From the Guidelines
Esophageal candidiasis is primarily associated with immunocompromised states, and the main risk factors include HIV/AIDS, diabetes mellitus, use of broad-spectrum antibiotics, corticosteroid therapy, and other immunosuppressive medications. The risk factors for esophageal candidiasis can be broken down into several categories, including:
- Immunocompromised states, such as HIV/AIDS (especially with CD4 counts below 200) 1
- Diabetes mellitus, particularly when poorly controlled 1
- Use of broad-spectrum antibiotics, which can disrupt the normal gastrointestinal microbiome 1
- Corticosteroid therapy and other immunosuppressive medications, which can weaken the immune system 1
- Cancer patients undergoing chemotherapy, organ transplant recipients on anti-rejection drugs, and individuals with hematologic malignancies are also at increased risk 1
- Local factors that disrupt esophageal defenses, such as achalasia, esophageal motility disorders, or the presence of esophageal stents, can predispose to infection 1
- Acid-suppressing medications like proton pump inhibitors may increase risk by altering the gastrointestinal microbiome 1
The pathophysiology of esophageal candidiasis involves opportunistic overgrowth of Candida species (most commonly Candida albicans) when normal immune defenses or competing microflora are compromised, allowing the yeast to invade esophageal mucosa 1. Patients typically present with dysphagia, odynophagia, or retrosternal chest pain, though some may be asymptomatic despite extensive infection 1.
According to the most recent and highest quality study, the use of antiretroviral therapy should be prioritized in HIV-infected patients with esophageal candidiasis, as it has been shown to decrease the rates of oral carriage of Candida species and reduce the frequency of symptomatic oropharyngeal candidiasis 1. Additionally, fluconazole is the recommended treatment for esophageal candidiasis, with a dosage of 400 mg/d, and treatment should be continued for 14-21 days until clinical improvement is seen 1.
From the Research
Esophageal Candidiasis Risk Factors
- Immunocompromised patients, including those with HIV/AIDS, leukemia, diabetes, and those receiving corticosteroids, radiation, and chemotherapy, are at high risk of developing esophageal candidiasis 2, 3, 4, 5
- Patients who use antibiotics frequently and those with esophageal motility disorders, such as cardiac achalasia and scleroderma, are also at risk 2, 6
- Other risk factors include alcoholic consumption and esophageal stasis disorders 6
- Approximately 10% of patients with AIDS or other immunodeficiency will experience esophageal candidiasis during their lifetime, and about 60% will experience a relapse within 6 months of the initial infection 3
- Over 90% of patients with AIDS will develop oropharyngeal candidiasis at some time during their illness, which can lead to esophageal candidiasis 4, 5
Patient Characteristics
- Patients with esophageal candidiasis often complain of pain on swallowing, difficulty swallowing, and pain behind the sternum 2
- Physical examination may reveal a plaque that often occurs together with oral thrush 2
- Endoscopic examination is the best approach to diagnose esophageal candidiasis, and the disease can be confirmed histologically by taking a biopsy or brushings of yeast and pseudohyphae invading mucosal cells 2