The clinical course of asymptomatic esophageal candidiasis incidentally diagnosed in general health inspection

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.

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

AIMS

Distinguishing true oesophageal Candida infections from oral contaminants is a common diagnostic issue. Historically, histological features believed to indicate true infection included epithelial invasion by pseudohyphae and intraepithelial neutrophils. Whether or not these features correlate with endoscopic lesions, symptoms and response to therapy has never been tested in a large cohort. The aim of this study was to determine whether specific histological features correlate with clinical and endoscopic findings when Candida is found in oesophageal biopsies.

METHODS AND RESULTS

We reviewed 271 biopsies in which Candida was detected. Cases were evaluated for the presence of desquamated epithelial cells, location/type of fungal forms, neutrophils, and ulceration. Medical records were reviewed for clinical history, endoscopic lesions, and response to antifungal therapy. Statistical analysis was used to determine whether any histological features significantly correlated with clinical variables. There were 120 males and 151 females with a mean age of 42 years. Fifty-nine per cent had symptoms referable to the oesophagus, particularly dysphagia (36%). Most (73%) patients had abnormal endoscopic findings, with plaques, ulcers, or macroscopic evidence of oesophagitis. Seventy-one per cent of patients with documented antifungal therapy showed symptomatic improvement. Overall, there was no statistically significant correlation between any histological feature and presenting symptoms, endoscopic findings, or response to therapy. Importantly, the lack of pseudohyphae, demonstrable invasion of intact epithelium or neutrophilic infiltrates did not exclude clinically significant infection.

CONCLUSIONS

We conclude that detection of Candida in oesophageal biopsies is always potentially clinically significant. Treatment decisions should be made on the basis of an integration of clinical, endoscopic and histological findings.

[Evaluation and management of infectious esophagitis in immunocompromised patients and immunocompetent individuals]

Among the many causes of the inflammatory process in the esophagus, infectious diseases are becoming increasingly important due to their steady growth. Previously esophageal infections have traditionally been associated with immunodeficiency syndromes, but now in clinical practice, these disorders are becoming increasingly recognized in immunocompetent individuals. Early diagnosis of infectious esophagitis is necessary to develop effective treatment tactics, and, as a result, reduce the risk of complications and adverse outcomes of the disease. This study reviewed the most clinical relevant pathogens of infectious esophagitis, both among patients with immunodeficiency and among healthy individuals. Specific diagnostic, risk factors, clinical presentation and therapeutic features were considered depending on the immune status of patients.

Variations in the Clinical Course of Patients with Herpes Simplex Virus Esophagitis Based on Immunocompetence and Presence of Underlying Esophageal Disease

BACKGROUND AND AIMS

Herpes simplex esophagitis (HSE) is the second most common cause of infectious esophagitis and occurs in both immunocompetent and immunocompromised patients. The aim of this study was to reappraise the clinical course of HSE in different patient populations based on degree of immunocompetence and the presence or absence of underlying esophageal disease.

METHODS

Patients with histopathologically confirmed HSE identified from the Mayo Clinic pathology database from 2006 to 2016 were included in this study. Relevant demographic, clinical, and endoscopic data were retrospectively reviewed and compared between two cohorts: (a) immunocompromised and immunocompetent patients and (b) patients with and without underlying esophageal disorders.

RESULTS

Forty-six patients were included in the study. The most common presenting symptoms were odynophagia (34.8%) and dysphagia (30.4%). Thirty-three (71.7%) patients were immunocompromised, and these patients who experienced longer duration of symptoms (25.5 ± 23.4 days vs. 7.0 ± 5.5 days, p = 0.04) were more likely to require an extension of treatment course (38.1% vs. 8.3%, p = 0.05) compared to their immunocompetent counterparts. Seventeen (37%) patients had underlying esophageal disease, and these patients were more likely to have concomitant esophageal candidiasis (41.2% vs. 10.3%, respectively; p = 0.01).

