What is the diagnosis and treatment for a 27-year-old male with leukocytosis, multiple body lumps, sclerosing mesenteritis, and esophageal candidiasis?

Underlying Diagnosis: Immunocompromised State with Opportunistic Infections

This 27-year-old male with leukocytosis, multiple body lumps, sclerosing mesenteritis, and esophageal candidiasis most likely has an underlying immunocompromised state that requires urgent investigation for HIV/AIDS, hematologic malignancy (particularly lymphoma), or other systemic immunosuppressive conditions. 1, 2

Critical Diagnostic Priorities

Immediate Immunologic Assessment Required

• HIV testing is mandatory given the constellation of esophageal candidiasis (a classic AIDS-defining illness) in a young patient with systemic manifestations 1, 2
• Hematologic malignancy workup is essential, as sclerosing mesenteritis has documented associations with non-Hodgkin lymphoma, and the combination with opportunistic infections suggests profound immunosuppression 3, 4
• The "lumps all over body" likely represent lymphadenopathy, which combined with leukocytosis (19.5) strongly suggests either lymphoproliferative disease or systemic inflammatory/infectious process 2

Why This Combination is Alarming

Esophageal candidiasis in a 27-year-old is highly abnormal and indicates severe immunocompromise 1, 2. The American Gastroenterological Association emphasizes that immunosuppression status—including HIV/AIDS, hematologic malignancies, solid organ transplantation, or prolonged granulocytopenia—must be assessed in all patients with esophageal candidiasis 2.

The presence of sclerosing mesenteritis adds another layer of concern, as this rare inflammatory mesenteric disorder has been associated with other systemic conditions including lymphoma 3, 4.

Immediate Management Steps

1. Treat the Esophageal Candidiasis

Start oral fluconazole 200-400 mg on day 1, followed by 200 mg daily for 14-21 days immediately 1, 5, 6, 7. The Infectious Diseases Society of America designates this as first-line therapy 5, 6.

• If the patient cannot tolerate oral therapy, use intravenous fluconazole at the same dosage 5, 6, 7
• Treatment should continue for at least 14 days and for at least 2 weeks following resolution of symptoms 5

2. Evaluate for Systemic Candidal Dissemination

All patients with esophageal candidiasis in the setting of immunocompromise require dilated retinal examination by an ophthalmologist to exclude candidal endophthalmitis 1. This is critical because delays in diagnosis may lead to loss of vision 1.

• Assess for hepatosplenomegaly with elevated alkaline phosphatase (hepatosplenic candidiasis) 2
• Monitor for persistent fever despite antifungal therapy, which suggests systemic spread 2

3. Investigate the Underlying Immunodeficiency

Order the following tests urgently:

• HIV antibody/antigen testing with CD4 count and viral load 1, 2
• Complete blood count with differential to characterize the leukocytosis 2
• Peripheral blood smear to evaluate for atypical lymphocytes or blasts
• Comprehensive metabolic panel including liver function tests 2
• Lactate dehydrogenase (LDH) as a marker for lymphoproliferative disease
• Biopsy of accessible "lumps" for histopathology and flow cytometry to rule out lymphoma 3

4. Address the Sclerosing Mesenteritis

Sclerosing mesenteritis requires tissue diagnosis for confirmation and to exclude malignancy 8, 4. However, given the acute presentation with esophageal candidiasis, this may need to be staged after stabilization.

• If the patient is symptomatic from sclerosing mesenteritis (abdominal pain, obstruction), consider tamoxifen in combination with prednisone, which showed 60% improvement in one series 4
• Critical caveat: Do not start immunosuppressive therapy (steroids) for sclerosing mesenteritis until the underlying immunodeficiency is characterized and active infections are controlled 4

Common Pitfalls to Avoid

Do Not Delay HIV Testing

The single most important diagnostic error would be failing to test for HIV in a young patient with esophageal candidiasis 1, 2. This is an AIDS-defining illness, and antiretroviral therapy is strongly recommended to reduce the incidence of recurrent infections 5, 6.

Do Not Assume Isolated Esophageal Disease

If symptoms do not improve after 7-14 days of appropriate antifungal therapy, perform repeat endoscopy to evaluate for refractory infection, azole resistance, or alternative diagnoses 1, 2. The American Gastroenterological Association emphasizes that additional biopsies should exclude HSV esophagitis, CMV esophagitis, and other conditions 2.

Monitor for Treatment Failure

Treatment failure is defined as persistence of symptoms after 7-14 days of appropriate therapy 5. For fluconazole-refractory disease, switch to echinocandins (micafungin 150 mg daily, caspofungin 70 mg loading dose then 50 mg daily, or anidulafungin 200 mg daily) for 14-21 days 5, 6.

Consider Infectious Disease Consultation

Once esophageal infection is identified, consultation with an infectious disease expert will aid in guiding appropriate treatment, especially if there are signs/symptoms suggesting immunocompromise leading to more systemic infection 1.

Prognosis Considerations

This clinical presentation carries significant morbidity and potential mortality risk 9, 10. Necrotizing Candida esophagitis with fungal dissemination, though rare, can be fatal in severely immunocompromised patients 10. Sclerosing mesenteritis itself can have a prolonged debilitating course with fatal outcomes in 17% of cases in one series 4.

The key to improving outcomes is rapid identification and treatment of the underlying immunodeficiency 1, 2. If HIV is confirmed, immediate initiation of antiretroviral therapy is essential 5, 6. If lymphoma is diagnosed, oncology consultation for systemic chemotherapy becomes the priority.