The diagnosis of clinically significant oesophageal Candida infections: a reappraisal of clinicopathological findings

The modern face of esophageal candidiasis in an oncology center: Correlating clinical manifestations, endoscopic grade, and pathological data in 323 contemporary cancer patients

OBJECTIVES

Clinical presentation and outcomes of esophageal candidiasis (EC) in cancer patients are scarcely studied in the azole era, as is the correlation between clinical, endoscopic, and histopathological EC manifestations.

METHODS

We retrospectively reviewed the risk factors, clinical features, and outcomes of pathology-documented EC cases at MD Anderson Cancer Center. We further assessed associations between presence of symptoms, standardized 4-stage endoscopic grade (Kodsi classification), histopathological data, and fluconazole treatment failure.

RESULTS

Among 323 cancer patients with EC, 89% had solid tumors, most commonly esophageal cancer (29%). Thirty-three percent of EC patients were asymptomatic. The proportion of symptomatic EC patients significantly increased with endoscopic grade (P = 0.005). Among 202 patients receiving oral fluconazole, 27 (13%) had treatment failure. Underlying esophageal disease was the only independent predictor of fluconazole treatment failure (odds ratio: 3.88, P = 0.005). Endoscopic grade correlated significantly with Candida organism burden (Correlation coefficient [ρ] = 0.21, P < 0.01) and neutrophilic inflammation (ρ = 0.18, P < 0.01). Candida invasion of the squamous mucosal layer was associated with treatment failure (P = 0.049).

CONCLUSIONS

EC was predominantly encountered in patients with solid tumors. One-third of EC patients were asymptomatic, challenging traditional symptom-based diagnosis. The development of integrated clinicopathological scoring systems could further guide the therapeutic management of cancer patients with EC.

Gastrointestinal colonization by Diutina (Candida) rugosa in a 6-year-old Siberian Husky

A 6-year-old 21.5 kg castrated male Siberian Husky was presented for acute onset of lethargy, vomiting, hemorrhagic diarrhea, and inappetence. Physical examination revealed marked discomfort upon abdominal palpation and 5%-7% dehydration. The CBC and biochemical profile revealed changes consistent with mild to moderate inflammation, dehydration, and gastrointestinal (GI) disease. Despite aggressive gastrointestinal support, anorexia persisted, and an upper GI endoscopy was performed in conjunction with esophagostomy tube placement. Endoscopy revealed abnormal gastric mucosa characterized by moderately well-demarcated areas of blue-black discoloration. Impression smears of a gastric biopsy revealed abundant extracellular yeasts with morphology most consistent with Candida spp. and frequent extracellular cocci. Similar yeast and bacteria, in lower numbers, were observed on cytologic analysis of a direct smear of the rectal mucosa. A rectal swab submitted for fungal culture yielded pure growth of fungal yeasts identified as Diutina (formerly Candida) rugosa by matrix-assisted laser desorption-ionization time-of-flight mass spectrometry. The dog's clinical signs improved with fluconazole, and he was discharged. Follow-up fungal culture of a rectal swab showed no growth of D. rugosa. To the authors' knowledge, this is the first case report that describes the clinical, hematologic, cytologic, and gross findings of enteric colonization by D. rugosa in a dog.

Prevalence, Predictive Factors, and Clinical Manifestations of Fungal Esophagitis in Children

OBJECTIVES

Fungal esophagitis (FE) is the most common cause of esophageal infection and its prevalence in immunocompetent adults is rising. However, there is minimal data on FE in children without human immunodeficiency virus. Therefore, the objective of this study was to determine the prevalence, symptoms, endoscopic appearances, and predictive factors of FE in children, regardless of immune status.

METHODS

A 2010-2020 retrospective case-control study was conducted on 1823 children presenting to Sydney Children's Hospital for elective endoscopy with esophageal biopsy. Histopathology reports were reviewed to identify FE cases and determine prevalence rates. Thirty-two patients with FE were age- and sex-matched (1:2) to 64 controls. Significant symptoms and risk factors of FE were identified via univariate and multivariate logistic regression analysis.

RESULTS

The prevalence of FE in children was 1.76%. Common symptoms included dysphagia (25%), heartburn (25%), poor oral intake (21.9%), vomiting (18.8%), cough (15.6%), nausea (12.5%), and weight loss (9.4%). No significant differences in symptoms were found between cases and controls. On endoscopy, although white plaques were associated with FE ( P < 0.001), visually normal findings were reported in 28.1% of cases. Topical swallowed corticosteroids were a significant independent risk factor for FE (adjusted odds ratio = 10.740, 95% confidence interval: 1.213-95.101, P = 0.033).

CONCLUSIONS

The prevalence of FE in this pediatric cohort reflects rates among immunocompetent adults. Given that many of these children presented with a wide range of gastrointestinal symptoms, esophageal biopsy is required to accurately diagnose FE. Pediatricians should consider the risk of FE when prescribing topical swallowed corticosteroids.

