S4397 Clindamycin-Induced Pill Esophagitis With Candida Superinfection and Lidocaine-Associated Bradycardia in a Healthy Adult

Introduction: Pill esophagitis is a well-recognized complication of oral medications such as clindamycin, which can disrupt the esophageal mucosal barrier and predispose to secondary infections. Candida superinfection in immunocompetent hosts remains uncommon. This case illustrates not only that risk but also highlights the potential for systemic absorption of viscous lidocaine across ulcerated mucosa, resulting in transient bradycardia. Case Description/Methods: A 20-year-old previously healthy active-duty woman presented with severe odynophagia and dysphagia 5 days after initiating clindamycin 300 mg BID for presumed pharyngitis. She had taken the medication without sufficient water and often before lying down. Symptoms progressed to sharp retrosternal pain with solids and liquids, reduced oral intake, and substernal discomfort. She denied fever, gastrointestinal bleeding, or prior reflux. Outside esophagogastroduodenoscopy revealed distal esophageal ulcerations with white exudate. Candida esophagitis was suspected, and intravenous micafungin was initiated. For analgesia, viscous lidocaine was prescribed, after which she developed bradycardia and transient junctional rhythm, attributed to mucosal absorption across ulcerated epithelium. Upon transfer, vitals were stable. Physical exam showed oropharyngeal erythema without thrush. Labs were unremarkable aside from mild hypokalemia. Repeat esophagogastroduodenoscopy showed persistent distal ulcerations with white plaques; biopsies revealed Candida albicans and drug-induced mucosal injury. She was transitioned to oral fluconazole and pantoprazole at discharge. Her odynophagia resolved within two weeks. Discussion: This case highlights 3 key teaching points: (1) clindamycin remains a common but preventable cause of pill esophagitis, particularly when taken without water or before recumbency; (2) mucosal disruption can predispose to opportunistic fungal infection even in immunocompetent individuals; and (3) viscous lidocaine, though considered safe, may cause systemic cardiotoxicity when absorbed through inflamed or ulcerated mucosa.