Persistent Esophageal Parakeratosis With Recurrent Candida Esophagitis in a Virally Suppressed Person With HIV

Esophageal parakeratosis is an uncommon histopathologic finding that can closely mimic malignancy endoscopically and has been linked to micronutrient deficiency states and chronic reflux. We report a 57-year-old man with well-controlled HIV (stable viral suppression and robust CD4 count) who developed progressive dysphagia with malignant-appearing esophageal plaques over a long segment of the mid-to-distal esophagus. Serial biopsies repeatedly showed parakeratosis/hyperkeratosis without dysplasia or malignancy, with intermittent Candida on histology. Despite the alarming appearance, cross-sectional imaging revealed no mass or nodal disease. Management included high-dose acid suppression, short courses of fluconazole for Candida esophagitis, and empiric zinc and riboflavin supplementation; the endoscopic extent of keratinization reduced but persisted, and dysphagia fluctuated without a fixed stricture. Given ongoing symptoms and easy passage of the scope, esophageal manometry was arranged to evaluate a motility contribution, and surveillance endoscopy was planned. This case emphasizes the importance of repeat histology before committing to oncologic pathways, consideration of micronutrient supplementation, cautious use of long-term proton-pump inhibition in patients at risk for Candida, and individualized surveillance where formal guidance is lacking.