Fatal Esophageal Perforation Caused by Invasive Candidiasis

Invasive Candida pneumonia, in association with Candida esophagitis and gastritis, in a presumably immunocompetent patient

Candida pneumonia remains a difficult diagnosis and is most common in immunocompromised individuals. It has been rarely reported in immunocompetent individuals. We present a case of unsuspected Candida pneumonia associated with Candida esophagitis and gastritis discovered on postmortem examination in a presumably immunocompetent patient. The patient was a 71-year-old male who presented with chest pain and was subsequently found to have a myocardial infarction treated with angioplasty and drug-eluting stent placement. The patient's recovery was complicated by pneumonia refractory to antibiotics, and he went on to experience acute hypoxic respiratory failure, sepsis, disseminated intravascular coagulation (DIC), and ultimately expired. Autopsy revealed evidence of myocardial infarction as well as unsuspected Candida albicans pneumonia, esophagitis, and gastritis. Our case highlights how a presumably immunocompetent individual can develop this infection and how Candida esophagitis and Candida gastritis can be seen in association with Candida pneumonia. Due to the difficulty in diagnosing Candida pneumonia antemortem, autopsies provide a key opportunity to better understand these cases and the factors that may contribute to their development.

The Forgotten Complication of Nasogastric Tube Insertion: Esophageal Perforation and Associated Hydropneumothorax and Hydropneumoperitoneum

Nutritional support is essential for critically ill patients to reduce mortality and length of stay. Frequently nasogastric (NG) tubes are used to provide enteral nutrition. A very rare risk of NG tube placement is esophageal perforation, most commonly in the thoracic portion of the esophagus. Here we describe a case of a 41-year-old male with multiple risk factors for esophageal integrity disruption who initially presented for diabetic ketoacidosis (DKA) requiring intubation. Following intubation, an NG tube was placed for nutritional support. The following day the patient developed hydropneumothorax and hydropneumoperitoneum. He was taken emergently for surgical correction of suspected perforation. It was found that the patient had esophageal perforation from the distal esophagus to the proximal portion of the lesser curvature of the stomach. The NG tube transversed the proximal portion of the tear and re-entered at a distal site. The distal portions of the esophagus showed necrotic superficial layers with viable muscularis layers. The patient gradually improved after surgical intervention and was discharged to a long-term acute care facility. It is essential as medical providers to be familiar with complications of NG tube placement and risk factors that could increase the risk of esophageal perforation.

Gastric Candidiasis Leading to Perforation: An Unusual Presentation

Candidal infection of the gastrointestinal tract (GIT) is rare but has recently increased due to the increased number of immunocompromised patients, injudicious use of antibacterial agents, and prolonged use of antacid drugs in immunocompetent patients. The most frequent organ involved in GIT candidiasis is the esophagus, followed by the stomach, small intestine, and large intestine. The clinical spectrum of gastric candidiasis ranges from asymptomatic to gastric perforation and even shock. This case report presents a 58-year-old immunocompetent male patient diagnosed with Candida tropicalis-induced gastric perforation peritonitis.

Catastrophic right-sided Candida empyema from spontaneous esophageal perforation

Right-sided empyema secondary to esophageal rupture are rare but reported in the medical literature. We describe an atypical CASE of right-sided empyema with Candida Tropicalis, Candida Glabrata, and Staphylococcus lugdenensis leading to a diagnosis of spontaneous esophageal rupture. We concluded that pleural effusion with fungal and multi-organism growth should immediately raise suspicion for underlying missed esophageal perforation. Prompt diagnosis of esophageal perforation can prevent fatal complications like pleuritis, pneumothorax, hydrothorax, pneumomediastinum, mediastinitis, acute respiratory distress syndrome, and septic shock.

Sudden Esophageal Necrosis and Mediastinitis Associated with Invasive Candidiasis: A Case Report

BACKGROUND Esophageal necrosis is a rare entity characterized by the presence of extensive circumferential necrosis of the esophagus. It generally affects older adults who have associated chronic pathologies and has a reported mortality rate of approximately 32%. Most patients with esophageal necrosis have a complex clinical course. CASE REPORT We present the case of a 37-year-old man with idiopathic chronic renal failure who presented to the Emergency Department with sudden esophageal necrosis and mediastinitis, associated with invasive candidiasis. Diagnosis was challenging owing to the rarity of the condition. The patient required intensive care management and multiple surgical procedures. CONCLUSIONS Esophageal necrosis is an uncommon pathology that can be fatal because of associated complications. Its pathophysiology is unclear, and its treatment is based on the control of local injury and signs and symptoms. Acute esophageal necrosis associated with invasive Candida sp. infection is even more infrequent, with only a few cases reported in the literature.

