HIV Versus the Human Body: A Case Report of an Immunity-Compromised Patient.

The immune system is the body's defense system against infection, pathogenic organisms, or foreign bodies. Human immunodeficiency virus (HIV) infection significantly reduces the number of cells involved in the immune system making the infected person prone to a greater number of infections like tuberculosis (TB). HIV infection reduces the CD4 T helper cell count and further replicates within the body. HIV-TB is a major health concern as there is more chance of progression to acquired immunodeficiency syndrome (AIDS) and the emergence of drug-resistant TB. In this case report, we see how the HIV-TB infection affects the body, significantly affecting the morbidity and mortality of the patient.

Contemporary Insights Into HIV Esophagitis: Pathogenesis, Therapeutic Strategies, and Prognostic Outcomes.

Opportunistic infections caused by various bacteria, viruses, fungi, or parasites can cause esophagitis. The fungus Candida albicans is often believed to be the thief behind this disorder. This condition's distinctive signs include the process of inflammation and the development of esophageal ulcers. The underlying immunodeficiency condition in HIV/AIDS patients, especially those in the late stages of the disease, may lead to severe illness or even death if the lowered immune system can no longer combat common infections. These individuals are, therefore, more at risk of contracting diseases like Candidiasis since they already have weakened immune systems. Furthermore, bacteria and mycobacteria can cause esophagitis in the same way that viruses can. Tobacco use, alcohol drinking, and nutritional deficiency are three additional problems that can lead to an HIV esophagitis infection. Complaints of inability to swallow, suffocating feeling or discomfort behind the breastbone, and painful swallowing are the primary symptoms of the patients. White plaques or ulcers observed in the esophagus during an endoscopy can be biopsied for further examination. The presence of C. albicans hyphae and inflammatory infiltrates in these samples confirms the diagnosis of HIV-associated esophagitis. Treatment involves the use of antifungal medications and addressing any underlying causes of esophagitis, which is linked to AIDS. For superficial to moderate infections, fluconazole is typically used first. If the disease is severe or recurs after treatment, intravenous amphotericin B may be necessary. Patients with recurring oral symptoms of HIV esophagitis might also need to take antifungal drugs as a preventative measure.

The modern face of esophageal candidiasis in an oncology center: Correlating clinical manifestations, endoscopic grade, and pathological data in 323 contemporary cancer patients.

OBJECTIVES: Clinical presentation and outcomes of esophageal candidiasis (EC) in cancer patients are scarcely studied in the azole era, as is the correlation between clinical, endoscopic, and histopathological EC manifestations. METHODS: We retrospectively reviewed the risk factors, clinical features, and outcomes of pathology-documented EC cases at MD Anderson Cancer Center. We further assessed associations between presence of symptoms, standardized 4-stage endoscopic grade (Kodsi classification), histopathological data, and fluconazole treatment failure. RESULTS: Among 323 cancer patients with EC, 89% had solid tumors, most commonly esophageal cancer (29%). Thirty-three percent of EC patients were asymptomatic. The proportion of symptomatic EC patients significantly increased with endoscopic grade (P = 0.005). Among 202 patients receiving oral fluconazole, 27 (13%) had treatment failure. Underlying esophageal disease was the only independent predictor of fluconazole treatment failure (odds ratio: 3.88, P = 0.005). Endoscopic grade correlated significantly with Candida organism burden (Correlation coefficient [ρ] = 0.21, P < 0.01) and neutrophilic inflammation (ρ = 0.18, P < 0.01). Candida invasion of the squamous mucosal layer was associated with treatment failure (P = 0.049). CONCLUSIONS: EC was predominantly encountered in patients with solid tumors. One-third of EC patients were asymptomatic, challenging traditional symptom-based diagnosis. The development of integrated clinicopathological scoring systems could further guide the therapeutic management of cancer patients with EC.

A Newly Diagnosed Patient With Human Immunodeficiency Virus (HIV)-Associated Epstein-Barr Virus (EBV)-Positive Diffuse Large B-cell Lymphoma and Esophageal Candidiasis: A Case Report.

The link between the Epstein-Barr virus (EBV) and the development of certain types of lymphomas in patients with human immunodeficiency virus (HIV) is of noteworthy clinical importance. Their immunocompromised state increases the risk of cancers such as lymphomas. Gastrointestinal (GI) lymphomas, though, can occur due to the immunosuppression caused by HIV, with diffuse large B-cell lymphoma (DLBCL) being common in this group. This case report describes a case of a patient with a newly diagnosed HIV who initially presented with symptoms associated with EBV-associated DLBCL and with esophageal candidiasis. This case report highlights the need for increased awareness of HIV-related complications and the importance of close follow-up. In addition, despite advancements in highly active antiretroviral therapy (HAART), acquired immunodeficiency syndrome (AIDS)-related lymphomas continue to be a concern requiring treatment approaches.

