Esophageal Candidiasis
Monilial Esophagitis

• Most common cause of infectious esophagitis
• Organism
  • C. albicans
  • Found in diseased skin, GI tract, female genital tract, urine in patients with an with an indwelling Foley catheter
• Usually occurs as an opportunistic infection in those with
  • Depressed immunity
    • AIDS
    • Hematologic disease
    • Renal transplant
    • Leukemia
    • Chronic debilitating disease
  • Diabetes mellitus
  • Steroids
  • Chemotherapy
  • Radiotherapy
  • Diseases which cause delayed esophageal emptying
    • Scleroderma
    • Strictures
    • Achalasia
    • S/P fundoplication
  • Rarely may occur in otherwise healthy individuals
• Produces whitish slightly raised plaques
  
  
• Clinical Findings
  
  
  • Dysphagia
  • Odynophagia
  • Intense substernal pain
  • Associated with oral thrush (oropharyngeal moniliasis) in 20-80%
    
    
• Location
  
  
  • Predilection for upper 1/2 of esophagus
    • Involvement of long esophageal segments
      
      
• Imaging Findings
  
  
  • Discrete plaque-like lesions
  • Plaques line-up longitudinally = grouping of tiny 1-2 mm nodular filling defects with linear orientation
  • Larger plaques may coalesce to produce "cobblestone" appearance
  • Further coalescence produces “shaggy” contour (from coalescent plaques, pseudomembranes, erosions, ulcerations, intramural hemorrhage) in fulminant candidiasis
    • More fulminant form is more often associated with AIDS

Candida Esophagitis (Moniliasis). Double-contrast esophagram shows markedly nodular mucosa
with multiple discrete ulcers covering all of esophagus

• Ulcers invariably appear only on a background of diffuse plaque formation, not as isolated findings
• Long, smoothly-tapering strictures may develop but are rare
  • More likely to develop in patients with cutaneous manifestations of Candidiasis
• Mycetoma resembling large intraluminal tumor is rare

• Diagnosis
  
  
  • Endoscopy most sensitive method of making diagnosis for mild cases
  • Double-contrast esophagography should pick up 90% of cases
    
    
• Treatment
  
  
  • Mycostatin®
  • Findings usually regress quickly
    
    
• Differential Diagnosis
  
  
  • Glycogenic esophagitis – asymptomatic nodularity
  • Reflux esophagitis – distal esophagus, nodules poorly defined
  • Superficial spreading carcinoma- nodular and irregular folds
  • Artifacts (undissolved effervescent crystals, air bubbles, retained food particles)
  • Herpes esophagitis – discrete ulcers surrounded by halo of edema
  • Acute caustic ingestion – long strictures are common
  • Intramural pseudodiverticulosis – unlike ulcers, pseudodiverticula don’t appear to connect to lumen
  • Varices – distal esophagus usually; serpiginous elongated filling defects

Candidiasis. Multiple images from a barium esophagram show slight irregularity of the wall (red arrows) caused by shallow ulcerations and deeper, barium-containing ulcers as well (white oval).