An interventional radiology technique to treat pharyngeal or esophageal perforation associated with mediastinal abscess in children

PURPOSE

Pharyngeal or esophageal perforation with mediastinal abscess is notably dangerous in children and can be very difficult to treat. We aimed to determine the safety and efficacy of the transnasal placement of a mediastinal drainage catheter and a nasojejunal feeding tube, with or without gastric decompression, in the treatment of the above perforations in children.

METHODS

We placed transnasal mediastinal drainage catheters and nasojejunal feeding tubes in 14 pediatric patients. Patients with esophageal perforation also underwent the placement of a gastric decompression tube. Four of these patients additionally received chest drainage tubes.

RESULTS

The fistula healed after a median of 66 days (range, 5-404 days). Corrosive esophagitis occurred in two patients with pharyngeal perforations. One of these patients underwent surgical treatment 2 months after fistula healing, and the other underwent repeated balloon dilatation procedures for cicatricial restenosis. Four months after the fistula had healed, the patients with esophageal perforations were all free from recurrence.

CONCLUSION

The use of interventional radiology to place a transnasal mediastinal drainage catheter, a nasojejunal feeding tube, and a gastric decompression tube is a safe, easy, inexpensive, and efficacious way to treat pharyngeal or esophageal perforation complicated by mediastinal abscess in children.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Diagnosis and Treatment of Esophageal Candidiasis: Current Updates

Esophageal candidiasis (EC) is the most common type of infectious esophagitis. In the gastrointestinal tract, the esophagus is the second most susceptible to candida infection, only after the oropharynx. Immunocompromised patients are most at risk, including patients with HIV/AIDS, leukemia, diabetics, and those who are receiving corticosteroids, radiation, and chemotherapy. Another group includes those who used antibiotics frequently and those who have esophageal motility disorder (cardiac achalasia and scleroderma). Patients complained of pain on swallowing, difficulty swallowing, and pain behind the sternum. On physical examination, there is a plaque that often occurs together with oral thrush. Endoscopic examination is the best approach to diagnose this disease by directly observing the white mucosal plaque-like lesions and exudates adherent to the mucosa. These adherent lesions cannot be washed off with water from irrigation. This disease is confirmed histologically by taking the biopsy or brushings of yeast and pseudohyphae invading mucosal cells. The treatment is by systemic antifungal drugs given orally in a defined course. It is important to differentiate esophageal candidiasis from other forms of infectious esophagitis such as cytomegalovirus, herpes simplex virus, gastroesophageal reflux disease, medication-induced esophagitis, radiation-induced esophageal injury, and inflammatory conditions such as eosinophilic esophagitis. Except for a few complications such as necrotizing esophageal candidiasis, fistula, and sepsis, the prognosis of esophageal candidiasis has been good.

Fatal necrotizing Candida esophagitis in a patient with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis

Esophageal infection by Candida spp. is a common opportunistic entity in immunocompromised hosts; however, systemic fungal dissemination due to perforation or transmural necrosis, also known as necrotizing Candida esophagitis (NCE), is rare. We report the case of a 61-year-old male patient with diagnosed ankylosing spondylitis, severe arteriosclerosis, and vasculitis under immunosuppressive therapy who presented NCE with fungal and bacterial septicemia diagnosed at autopsy. Necrotizing esophagitis is a rare manifestation of Candida infection, which may be a final complication in severely ill patients. Unfortunately, it may be underdiagnosed, and we call attention to this devastating complication in patients with leukocytoclastic cutaneous vasculitis and ankylosing spondylitis.

Review article: fungal microbiota and digestive diseases

BACKGROUND

The role of the fungal microbiota in digestive diseases is poorly defined, but is becoming better understood due to advances in metagenomics.

AIM

To review the gastrointestinal fungal microbiota and its relationship with digestive diseases.

METHODS

Search of the literature using PubMed and MEDLINE databases. Subject headings including 'fungal-bacterial interactions', 'mycotoxins', 'immunity to fungi', 'fungal infection', 'fungal microbiota', 'mycobiome' and 'digestive diseases' were used.

RESULTS

The fungal microbiota is an integral part of the gastrointestinal microecosystem with up to 10(6) microorganisms per gram of faeces. Next-generation sequencing of the fungal 18S rRNA gene has allowed better characterisation of the gastrointestinal mycobiome. Numerous interactions between fungi and bacteria and the complex immune response to gastrointestinal commensal or pathogenic fungi all impact on the pathophysiology of inflammatory bowel disease and other gastrointestinal inflammatory entities such as peptic ulcers. Mycotoxins generated as fungal metabolites contribute to disturbances of gastrointestinal barrier and immune functions and are associated with chronic intestinal inflammatory conditions as well as hepatocellular and oesophagogastric cancer. Systemic and gastrointestinal disease can also lead to secondary fungal infections. Fungal genomic databases and methodologies need to be further developed and will allow a much better understanding of the diversity and function of the mycobiome in gastrointestinal inflammation, tumourigenesis, liver cirrhosis and transplantation, and its alteration as a consequence of antibiotic therapy and chemotherapy.