Severe Esophageal Stricture Caused by Esophageal Candidiasis in a Non-HIV Patient.

Esophageal candidiasis (EC) is a common opportunistic infection in immunocompromised individuals, often encountered in situations such as untreated HIV/AIDS or following organ transplantation with immunosuppressant usage. While the main manifestation of esophageal candidiasis is mucosal inflammation, its progression and severe cases may lead to esophageal complications like dysphagia, odynophagia, and weight loss. One of the rare complications is esophageal stricture (ES). Few cases have been reported in the literature to date. Esophageal candidiasis can lead to the formation of ES through chronic inflammation, tissue damage, fibrosis, scarring, and ultimately narrowing of the esophageal lumen. Patients with ES often present with dysphagia, odynophagia, and other symptoms related to impaired swallowing. Esophageal strictures related to EC could seriously affect the patient's quality of life. Malnutrition and weight loss can be easily encountered in those cases. So, prompt diagnosis and appropriate antifungal therapy are important. Management should include addressing the stricture through endoscopic dilation interventions. Timely recognition of this complication is crucial for improving patient outcomes and quality of life. We present the case of a 46-year-old male with EC complicated by severe ES, dysphagia, and weight loss of more than 30 lbs. The diagnosis was made based on the histopathological examination of the esophageal biopsies.

Case Report: Repeated esophageal obstruction in a patient with type 3C diabetes mellitus.

Although diabetic neuropathy is a well-known cause of gastrointestinal motility disorders, it is rare that diabetic neuropathy brings about esophageal obstruction. Here, we report a case with Type 3C diabetes mellitus (DM) lasting over 15 years and repeated esophageal obstruction resulting in chicken-meat-induced esophageal obstruction and candidiasis. This case highlights the importance of management of DM to prevent the development of complications such as diabetic neuropathy and associated symptoms.

The Forgotten Complication of Nasogastric Tube Insertion: Esophageal Perforation and Associated Hydropneumothorax and Hydropneumoperitoneum.

Nutritional support is essential for critically ill patients to reduce mortality and length of stay. Frequently nasogastric (NG) tubes are used to provide enteral nutrition. A very rare risk of NG tube placement is esophageal perforation, most commonly in the thoracic portion of the esophagus. Here we describe a case of a 41-year-old male with multiple risk factors for esophageal integrity disruption who initially presented for diabetic ketoacidosis (DKA) requiring intubation. Following intubation, an NG tube was placed for nutritional support. The following day the patient developed hydropneumothorax and hydropneumoperitoneum. He was taken emergently for surgical correction of suspected perforation. It was found that the patient had esophageal perforation from the distal esophagus to the proximal portion of the lesser curvature of the stomach. The NG tube transversed the proximal portion of the tear and re-entered at a distal site. The distal portions of the esophagus showed necrotic superficial layers with viable muscularis layers. The patient gradually improved after surgical intervention and was discharged to a long-term acute care facility. It is essential as medical providers to be familiar with complications of NG tube placement and risk factors that could increase the risk of esophageal perforation.

Esophageal Candidiasis in a Non-HIV Patient: A Primary Care Diagnosis.

A 74-year-old man visited his family doctor for dysphagia and was diagnosed with esophageal candidiasis. His risk factors included type 2 diabetes mellitus, long-term intake of budesonide/formoterol inhaler 160/45 µg, and pantoprazole 20 mg. He was treated with fluconazole 200 mg per day for 14 days. Other factors of immunosuppression were excluded, and his chronic medication was adapted by starting him with a proton pump inhibitor withdrawal plan and switching his inhaled device to a formoterol-only device without an inhaled corticosteroid. The patient had complete remission of the symptoms on the seventh day of treatment without relapse to date. The key point is that iatrogenic factors should be considered in the presence of esophageal candidiasis in immunocompetent patients and a therapeutic review is an important tool that should be used in every primary care appointment to refrain from long-term prescriptions without clinical indication and, consequently, to avoid adverse events.

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) and esophageal rupture by candida infection: A case report and review.

