Refractory hemorrhagic esophageal ulcers by Candida esophagitis with advanced systemic sclerosis

Abstract

A 64-year-old woman diagnosed with rheumatoid arthritis (RA) and systemic sclerosis (SSc) was admitted to our hospital with chief complaints of uncontrolled bleeding from esophageal ulcers and an inability to consume meals. For RA and SSc, she was treated with prednisolone and abatacept and was taking vonoprazan as prophylaxis for steroid-induced gastric ulcers. She was diagnosed with severe Candida esophagitis, with multiple large and small ulcers with bleeding, based on esophagogastroduodenoscopy and pathological findings. We performed comprehensive treatment; abatacept was discontinued, and total parenteral nutrition was initiated along with antifungal therapy. Improvement in the esophageal ulcers was observed. Although severe Candida esophagitis is a rare condition, we should keep in mind that severe Candida esophagitis can occur in patients with an immunosuppressive compromised host and esophageal movement disorders such as SSc. Regular follow up by endoscopy and prophylactic treatment to prevent severe esophagitis may be necessary.

Genotyping, antifungal susceptibility, enzymatic activity, and phenotypic variation in Candida albicans from esophageal candidiasis

“…In a case‐control study of patients with esophageal candidiasis (≥65 years old) a 6‐month mortality rate of 47% compared to 5% in controls 43 was reported. In some rare cases, esophageal candidiasis may result in hemorrhagic esophageal ulcers, 44 invasive candidiasis, 45 and esophageal squamous cell carcinoma. 46 …”

Dysphagia, reflux and related sequelae due to altered physiology in scleroderma

“…Given that Candida infection and certain culprit medications can also cause esophagitis, providers should carefully screen for these in SSc patients. Signs of fungal infection should be treated promptly to prevent complications and culprit medications should be generally avoided[ 73 , 79 ].Underlying Gp may also contribute to symptoms and should be managed with prokinetic agents and dietary modification[ 2 , 57 ]. Being cognizant of the various contributing factors that result in dysphagia can allow physicians to develop better, more well-rounded therapeutic plans.…”

“…As a result, CE and secondary stricture formation is likely to occur with SSc, further complicating dysphagia and esophageal dysfunction in these patients[ 71 ]. Patients with CE respond well to anti-fungal treatment, limiting the progression of disease to stricture formation and necrotizing CE[ 72 , 73 ]. Therefore, although CE is rare, early detection and treatment of this condition in SSc esophagus is very important to avoid development of esophagus-related complications that have high mortality rates.…”