucosal damage from GERD predisposes to secondary candidal infection, as demonstrated in studies showing candidiasis present in 15% of patients with esophagitis 3
• Local tissue injury at the GE junction provides an entry point for fungal invasion 3
• The 2024 AGA guidelines specifically identify recent antibiotics, immunosuppression, and PPI use as key risk factors for candidal esophagitis 1

Treatment Recommendations

Fluconazole is the preferred first-line treatment at 200-400 mg daily for 14-21 days, as recommended by available guidelines. 1

Alternative considerations:

• Nystatin can be used for prophylaxis in high-risk patients or when distinguishing infection from colonization is unclear 1
• Some studies suggest candidiasis may resolve when the inciting risk factor is removed in immunocompetent hosts, but available guidelines still recommend fluconazole as preferred treatment 1

Diagnostic Confirmation

The diagnosis is already established in your case since:

• Biopsy demonstrates fungal forms (the gold standard for diagnosis) 1, 2
• Fungal invasion of tissue differentiates true infection from colonization 2
• Cytobrush or esophageal biopsies showing fungal forms are diagnostic 1

Important Clinical Pitfalls

Do not assume asymptomatic candidiasis is benign. While one study showed asymptomatic candidiasis rarely becomes symptomatic, guidelines still recommend treatment when fungal forms are identified on biopsy. 1 The presence of tissue invasion on histology mandates treatment regardless of symptom severity.

Address the underlying GERD aggressively, as the chronic reflux and mucosal damage likely contributed to the candidal infection. 3 The candidiasis is typically secondary to the mucosal damage from reflux. 3

Treatment Algorithm

1. Initiate fluconazole 200-400 mg daily for 14-21 days 1
2. Optimize GERD management with appropriate PPI therapy to heal the underlying mucosal damage 3
3. Reassess after treatment completion if symptoms persist or if the patient has ongoing risk factors for recurrence 1
4. Consider prophylactic nystatin if multiple risk factors persist (ongoing immunosuppression, recurrent antibiotic use, severe GERD) 1