We probably describe the first report of esophageal rupture in a patient with autoimmune polyendocrinopathy - candidiasis - ectodermal dystrophy (APECED, OMIM # 240300), who had candida esophagitis as the main feature for decades. Strong evidence shows that this rupture may have been caused directly and indirectly by chronic candidiasis. In this way, we demonstrate how severe and harmful the persistent esophageal candidiasis can cause in the esophagus, especially in immunodeficient patients.

Prevalence, Predictors, and Outcomes of Esophageal Candidiasis in Cirrhosis: An Observational Study With Systematic Review and Meta-Analysis (CANDID-VIEW).

BACKGROUND: Gastrointestinal candidiasis is often neglected and potentially serious infection in cirrhosis patients. Therefore, we evaluated the prevalence, risk factors, and outcomes of esophageal candidiasis (EC) in cirrhotics and did a systematic review to summarize EC's available evidence in cirrhosis. METHODS: Consecutive patients with cirrhosis posted for esophagogastroduodenoscopy (EGD) at a tertiary care institute were screened for EC (cases) between January 2019 and March 2020. EC was diagnosed on EGD findings and/or brush cytology. Controls (without EC) were recruited randomly, and EC's risk factors and outcomes were compared between cases and controls.Four electronic databases were searched for studies describing EC in cirrhosis. Prevalence estimates of EC were pooled on random-effects meta-analysis, and heterogeneity was assessed by I2. A checklist for prevalence studies was used to evaluate the risk of bias in studies. RESULTS: EC was diagnosed in 100 of 2762 patients with cirrhosis (3.6%). Patients with EC had a higher model for end-stage liver disease (MELD) (12.4 vs. 11.2; P = 0.007), acute-on-chronic liver failure (ACLF) (26% vs. 10%; P = 0.003) and concomitant bacterial infections (24% vs. 7%; P = 0.001), as compared with controls. A multivariable model, including recent alcohol binge, hepatocellular carcinoma (HCC), upper gastrointestinal (UGI) bleed, ACLF, diabetes, and MELD, predicted EC's development in cirrhosis with excellent discrimination (C-index: 0.918). Six percent of cases developed the invasive disease and worsened with multiorgan failures, and four patients with EC died on follow-up.Of 236 articles identified, EC's pooled prevalence from 8 studies (all with low-risk of bias) was 2.1% (95% CI: 0.8-5.8). Risk factors and outcomes of EC in cirrhosis were not reported in the literature. CONCLUSIONS: EC is not a rare infection in cirrhosis patients, and it may predispose to invasive candidiasis and untimely deaths. Alcohol binge, HCC, UGI bleed, ACLF, diabetes, and higher MELD are the independent predictors of EC in cirrhosis. At-risk patients with cirrhosis or those with deglutition symptoms should be rapidly screened and treated for EC.

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.

Oropharyngeal candidiasis outcomes in renal transplant recipients receiving nystatin versus no antifungal prophylaxis.

OBJECTIVE: To compare the incidence of oropharyngeal candidiasis (OC), or thrush, in renal transplant recipients receiving nystatin versus no antifungal prophylaxis. METHODS: This was a single-center, retrospective, non-inferiority study of adult renal transplant recipients (RTRs) who received nystatin for 30 days for OC prophylaxis (nystatin group) or no antifungal prophylaxis therapy (No PPX group). The primary outcome was the incidence of OC within 3 months post-transplant. Secondary outcomes included time to OC occurrence and severity of OC. The pre-specified non-inferiority margin was 10%. RESULTS: The incidence of OC within 3 months post-transplant among 257 RTRs was 7.8% (10/128) in the No PPX group and 4.7% (6/129) RTRs in the nystatin group, a risk difference of 3.2% (95% CI, -2.7% to 9.1%, non-inferiority P = .04). The median time to OC was 7.5 days (IQR 6.3-34.3 days) in the nystatin group and 9.5 days (IQR 5.3-30.5 days) in the No PPX group (P = .64). Esophageal candidiasis was observed in 10% (1/10) of RTRs with OC in the No PPX group compared to 16.7% (1/6) RTRs in the nystatin group (P = 1.00). All RTRs with OC achieved symptom resolution with fluconazole and/or nystatin. Two patients in the No PPX group required readmission for decreased oral intake, and OC was diagnosed and treated during their hospital day. CONCLUSIONS: In this retrospective study of adult RTRs, the absence of antifungal prophylaxis demonstrated non-inferiority to 30-day nystatin prophylaxis at reducing the incidence of OC within 3 months of transplant. OC prophylaxis may not be warranted after renal transplant.

