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

BACKGROUND: Esophageal candidiasis is the most frequent form of esophagitis. The pathogenicity of Candida spp. is related to a combination of microbial factors, hydrolytic enzyme secretion and phenotypic switching. This study was designed to investigate esophageal candidiasis, antifungal activity, enzymatic activity patterns, phenotyping, and genotyping profiles of Candida albicans species. METHODS: Nine hundred thirty-three visited patients were evaluated, and esophageal biopsies from patients were included in this study during 2019-2020. Direct smear, Gram staining, and culture on CHROMagar were performed for each sample. Isolated species were identified with conventional procedures and PCR-RFLP. Susceptibility to antifungals was determined according to CLSI guidelines. ABC typing, phenotype switching, hemolysin, proteinase, phospholipase, and esterase activity were also determined with the appropriate protocols. RESULTS: Twenty-three (2.5%) patients (mean age 55.2 years) were diagnosed with esophageal candidiasis. The species isolated were 19(82.6%) C. albicans, 3(13.1%) C. glabrata, and 1(4.3%) C. tropicalis. Genotype A (57.9%) was the predominant type in C. albicans isolates. 50% of C. albicans isolates exhibited a white phenotype. A high level of phospholipase (47.4%), hemolysin (68.4%), and proteinase activity (36.8%) was observed in the C. albicans isolates. Only three C. glabrata isolates displayed non-wild type susceptibility to voriconazole and itraconazole. CONCLUSION: This study shows that C. albicans are still the most frequent isolates from patients with esophageal candidiasis. The predominance of genotype A, the white phenotype, and strong hemolysin activity may indicate a high prevalence of pathogenicity in these isolates. Sensitivity to antifungal drugs was greatest for amphotericin and fluconazole.

Deep Neck Infection Complicated by Phlegmonous Esophagitis and Mediastinitis.

Descending necrotizing mediastinitis is a life-threatening disease that extends into the pretracheal, perivascular, retrovisceral, and/or prevertebral spaces, generally sparing the esophagus. We report a case of deep neck abscess complicated by phlegmonous esophagitis and mediastinitis. The patient was successfully treated with antibiotics and surgery, combining transcervical and bilateral thoracoscopic transthoracic mediastinal drainage. However, a pseudo-lumen with a large amount of pus remained in the esophagus. The septum between the true and the pseudo-lumen was cut endoscopically, after which the patient recovered well without any complications.

Fístula traqueoesofágica por Candida galbrata: una patología infrecuente / Tracheoesophageal fistula due to candida galbrata: a rare pathology

La fístula traqueoesofágica consiste en una comunicación anómala entre el sistema respiratorio y el digestivo, que puede ser a causa de una enfermedad congénita, o bien secundaria a una patología tal como la infecciosa, la tumoral o postraumática. Entre las etiologías infecciosas, Candida o Aspergillus son dos hongos que provocan esofagitis fúngica, la cual podría complicarse con esta entidad, aunque son casos extremadamente raros. El diagnóstico de las fístulas se basa en la clínica, las pruebas de imagen como la TC y la endoscopia, donde se podrá apreciar la solución de continuidad. Este defecto debe ser tratado mediante cirugía o endoscópicamente

The tracheoesophageal fistula consists of an abnormal communication between the respiratory and digestive systems, which may be due to a congenital disease or secondary to a pathology such as infectious, tumorous or post-traumatic. Among the infectious etiologies, Candida or Aspergillus are two fungi that cause fungal esophagitis, which could be complicated by this entity, although they are extremely rare cases. The diagnosis of fistulas is based on the clinic, imaging tests such as CT and endoscopy, where the solution of continuity can be appreciated. This defect must be treated surgically or endoscopically, a technique that is currently on the rise due to its fewer complications

[The state and role of esophagus, stomach, intestinal microbiota in patients with ulcer disease, chronic gastritis, esophagitis.]