Diagnostic Delay in Patients With Eosinophilic Esophagitis Has Not Changed Since the First Description 30 Years Ago: Diagnostic Delay in Eosinophilic Esophagitis

INTRODUCTION

Eosinophilic esophagitis (EoE) is a chronic progressive disease. Diagnostic delay (DD) is associated with increased risk of esophageal strictures and food impactions. We aimed to assess the evolution of DD since the first description of EoE in 1993 until 2021.

METHODS

We analyzed data from patients prospectively included in the Swiss EoE database. DD was calculated as the time interval between the first occurrence of EoE symptoms and the confirmed diagnosis. DD was analyzed annually over time (1989-2021) and according to milestone publications in the field (1993: first description; 2007: first consensus recommendations; and 2011: updated consensus recommendations). In addition, a Cox proportional hazards model has been used to describe the relation between DD and covariates.

RESULTS

Complete data of 1,152 patients (857 male [74%]; median age at diagnosis: 38 years, interquartile range: 28-49, range: 1-86) were analyzed. Overall, median DD was 4 years (interquartile range: 1-11, range, 0-56), with DD ≥ 10 years in 32% of the population. Over time, DD did not significantly change, neither annually nor according to release dates of milestone publications with a persistently stable fraction of roughly one-third of all patients with a DD of ≥10 years. Both ages at diagnosis ( P < 0.001, with an increase in DD up to the age of 31-40 years) and at symptom onset (younger patients had a longer DD; P < 0.001) were significantly associated with DD.

DISCUSSION

DD has not changed since the first description of EoE almost 30 years ago and remains substantial. Even today, one-third of patients have a persistently high DD of ≥10 years. Substantial efforts are warranted to increase awareness for EoE and its hallmark symptom, solid food dysphagia, as an age-independent red-flag symptom among healthcare professionals and presumably the general population alike to lower risk of long-term complications.

Microscopic Esophageal Sloughing Is Not Specific to "Sloughing Esophagitis"

OBJECTIVES

"Sloughing esophagitis" (SE) is characterized by a 2-toned squamous epithelium with superficial necrotic keratinocytes overlying viable epithelium. We compared histologic and clinical findings to determine how cases clinically diagnosed as SE differed from cases with histologic sloughing but a different clinical diagnosis. In addition, we compared cases with inflammatory and noninflammatory histology.

METHODS

We searched departmental archives for esophageal biopsies with histologic sloughing features. We compared clinical and histologic findings for cases with and without clinical confirmation of SE and with and without histologic inflammation.

RESULTS

We identified 52 patients, of whom 10 (19%) had clinically diagnosed SE, 18 (35%) had another diagnosis, and 24 (46%) had an unclear diagnosis. Endoscopic sloughing tended to be reported more often in cases with SE (P = .07). Histologic features did not discriminate between SE and other etiologies. Esophagitis resolved in 18 of 31 patients with follow-up, with no difference between sloughing and nonsloughing cases (P = .26). There were no clinical differences based on inflammatory and noninflammatory histology.

CONCLUSIONS

SE has a classic microscopic appearance, but its findings are not specific, although endoscopic sloughing helps correlate histologic and clinical findings. In cases with histologic sloughing, pathologists should raise a broad differential diagnosis.

Clinicopathologic Characteristics of Esophageal Ectopic Sebaceous Glands: Chronological Changes and Immunohistochemical Analysis

Esophageal ectopic sebaceous glands are very rare lesions. A series of 5 cases in a single report has been the maximum number described in the English literature to date. We conducted a clinicopathologic study of 8 cases of esophageal ectopic sebaceous glands. The median patient age at the time of diagnosis was 60 years (range, 50-71 years), and 7 of the 8 patients were male. A focal lesion was observed in 7 cases, whereas 1 case exhibited multiple lesions throughout the esophagus. Four patients had previously undergone upper gastrointestinal endoscopy; in 3 patients, the focal lesion had not been detected. After diagnosis, 3 cases showed spontaneous regression at least once. Immunohistochemically, sebocytes of all 8 cases were negative for the estrogen receptor (ER) and the progesterone receptor (PgR), whereas sebocytes of 5 cases were positive for the androgen receptor (AR). Basal/parabasal cells were positive for AR, ER, and PgR in 5, 7, and 4 cases, respectively. GATA3 was expressed in the sebocytes and basal/parabasal cells of 6 out of 7 available cases, whereas all of 7 available cases were negative for mammaglobin and GCDFP15. Our report provides the basic clinicopathologic characteristics of esophageal ectopic sebaceous glands by the largest case series reported in English literature to date. Furthermore, the chronological changes, particularly spontaneous regression, and immunohistochemical expression of hormone receptors and GATA3 are compatible with lesions resulting from congenital misplacement under hormonal regulation. Therefore, they seem to be congenital misplacements detectable as a result of hormonal stimulated growth.