CONCLUSIONS

The fungal microbiota and its metabolites impact gastrointestinal function and contribute to the pathogenesis of digestive diseases. Further metagenomic analyses of the gastrointestinal mycobiome in health and disease is needed.

A rare cause of gastric perforation-Candida infection: a case report and review of the literature

Fungal microorganisms as a cause of gastric perforation, is very rare. Most of the cases of gastric perforation are seen as the complications of peptic ulcer disease, the intake of NSAIDs (Non Steroidal Anti-Inflammatory Drugs), neoplastic diseases, etc. We are reporting a case of a 50 year old male who presented with a sudden onset of abdominal pain and shock and was diagnosed as acute peritonitis which was caused by a gastrointestinal perforation. An emergency exploratory laporotomy was performed and a gastric perforation repair with omentoplexy was done. However, the patient died in the post operative period due to a sudden cardiac arrest. A gastric perforation edge biopsy revealed the presence of fungal hyphae. The peritoneal fluid culture revealed Candida albicans colonies.

On a fatal case of Candida krusei pleural empyema in a pregnant woman with spontaneous esophagus perforation

INTRODUCTION

Candida empyema thoracis can be a consequence of operation, gastropleural fistula, and esophageal perforation. Case report and review of the literature. A fatal case of a 45-year-old pregnant woman with Candida krusei empyema thoracis secondary to spontaneous esophagus perforation associated with candida esophagitis is reported. The case is contextualized among similar cases found through a PubMed search.

CONCLUSIONS

A suspect of esophagus rupture should arise in the presence of a fungal empyema. Candida esophagitis should be always considered as a possible cause or con-cause of esophagus rupture. An empirical systemic antimycotic therapy should always be considered in an ideal multidisciplinary approach to the management of patients with esophagus rupture.

Successful nonoperative management of gastrointestinal mucormycosis: novel therapy for invasive disease

BACKGROUND

Invasive opportunistic fungal infections caused by agents of Mucorales that involve the gastrointestinal tract are uncommon but aggressive. These ubiquitous fungal spores typically are inhaled and can germinate in immunocompromised hosts. Standard therapy for invasive mucormycosis includes parenteral amphotericin B (AMB) in combination with radical debridement of infected tissues. Early diagnosis and treatment are of paramount importance. Unfortunately, long-term survival is poor owing to the prohibitive morbidity and mortality rates associated with the medical and surgical therapies. Posaconazole is a novel, extended-spectrum triazole oral antifungal agent with documented success in the treatment of patients with invasive mucormycosis.

METHODS

Case report and literature review.

RESULTS

A 50-year-old man presented with invasive mucormycosis of the lower esophagus, stomach, and liver, resulting in gastrointestinal hemorrhage. The infection did not respond to AMB but was treated successfully with a combination of posaconazole and liposomal AMB (LAMB) without surgical debridement.

CONCLUSIONS

To our knowledge, this is the first reported case of extensive gastric and intrahepatic mucormycosis that responded to combination posaconazole and LAMB without surgical debridement. This approach may be an alternative to surgery in patients who are precluded from extensive surgical intervention.

Candida esophagitis complicated by an esophago-airway fistula: report of a case

Candida esophagitis rarely involves life-threatening complications, such as necrosis, perforation, or fistula formation between the esophagus and the airway. We herein report a case of Candida esophagitis complicated by esophagobronchial and esophagopulmonary fistulas. The patient in our study was a 70-year-old man with a 3-month history of dysphagia. Based on endoscopy and histological findings, he was diagnosed with a coinfection of Candida spp. and herpes simplex virus. Antifungal and antiviral therapy was administered without success. The esophagopulmonary fistula formation and a lung abscess were identified 7 months later. The patient was deemed intolerable to an esophagectomy due to his poor general condition, thus necessitating a two-stage operation. A cervical esophagostomy and a tube drainage of the thoracic esophagus were followed by an esophageal bypass using the pedicled jejunum via an antethoracic route. Although the lung abscess resolved, the inflammation of the esophagus persisted. A fistula between the esophagus and the left main bronchus eventually formed postoperatively and the patient died due to respiratory failure.

Candida esophageal perforation and esophagopleural fistula: a case report

Introduction

Esophageal perforation is a rare disease, which can lead to significant morbidity and mortality. Its clinical presentation can mimic other disease processes and, therefore, it can be easily misdiagnosed. Candida infection of the esophagus is an extremely rare cause of esophageal perforation.

Case presentation

We report the youngest pediatric case in the medical literature of spontaneous esophageal perforation and an esophagopleural fistula due to Candida infection.

Conclusion

A high index of suspicion, especially in the presence of Candida empyema and the absence of disseminated infection, should raise the possibility of esophageal perforation with esophagopleural fistula formation. This can lead to early diagnosis and surgical intervention, which would decrease the high mortality rate of this rare condition.