The microflora of 64 biopsies taken during fibrogastroduodenoscopy of the mucous membrane of the esophagus, stomach and duodenum in healthy volunteers and 1120 samples obtained from the same parts of the digestive tract in patients with esophagitis, chronic gastritis and peptic ulcer disease were studied. The patients ranged in age from 18 to 62 years. Traditional bacteriological method was used to isolate and identify microorganisms. Staphylococcus spp., Streptococcus spp., Lactobacillus spp., Bacteroides spp., Stomatococcus spp., Enterobacteriaceae, Corynebacterium spp., Micrococcus spp., Neisseria spp., Veilonella spp. were isolated from biopsies of healthy respondents in an average amount from 3.2 to 4.68 lg CFU/g. H.pylori was found in 60% (5.66 lg CFU/g) in the esophagus, in 33.3% of cases (5.12 lg CFU/g) from the fundal part of the stomach, in 44.4% (5.25 lg CFU/g) from the antral part of the stomach, in 5.5% (4.2 lg CFU/g) in the duodenal mucosa. In samples obtained from the inflamed and eroded mucous membrane of the esophagus, stomach and duodenum, opportunistic bacteria of the genera Klebsiella, Enterobacter, Proteus, Pseudomonas, Peptococcus, Actinomyces, yeast fungi of the genus Candida etc. were detected in an amount exceeding 4 lg CFU/g. H. pylori isolated in 6.3-16.7% of patients (4.25-4.6 lg CFU/g) and did not dominate in relation to other microorganisms, and in most cases had a low frequency of its occurrence. In patients with the recurrence of peptic ulcer disease, exacerbation of chronic gastritis and esophagitis, dysbiosis was developed, characterized by an increase in the species and quantitative composition of opportunistic microflora, an increase in its enzymatic and cytotoxic activity, which can contribute to the maintenance of inflammatory and necrotic processes and inhibit the elimination of the pathological process.

The diagnosis of clinically significant oesophageal Candida infections: a reappraisal of clinicopathological findings.

AIMS: Distinguishing true oesophageal Candida infections from oral contaminants is a common diagnostic issue. Historically, histological features believed to indicate true infection included epithelial invasion by pseudohyphae and intraepithelial neutrophils. Whether or not these features correlate with endoscopic lesions, symptoms and response to therapy has never been tested in a large cohort. The aim of this study was to determine whether specific histological features correlate with clinical and endoscopic findings when Candida is found in oesophageal biopsies. METHODS AND RESULTS: We reviewed 271 biopsies in which Candida was detected. Cases were evaluated for the presence of desquamated epithelial cells, location/type of fungal forms, neutrophils, and ulceration. Medical records were reviewed for clinical history, endoscopic lesions, and response to antifungal therapy. Statistical analysis was used to determine whether any histological features significantly correlated with clinical variables. There were 120 males and 151 females with a mean age of 42 years. Fifty-nine per cent had symptoms referable to the oesophagus, particularly dysphagia (36%). Most (73%) patients had abnormal endoscopic findings, with plaques, ulcers, or macroscopic evidence of oesophagitis. Seventy-one per cent of patients with documented antifungal therapy showed symptomatic improvement. Overall, there was no statistically significant correlation between any histological feature and presenting symptoms, endoscopic findings, or response to therapy. Importantly, the lack of pseudohyphae, demonstrable invasion of intact epithelium or neutrophilic infiltrates did not exclude clinically significant infection. CONCLUSIONS: We conclude that detection of Candida in oesophageal biopsies is always potentially clinically significant. Treatment decisions should be made on the basis of an integration of clinical, endoscopic and histological findings.

Potential roles of Helicobacter pylori treatment, body mass index and waist circumference in the causation of erosive esophagitis: a randomized clinical trial (HEROES-GERD).

BACKGROUND: In recent decades, the prevalence of gastroesophageal reflux disease (GERD) and obesity has been increasing while Helicobacter pylori infection has been decreasing. OBJECTIVE: To evaluate if H. pylori treatment, excess body weight and other anthropometric measurements are associated with incident erosive esophagitis, as a secondary objective of a trial which tested the efficacy of treatment of H. pylori on the symptoms of functional dyspepsia. SUBJECTS/METHODS: Upper gastrointestinal endoscopy and anthropometric assessments were performed, at baseline and after 12 months, in H. pylori positive patients with functional dyspepsia who had no baseline reflux symptoms or esophagitis. Patients were randomly assigned to receive omeprazole, amoxicillin, and clarithromycin (antibiotic group; n = 201) or omeprazole plus placebo (control group; n = 203). The primary outcome was the incidence of esophagitis 12 months after randomization, according to treatment groups, and the association of BMI and other anthropometric measurements. RESULTS: Four hundred and four patients were included (mean age, 46.1 years; 78.7% women). The 12-month follow-up endoscopic esophagitis rates for the antibiotic and control groups were 10.9% (22/201) and 9.4% (19/203), respectively (p = 0.60). The number needed to harm was 67. Baseline anthropometric measurements were performed in 94% (380/404) of patients. The 12-month follow-up esophagitis rates for overweight and normal body weight patients were 13.6% (29/213) and 6.0% (10/167), respectively (p = 0.015); rates for patients with and without increased baseline waist circumference were 15.4% (24/156) and 6.7% (15/224), respectively (p = 0.006). Following logistic regression, only the combination of increased baseline body mass index and waist, but not H. pylori treatment, was independently associated with new-onset esophagitis (OR 2.88; 95% CI: 1.28-6.45). CONCLUSIONS: Excess body weight and concomitant increased waist circumference, but not H. pylori treatment, predicts new-onset esophagitis.