Prevalence of HIV-associated esophageal candidiasis in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: Esophageal candidiasis (OC) is a common AIDS-defining opportunistic infection. Antiretroviral therapy (ART) reduces the occurrence of OC and other opportunistic infections among persons living with HIV (PLHIV). We sought to determine and compare the prevalence of OC in the ART and pre-ART era among PLHIV in sub-Saharan Africa (SSA). METHODS: We searched PubMed, Embase, Web of Science, and the African Journals Online databases to select studies in English and French reporting the prevalence of HIV-associated OC in SSA from January 1980 to June 2020. Reviews, single-case reports, and case series reporting < 10 patients were excluded. A random-effect cumulative meta-analysis was performed using STATA 16.0, and trend analysis performed using GraphPad Prism 8.0. RESULTS: Thirteen eligible studies from 9 SSA countries including a total of 113,272 patients were qualitatively synthesized, and 9 studies were included in the meta-analysis. Overall pooled prevalence of HIV-associated OC was 12% (95% confidence interval (CI): 8 to 15%, I 2 = 98.61%, p <. 001). The prevalence was higher in the pre-ART era compared to the ART era, but not to statistical significance (34.1% vs. 8.7%, p = 0.095). In those diagnosed by endoscopy, the prevalence was higher compared to patients diagnosed by non-endoscopic approaches, but not to statistical significance (35.1% vs. 8.4%, p = .071). The prevalence of OC significantly decreased over the study period (24 to 16%, p < .025). CONCLUSION: The prevalence of OC among PLHIV in the ART era in SSA is decreasing. However, OC remains a common problem. Active endoscopic surveillance of symptomatic patients and further empirical studies into the microbiology, optimal antifungal treatment, and impact of OC on quality of life of PLHIV in SSA are recommended.

Acute dysphagia presentation and its association with esophagitis dissecans and concomitant diseases. A diagnostic challenge.

Esophagitis dissecans (ESD) is an uncommon disease that is associated with eosinophilic esophagitis (EoE), candidiasis and/or drugs. We aim to characterize the clinical, endoscopic and histological damage of the mucosal in subjects with dysphagia, its relation to concomitant entities and the treatment response. This is a retrospective observational study in patients with dysphagia and esophageal mucosal damage We included 23 patients (mean age = 55 years) who had GERD symptoms, dysphagia and/or odynophagia. There were 10, 9 and 4 cases of esophagitis dissecans, desquamative/esfacelante (ESD/ES) and fibrostenotic, respectively. ESD/SE is a rare entity with variable clinical, endoscopic and histological spectrum. The association with GERD was frequent.

La esofagitis disecante (ESD) es una enfermedad rara que puede asociarse a esofagitis eosinofílica, candidiásica o medicamentos. Se analizaron las características clinico-endoscópicas e histopatológicas en sujetos con disfagia de corta evolución asociada a afecciones concurrentes. Estudio observacional de cohorte retrospectiva con disfagia y daño mucoso. Se ingresaron 23 pacientes con edad media de 55 años. Todos tuvieron síntomas de reflujo gastroesofágico (ERGE), disfagia y odinofagia. Fueron 10, 9 y 4 casos de ESD, descamativa/esfacelante (ESD/ES) y fibroestenosis, respectivamente. La ESD/SE es una afección rara, con un espectro clínico, endoscópico e histológico variable.

Predictors of esophageal candidiasis among patients attending endoscopy unit in a tertiary hospital, Tanzania: a retrospective cross-sectional study.

BACKGROUND: Esophageal candidiasis is a common disease among patients with impaired cell mediated immunity. In the current study, we report esophageal candidiasis among patients with various co-morbidities attending the endoscopic unit at the Bugando Medical Centre. METHODS: This retrospective study was conducted from June to September 2015. All data of the patients who attended the endoscopic unit between 2009 and 2014 were retrieved and analyzed. RESULTS: A total of 622 patients who underwent oesophagogastroduodenoscopy were analyzed. A slight majority 334/622(53.7%) of patients were female. Out of 622 patients; 35(5.6%) had esophageal candidiasis. Decrease in age (OR 1.1, 95%CI; 1.0-1.1), female sex (OR 3.8, 95%CI; 1.1-13.1), drinking alcohol (OR 17.1, 95%CI; 4.9-58.9), smoking (OR 8.3, 95%CI; 1.7-41.0), antibiotic use (OR 5.7, 95%CI; 2.0-16.4), positive HIV status (OR 10.3, 95%CI; 4.6-6.0) and presence of peptic ulcer disease (OR 13.2, 95%CI; 3.5-49.0) independently predicted esophageal candidiasis. CONCLUSION: Patients with a history of drinking alcohol, smoking, use of antibiotics and those with chronic diseases such as peptic ulcers were at high risk of developing esophageal candidiasis. Further studies are needed to identify Candida spp. and their anti-fungal susceptibility for proper management of esophageal candidiasis in HIV and non-HIV individuals.

