S4345 Invasive Fistulizing Esophageal Candidiasis

Introduction: Esophageal candidiasis is the infection of the esophagus caused by the fungus Candida, often seen in immunocompromised individuals. While odynophagia is the hallmark of esophageal candidiasis, other common symptoms include dysphagia, diarrhea, nausea, and vomiting. Numerous complications of esophageal candidiasis have been reported, however, serious complications such as fistulation, perforation, and pseudodiverticulosis formation are exceptionally rare. Here, we present the case of candidiasis resulting in esophageal fistula formation along with pseudodiverticulosis in an immunocompetent individual. Case Description/Methods: A 52-year-old man with a 1-year history of solid food dysphagia, weight loss, and percutaneous endoscopic gastrostomy tube placement was referred for further evaluation of undiagnosed esophagitis. Esophagogastroduodenoscopy showed diffuse mucosal ulceration in the middle and lower esophagus with 3 chronic fistulas identified. Subsequent repeat esophagogastroduodenoscopy about 1.5 months later revealed the persistent severe esophagitis along with extensive white plaques dispersed throughout. Additionally, progression of diverticula and pseudodiverticula, along with multiple fistulous tracts, were found in the middle and lower esophagus at the site of prior ulceration. The biopsies showed squamous mucosa with severe inflammation, reactive changes, and multiple fungal elements. Fungal cultures were obtained, returning positive for Candidaalbicans, for which he was prescribed fluconazole with close outpatient follow-up planned. Discussion: Generally, esophageal candidiasis occurs in the form of superficial candidiasis, and fistula formation along with pseudodiverticula formation within the deeper layers of the esophageal wall are rare complications. Candida infection causes inflammation and fibrosis within the esophageal wall and gland ducts, leading to the formation of fistulas and esophageal intramural pseudodiverticula, as seen in our patient. Early recognition with a high index of suspicion, through serial EGDs, along with initiation of infection treatment with antifungals, is crucial for symptomatic control and to prevent further complications that may ultimately lead to death, including esophageal stenosis and perforation.