Case Report: Candida Ball in the Esophagus

A 70-year old African American male patient who presented with complaints of gradually worsening dysphagia for both solids and liquids with an EGD revealing a nearly obstructing mass in the esophagus 25cm from incisors occupying 75-99% of the circumference of the esophagus with the inability to traverse the obstructing mass using the 11mm diameter scope. Biopsies were taken from the mass showing acute inflammatory exudates and necrotic debris consistent with erosive esophagitis with rare Candida organisms identified. Patient was prescribed a course of PPI and antifungal agent and his dysphagia has improved. Three years later, he presented to our hospital with recurrent dysphagia, odynophagia and significant weight loss. He was ill-appearing and cachectic but his physical examination was otherwise unremarkable. The initial laboratory work-up showed normal complete blood count, acute renal injury with creatinine 11.5mg/dL, sodium 127, potassium 3.9, normal TSH and negative HIV testing. Repeat EGD revealed a mass at 25cm from incisors (image A,B) with a biopsy revealing active esophagitis with intraepithelial fungi consistent with Candida with no dysplasia and malignancy. The patient was treated with oral fluconazole for two weeks with partial improvement in the patient’s symptoms.

showed normal complete blood count, acute renal injury with creatinine 11.5mg/dL, sodium 127, potassium 3.9, normal TSH and negative HIV testing. Repeat EGD revealed a mass at 25cm from incisors (image A,B) with a biopsy revealing active esophagitis with intraepithelial fungi consistent with Candida with no dysplasia and malignancy. The patient was treated with oral fluconazole for two weeks with partial improvement in the patient's symptoms.
Repeat EGD was arranged for follow up to make sure that the mass has resolved and to look for any hidden malignancy, it was done 3 months later showing a pinhole stricture with scarring at 25cm from the incisors (image C), biopsies from the stricture were taken showing esophageal mucosa with reactive changes but no malignancy. EUS was also performed and did not show any masses (Figure 1a, 1b & 1c).

Discussion
Candidal infections in the gastrointestinal tract can rarely cause complications. These complications include fungal balls or masses, perforation of the oesophagus [3], stomach [4] and intestine [5] and formation of trachea-oesophageal fistula [6]. Fungal masses have been also reported in the myocardium [7], pleural cavity [8], in a peritoneal dialysis catheter [9], paranasal air sinuses and are well recognized in the urinary tract [10][11][12][13]. Hepatobiliary complications of candidal infection include hepatosplenic granulomata [14] and acalculus cholecystitis [15]. Biliary tract obstruction secondary to a fungal mass in the biliary tree in association with biliary stasis [16][17][18] has been reported. The diagnosis of Candida esophagitis manifesting as an esophageal mass has been quite challenging in terms of confirming the diagnosis and ruling out any evidence of malignancy.
Rajablou et al. [19] reported a case of a CLL patient who presented with fever, nausea, vomiting, and upper abdominal pain with the EGD revealing a circumferential ulcerated mass in the distal esophagus with the biopsy showing ulcerated mucosa, with abundant granulation tissue, numerous yeast, and pseudohyphal fungal forms consistent with Candida albicans, duodenum with no evidence of malignancy. Patient was successfully treated with a course of fluconazole and follow up EGD showed healing of the previous lesions.
Mehmet et al. [1] reported a case of a 71-year-old man with history of achalasia status post esophageal balloon dilatation and Botox therapy presented to the hospital with anorexia, difficulty in swallowing and epigastricpain.EGD revealed mid-esophageal diverticula, diffuse edematous mucosa, mucosal granularity, and a 5x10 mm focal mucosal protuberance with non-smooth contours superior to the Z line, with suspicion of malignancy. Endoscopic biopsy specimen yielded fungal esophagitis. Culture of the biopsy material yielded Candida albicans as the etiologic microorganism and the patient was successfully treated with antifungal therapy with improvement of the patient's symptoms.
Hyun JJ et al. [20] described a case of a 31-year-old immunocompetent woman with history of previously treated candida esophagitis seven years ago who presented with five years of recurrent worsening dysphagia. The endoscopy revealed esophageal luminal narrowing at 23 cm from the central incisor, with irregular mucosa and multiple ulcers and whitish exudates. Multiple biopsies revealed candidal infection which improved transiently after a course of fluconazole but then worsened again with the EGD revealing worsening stenosis.
Horan et al. [21] reported a case of a 52-year-old woman presented with progressive dysphagia over 6 months with weight loss with multiple EGDs all revealing oesophageal candidiasis and a papillomatous growth in the midoesophagus. Histology showed severely dysplastic squamous epithelium with no definitive stromal invasion. Endoscopic ultrasound (EUS) showed a circumferential growth in the upper to mid-oesophagus, involving all the oesophageal layers to the adventitia with clear breach of the adventitia. A positron emission tomography-computed tomography (PET-CT) scan demonstrated a metabolically active large concentric thickening of the oesophagus from the level of the carina to the inferior pulmonary vein, with increased fluorodeoxyglucose (FDG) activity. She underwent a three-stage oesophagectomy. Macroscopic and microscopic examination of the oesophagogastrectomy specimen revealed a well-differentiated squamous cell carcinoma (SCC) arising on the background of surface squamous papillomatosis. The final diagnosis was carcinoma cuniculatum, a rare morphological variant of squamous cell carcinoma A prospective study on the frequency of gastro-esophageal candidiasis in 465 patients who underwent endoscopy, showed that candidiasis was more prevalent in patients with esophageal carcinoma (27%) than in patients with other forms of mucosal injury, such as esophagitis (15%) [22,23]. Although candidiasis can develop secondary to malignancy, possibly due to impaired antifungal host defense due to mucosal damage, there is increasing evidence that Candida infection itself has carcinogenic properties. One important mechanism that has been proposed to underlie this phenomenon is the catalytic activity of Candida, which facilitates the production of carcinogenic nitrosamines such as nitroso-N-methylbenzylamine (NBMA) from their precursors [22,24].
Our case demonstrates a patient with esophageal candidiasis that is manifesting as an obstructing esophageal mass with the biopsy revealing active esophagitis with intraepithelial fungi consistent with Candida with no dysplasia and malignancy. EUS was performed due to concerns of underlying malignancy and it showed a short stricture with scarring which could have resulted from the healing process of the mass but no evidence of malignancy.