CONCLUSION

Herpes simplex virus causes esophagitis in both immunocompetent and immunocompromised patients. While the disease course appears to be self-limited for all patient populations, clinical and endoscopic differences in the disease presentation and clinical course based on immune status and the presence or absence of underlying esophageal disease exist.

Course of Esophageal Candidiasis and Outcomes of Patients at a Single Center

Candida infection in the gastrointestinal tract is most studied in immunocompromised patients. Patients without systemic immunodeficiency, however, may have esophageal candidiasis associated with antibiotic or steroid medication use, alcoholic consumption, diabetes mellitus, and esophageal stasis disorders such achalasia or scleroderma esophagus.^1-5 This population has not been well studied. We aim to describe demographics, risk factors, and relevant clinical outcomes for patients with Candida esophagitis with an emphasis in systemically immunocompetent patients.

Infections of the esophagus: an update on risk factors, diagnosis, and management

Infectious esophagitis is a leading cause of esophagitis worldwide. While esophageal infections have traditionally been associated with immunocompromised patients, these disorders are becoming increasingly recognized in immunocompetent individuals. The three most common etiologies of infectious esophagitis are Candida, herpes simplex virus, and cytomegalovirus. Human papilloma virus infection can also involve the esophagus in the form of ulcerative lesions and papillomas. Less common etiologies include various other fungal, bacterial, and viral organisms. This review provides a comprehensive update on risk factors, diagnosis, and management of both common and less common infections of the esophagus.

Evaluation and Management of Infectious Esophagitis in Immunocompromised and Immunocompetent Individuals

Among the many inflammatory processes that may account for esophageal symptoms, infection represents an important etiologic category with numerous clinically relevant subdivisions. While features of the history and physical exam are informative, diagnosis often hinges on endoscopic visualization and histopathologic analysis. This chapter will review in series the most clinically relevant causative agents for infectious esophagitis, with specific diagnostic and therapeutic features of note divided into one of two immune milieus. Our discussion focuses primarily on Candida species, herpes simplex virus, and cytomegalovirus as the most common causes of infectious esophagitis while also addressing a number of less common pathogens worth keeping in mind.

Antifungal Treatment is Not Required for Immunocompetent Individuals With Asymptomatic Esophageal Candidiasis

Although esophageal candidiasis (EC) is an opportunistic infection, asymptomatic EC (AEC) is occasionally encountered in otherwise healthy individuals. This study evaluates the impact of antifungal treatment in immunocompetent individuals with AEC and investigates risk factors for persistent or recurrent EC. The authors identified patients with biopsy-proven AEC from the database of individuals receiving screening endoscopy (n = 99,255). After excluding patients receiving immunosuppressive therapy, being positive for human immunodeficiency virus, receiving no follow-up endoscopy, or having no antifungal treatment data, a total of 142 patients were divided into remission and nonremission groups. Remission was defined when EC was not detectable on follow-up endoscopy. On baseline comparison, nonremission group was older (57.5 ± 10.3 versus 52.5 ± 10.5 years, P = 0.017) and more likely to have cardiovascular disease (12.9% versus 1.8%, P = 0.021) and history of pulmonary tuberculosis (PTB) (22.6% versus 4.5%, P = 0.004) and exhibited a lower triglyceride level (101.4 ± 37.4 versus 122.6 ± 79.6 mg/dL, P = 0.039) than remission group, whereas grade of EC and concomitant endoscopic findings did not differ between 2 groups. Antifungal treatment was also similarly performed between 2 groups. Multivariate analysis revealed that history of PTB is independently associated with nonremission (odds ratio 4.495, 95% confidence interval 1.023-19.762, P = 0.047). No patients demonstrated EC-related complications during a mean follow-up of 28.0 ± 12.0 months. In conclusion, our results suggested that antifungal treatment is not required for immunocompetent individuals with AEC and past history of PTB is an independent predictor for persistent or recurrent EC.