Possible Risk Factors for Candida Esophagitis in Immunocompetent Individuals.

BACKGROUND: Candida esophagitis (CE) is a condition typically diagnosed in patients who are immunocompromised. Risk factors leading to the development of CE in immunocompetent patients have not been entirely elucidated. This study set out to identify risk factors associated with the development of CE in immunocompetent patients. METHODS: This study was a single-center retrospective chart review. Patients diagnosed with CE confirmed by endoscopic biopsy or brushings at our hospital between 2007 and 2017 were reviewed. The medical histories, endoscopy reports and pathology results were noted. Abdominal pain, heartburn, dysphagia and odynophagia were the common indications for endoscopy. A total of 241 patients were identified as having been diagnosed with CE by endoscopic brushing or biopsy. Of these patients, 161 were excluded due to the presence of immunocompromising and 80 patients were included who had no underlying immunocompromising conditions. RESULTS: Eighty patients with CE satisfied the inclusion criteria. The mean age of patients at the time of diagnosis was 39.8 years old (95% CI: 34.9 - 44.7). The incidences in men and women were similar in this study (49% women and 51% men). Of these patients, 56 (70%) (95% CI: 59-80%; P < 0.005) were taking proton pump inhibitors (PPIs). Fifteen patients (19%) had a previous upper endoscopy with evidence of reflux esophagitis, and they were all treated with PPIs and subsequently found to have CE on repeat upper endoscopy with a mean of 21.6 months of PPI treatment. There were 16 (20%) patients without any attributable risk factor and were completely healthy. CONCLUSIONS: CE is an opportunistic infection typically seen in immunocompromised. We report incidence of CE in immunocompetent patients. In our cohort of immunocompetent patients, PPI use was the most common risk factor associated with the development of CE. This could be related to hypochlorhydria resulting from PPI use. However, the cause remains unclear in some patients.

Challenges to "Classic" Esophageal Candidiasis: Looks Are Usually Deceiving.

Objectives: We undertook the first case control study of histologically confirmed esophageal candidiasis (EC). Methods: A computer search from July 2012 through February 2015 identified 1,011 esophageal specimens, including 40 cases of EC and 20 controls. Results: The EC incidence was 5.2%; it was associated with immunosuppression and endoscopic white plaques and breaks. Smoking was a predisposing factor, and alcohol was protective. EC had no unique symptoms, and 54% of endoscopic reports did not suspect EC. Important histologic clues included superficial and detached fragments of desquamated and hyper-pink parakeratosis, acute inflammation, intraepithelial lymphocytosis, dead keratinocytes, and bacterial overgrowth. Thirty percent had no neutrophilic infiltrate. Pseudohyphae were seen on H&E in 92.5% (n = 37/40). "Upfront" periodic acid-Schiff with diastase (PAS/D) on all esophageal specimens would have generated $68,333.49 in patient charges. Our targeted PAS/D strategy resulted in $13,044.87 in patient charges (cost saving = 80.9%, $55,288.62). Conclusions: We describe the typical morphology of EC and recommend limiting PAS/D to cases where the organisms are not readily identifiable on H&E and with at least one of the following: (1) ulcer, (2) suspicious morphology, and/or (3) clinical impression of EC.

An unusual complication after interventional cardiology reveals and infrequent condition: Idiopathic CD4 deficiency.

Herpes zoster (HZ) is of rare occurrence after interventional procedures with few events reported until now. A 74 year-old man with a past medical history of idiopathic thrombocytopenic purpura, splenectomy, autoimmune hemolytic anemia, and polymyalgia rheumatica developed HZ on the right median nerve 7 days after he underwent a coronariography for managing an acute coronary syndrome. He evolved with cutaneous dissemination and required intravenous acyclovir therapy. Laboratory evaluation disclosed a previously unknown idiophatic CD4 lymphocytopenia. HZ should be added to the list of complications after interventional cardiology and associated immunosuppressive factors ruled out.