Diagnosis and Treatment of Esophageal Candidiasis: Current Updates.

Esophageal candidiasis (EC) is the most common type of infectious esophagitis. In the gastrointestinal tract, the esophagus is the second most susceptible to candida infection, only after the oropharynx. Immunocompromised patients are most at risk, including patients with HIV/AIDS, leukemia, diabetics, and those who are receiving corticosteroids, radiation, and chemotherapy. Another group includes those who used antibiotics frequently and those who have esophageal motility disorder (cardiac achalasia and scleroderma). Patients complained of pain on swallowing, difficulty swallowing, and pain behind the sternum. On physical examination, there is a plaque that often occurs together with oral thrush. Endoscopic examination is the best approach to diagnose this disease by directly observing the white mucosal plaque-like lesions and exudates adherent to the mucosa. These adherent lesions cannot be washed off with water from irrigation. This disease is confirmed histologically by taking the biopsy or brushings of yeast and pseudohyphae invading mucosal cells. The treatment is by systemic antifungal drugs given orally in a defined course. It is important to differentiate esophageal candidiasis from other forms of infectious esophagitis such as cytomegalovirus, herpes simplex virus, gastroesophageal reflux disease, medication-induced esophagitis, radiation-induced esophageal injury, and inflammatory conditions such as eosinophilic esophagitis. Except for a few complications such as necrotizing esophageal candidiasis, fistula, and sepsis, the prognosis of esophageal candidiasis has been good.

Esophageal candidiasis in patients from a specialty hospital / Candidiasis esofágica en pacientes de un hospital de especialidades

Background: Esophageal candidiasis (EC) is the most common cause of infectious esophagitis. So far, its main risk factor has been HIV infection; in recent years, EC has been favoured by the increasing of diabetes mellitus, wide-spread use of acid-lowering agents, broad-spectrum antibiotics, and inhaled steroids. In Mexico EC has been poorly studied. Objectives: To determine the clinical and epidemiological characteristics of EC, and to identify its etiological agents as well as its antifungal susceptibility. Methods: Patients who revealed the presence of scattered white spots through an upper gastrointestinal system endoscopy, in a period of one year, in a tertiary care hospital, were included. Samples from patches were collected for microscopic examination, culture, and susceptibility tests. Results: Out of 1763 patients studied, 23 had scattered white spots, and most of them presented Kodsi grade I; 13 were men; half of the patients were between the ages 20 to 40; main comorbidity was liver cirrhosis; use of omeprazole was significant. 22 isolates were obtained from 17 patients. The most frequent species were C. albicans (14) and C. parapsilosis (3). In five cases we found a two-species association v. g. Candida famata with Trichosporon mucoides. Half of the isolates showed resistance to one or several antifungal drugs. Conclusions: EC frequency in this study was similar to other studies' results. Obtained isolates showed high resistance to azolic compounds and to caspofungin, which is relevant information to take a therapeutic decision.

Introducción: la candidiasis esofágica (CE) es la causa más común de esofagitis infecciosa. Su principal factor de riesgo ha sido la infección por VIH. En México ha sido poco estudiada. Objetivos: determinar las características clínico-epidemiológicas de la CE e identificar sus agentes etiológicos y su sensibilidad a antifúngicos. Métodos: se incluyeron pacientes a quienes se les detectaron placas blanquecinas durante una endoscopía esofágica, en un periodo de un año, en un hospital de tercer nivel de atención. Se tomó muestra de las placas para examen microscópico, cultivo, y estudios de sensibilidad. Resultados: de 1763 pacientes estudiados, 23 presentaron placas blanquecinas; 13 fueron hombres; la mitad tenía de 20 a 40 años de edad; la principal comorbilidad fue cirrosis hepática; el uso de omeprazol fue significativo. Se obtuvieron 22 aislados de 17 pacientes; predominaron Candida albicans (14) y Candida parapsilosis (3). En cinco casos se encontró asociación de dos especies v. g. Candida famata con Trichosporon mucoides. La mitad de los aislados mostró resistencia a antimicóticos. Conclusiones: la frecuencia de CE fue similar a la de otras casuísticas. Los aislados obtenidos mostraron resistencia elevada a compuestos azólicos y a caspofungina, información relevante para tomar una decisión terapéutica.

