S4477 Beyond Immunosuppression: Recurrent Esophageal Candidiasis and Stricture Formation in a Patient With Chronic Alcohol Use

Introduction: Esophageal candidiasis (EC) remains the most common cause of infectious esophagitis, predominantly affecting the immunocompromised. It typically presents with odynophagia, dysphagia, and retrosternal discomfort, and progression to esophageal stricture formation is rare. Here, we report a case of EC leading to symptomatic esophageal strictures in a patient without overt immunosuppression. Case Description/Methods: Sixty-eight-year-old man with significant alcohol use disorder and known recurrent EC came with dysphagia, odynophagia, and coffee-ground emesis. He described pain and difficulty swallowing both solids and liquids, for the past few months. Vital signs were stable, and hemoglobin was low but stable at around 9 g/dL. His serum alcohol level on admission was significantly elevated at 200 mg/dL. He underwent an esophagogastroduodenoscopy that showed extensive candidiasis and both proximal and distal esophageal strictures, which were dilated using a balloon up to 15 mm. On further review of his medical chart, it was found that he recently had an esophagogastroduodenoscopy outpatient with balloon dilation for the same esophageal stricture. The patient was started on intravenous Fluconazole, and an HIV test performed was negative. The patient reported significant improvement in his symptoms after the esophageal dilation. The patient was discharged home with oral Fluconazole and was asked to follow up as an outpatient. Discussion: EC is an opportunistic infection, affecting individuals with HIV/AIDS, malignancies, diabetes mellitus, or on immunosuppressants. In this patient, chronic alcohol likely played a contributing role. Several smaller studies and case reports suggest that chronic alcohol consumption can predispose individuals to Candida infections even in the absence of overt immunosuppression. A rare complication was the development of a proximal and distal esophageal strictures. Importantly, no alternate causes of stricture, such as gastroesophageal reflux disease, medication-induced injury, or caustic ingestion, were identified in this patient. Less common complications of EC include ulceration (seen in our patient), intramural pseudo-diverticulosis, and hyperkeratosis, which may predispose to perforation or fistula formation. This case emphasizes that EC, while uncommon in immunocompetent individuals, can still occur and lead to complications such as esophageal strictures. Chronic alcoholism may act as a contributing factor. Early recognition and a combined approach involving antifungal therapy and endoscopic dilatation may be necessary for optimal management.