Esophageal Candidiasis in Immunocompetent Patients Without Corticosteroid Use
Yes, esophageal candidiasis can occur in immunocompetent individuals who have never used corticosteroids, though it is less common than in immunosuppressed populations. 1
Key Evidence from Guidelines
The most recent AGA Clinical Practice Update (2024) explicitly states that "infectious esophagitis may occur in immunocompetent hosts" despite being more common in immunosuppressed patients. 1 This represents the highest quality guideline evidence directly addressing your question.
Risk Factors in Immunocompetent Patients
Even without immunosuppression or corticosteroid use, esophageal candidiasis can develop in the presence of:
- Recent antibiotic use (disrupts normal flora) 1
- Proton pump inhibitor (PPI) use (alters esophageal pH) 1
- Older age (declining immune surveillance) 1
- Chronic alcohol consumption (mucosal injury) 1, 2
- Diabetes mellitus (impaired neutrophil function) 1, 3
- Esophageal motility disorders such as achalasia or scleroderma (esophageal stasis allows fungal overgrowth) 1, 2, 3
- Chronic kidney disease 1
- Malignancy (even without active chemotherapy) 1
Clinical Presentation and Natural History
Symptomatic patients typically present with dysphagia or odynophagia with characteristic white nummular lesions on endoscopy. 1
Asymptomatic esophageal candidiasis is occasionally encountered in otherwise healthy individuals during screening endoscopy. 4 Research demonstrates that in immunocompetent patients with asymptomatic disease, antifungal treatment may not be required, as some cases resolve spontaneously when inciting risk factors are removed. 1, 4
Treatment Considerations
For symptomatic immunocompetent patients, fluconazole remains first-line therapy (200-400 mg daily for 14-21 days). 1
For asymptomatic immunocompetent patients, a study of 142 patients found no EC-related complications during mean follow-up of 28 months without antifungal treatment, suggesting observation may be appropriate. 4 However, patients with history of pulmonary tuberculosis had higher rates of persistent or recurrent disease. 4
Important Clinical Pitfalls
Do not assume all esophageal candidiasis indicates immunosuppression. The presence of other risk factors (PPIs, antibiotics, diabetes, motility disorders) can explain infection in immunocompetent hosts. 1, 2
Evaluate for underlying esophageal motility disorders (achalasia, scleroderma) as these create esophageal stasis predisposing to candidal overgrowth even without immune compromise. 1, 2, 3
Consider medication history carefully - even inhaled corticosteroids (not systemic) can cause esophageal candidiasis in rare cases, though this represents a different scenario than your question. 5
Rare but serious complications including esophageal stricture, fistula formation, and necrotizing esophagitis can occur, emphasizing the importance of appropriate treatment in symptomatic cases. 6, 3