Simultaneous candida albicans and herpes simplex virus type 2 esophagitis in a renal transplant recipient.

Renal transplant recipients are prone to opportunistic infections due to iatrogenic immunosuppression. Infectious esophagitis can present as an opportunistic infection in the post-transplant period. Common pathogens are candida, herpes simplex virus (HSV) and cytomegalovirus (CMV). Having a dual infection is uncommon and the diagnoses can be missed at initial presentation. Our patient, a 29-year-old African-American woman, status post deceased-donor-kidney transplant presented with difficulty and pain in swallowing with clinical features suggestive of candida esophagitis, confirmed by fungal culture. She did not get better with antifungal treatment. On further testing, the patient was found to have HSV-2 infection of the oesophagus as well. She received both fluconazole as well as acyclovir that lead to complete resolution of her symptoms. In the right clinical setting, esophagitis can be caused by more than one organism present at the same time and a high level of suspicion is warranted.

[Esophageal actinomycosis in patients with HIV infection]. / Actinomicosis esofágica en pacientes con infección por VIH.

Esophageal pathology is common in patients with HIV, frequently due to Candida, cytomegalovirus or herpes virus. However, esophageal actinomycosis is a rare infection, even in patients with HIV. We report the case of a 33-year-old male patient, with a recent diagnosis of HIV who was admitted for fever, odynophagia, dysphagia and retrosternal pain. Upper gastrointestinal endoscopy evidenced multiple esophageal ulcers and the histopathological report of the esophageal biopsy described a chronic esophagitis with colonies of PAS positive bacilli, compatible with Actinomyces, initiating favorable antimicrobial therapy. Although it is an uncommon disease, about one-third of cases of esophageal actinomycosis occur in patients with HIV infection, and endoscopic biopsies are required to define diagnosis and appropriate treatment.

Actinomicosis esofágica en pacientes con infección por VIH / Esophageal actinomycosis in patients with HIV infection

La patología esofágica es común en pacientes con VIH, frecuentemente debido a Candida, citomegalovirus o virus herpes simple. Sin embargo, la actinomicosis esofágica es una infección rara, incluso en pacientes con infección VIH. Reportamos el caso en un paciente varón de 33 años, con diagnóstico reciente de VIH que acudió a consulta por fiebre, odinofagia, disfagia y dolor retroesternal. La endoscopia digestiva alta evidenció múltiples úlceras esofágicas y el informe histopatológico de la biopsia esofágica describió una esofagitis crónica con presencia de colonias de bacilos PAS positivos, compatibles con Actinomyces, iniciando tratamiento antimicrobiano con evolución favorable. Aunque es una enfermedad no común, cerca de un tercio de los casos de actinomicosis esofágica se presentan en pacientes con infección VIH, y es preciso el estudio endoscópico con toma de biopsia para definir el diagnóstico y manejo apropiado.

Esophageal pathology is common in patients with HIV, frequently due to Candida, cytomegalovirus or herpes virus. However, esophageal actinomycosis is a rare infection, even in patients with HIV. We report the case of a 33-year-old male patient, with a recent diagnosis of HIV who was admitted for fever, odynophagia, dysphagia and retrosternal pain. Upper gastrointestinal endoscopy evidenced multiple esophageal ulcers and the histopathological report of the esophageal biopsy described a chronic esophagitis with colonies of PAS positive bacilli, compatible with Actinomyces, initiating favorable antimicrobial therapy. Although it is an uncommon disease, about one-third of cases of esophageal actinomycosis occur in patients with HIV infection, and endoscopic biopsies are required to define diagnosis and appropriate treatment.

A rare case report of fungal esophagitis combined with giant gastric ulcer in an immunocompetent patient.

RATIONALE: Fungal infection of gastrointestinal (GI) tract is usually seen in immunocompromised patients, but can rarely occur in immunocompetent people in whom no permissive factor is present. PATIENT CONCERNS: We describe a 68-year-old male immunocompetent patient presenting with simultaneous fungal esophagitis and giant gastric ulcer. DIAGNOSES: Repeated endoscopic biopsies were taken from the giant gastric ulcer edge and base and histology demonstrated granulation tissue and pseudohyphal fungal forms. INTERVENTIONS: The patient was treated with fluconazole and omeprazole for 8 weeks. OUTCOMES: After antifungal treatment with fluconazole, the patient's clinical symptoms gradually disappeared with the healing of gastric ulcer, which never recurred in this patient until 3 months after follow-up. LESSONS: Nonhealing gastroesophageal ulcers highlights the importance of repeated endoscopies and biopsies.