Full text of DOI:10.1067/mge.2000.108922

B-W Kim, S-H Cho, S-E Rha, et al.
Esophageal candidiasis: esophageal fistula and stricture
before admission, the patient had received antibiotic ther-
apy (Cefixime 200 mg/day for 1 week) due to acute epiglot-
titis. Esophagography, performed due to complaints of a
foreign body sensation, revealed no definitive abnormali-
ty at the time.
CASE REPORTS
On admission, laboratory data included the following
(normal values in parentheses): fasting glucose 235 mg/dL
(70 to 110), total protein 5.3 g/dL (6.5 to 8.3), and albumin
2.2 g/dL (3.8 to 5.1). Hemoglobin A1c was 10.4% (<6%).
The other hematologic and biochemical results were with-
in normal limits.
Esophagomediastinal fistula and
esophageal stricture as a complication of
esophageal candidiasis: a case report
Byung-Wook Kim, MD, Se-Hyun Cho, MD, Sung-Eun Rha,
MD, Hwang Choi, MD, Kyu-Yong Choi, MD, Sang-Bok
Cha, MD, Myung-Gyu Choi, MD, In-Sik Chung, MD, Hee-
Sik Sun, MD, Doo-Ho Park, MD
EGD revealed an opening of a fistula in the distal
esophagus (Fig. 1A), ulceration of the proximal and mid
esophagus, and multiple ulcers in the gastric antrum. A
barium-contrast esophagogram revealed an esophagome-
diastinal fistula in the distal esophagus (Fig. 1B). CT of
the chest showed an abnormal air density in the medi-
astinum with thickening of esophageal mucosa (Fig. 2).
Candida was demonstrated in a biopsy specimen taken
from the esophagus (Fig. 3), but granulomas were not
detected. IgM antibodies to aspergillus, cytomegalovirus,
and herpes simplex virus were all negative. Treatment was
started with nystatin (4,000,000 units/day) and flucona-
zole (200 mg/day). Total parenteral nutrition was initiated.
Esophagography after 2 weeks revealed resolution of
the esophagomediastinal fistula but there were multiple
ulcerations and a stricture of the esophagus (Fig. 4A).
Esophagoscopy, performed after 3 weeks, revealed that
the opening of the esophagomediastinal fistula had disap-
peared; however, the ulceration had worsened and a newly
formed stricture of the esophagus had appeared (Fig. 4B).
After anti-fungal therapy for 8 weeks, dilation was
performed under fluoroscopy using polyvinyl over-
the-guidewire dilators of 9, 11, and 13 mm at first and
after 1 week using 13 and 15 mm dilators. Esoph-
agography revealed dilatation of the stricture segment
(Fig. 5). Currently, the patient’s condition has improved
and she tolerates solid food and is being followed up on an
ambulatory basis.
Candida species are the most common esophageal
pathogens. Conditions predisposing to esophageal
candidiasis in a host with normal immunity include
antibiotic use, inhaled or ingested corticosteroids,
antacid therapy or hypochlorhydric state, diabetes
mellitus, alcoholism, old age, radiotherapy to head
and neck, and esophageal motility disturbances.
Complications from esophageal candidiasis are
extremely uncommon. They include esophageal hem-
orrhage, lumenal obstruction secondary to fibrosis
and stricture formation, and fistulization into the
bronchial tree.1-3 Only rarely does esophageal can-
didiasis result either in esophageal perforation into
the mediastinum or in esophageal stricture. This is a
report of a patient with both esophagomediastinal
fistula and esophageal stricture, probably resulting
from esophageal candidiasis.
CASE REPORT
A 57-year-old woman presented with a 2-week history
of dysphagia, nausea, and vomiting without fever or chills.
The patient was known to have suffered from diabetes
mellitus for a period of 4 years. She was receiving oral
hypoglycemic agents, which had controlled the diabetes
well. There was no history of antacid therapy, alcoholic
abuse, or radiotherapy to head and neck. About 3 weeks
DISCUSSION
Infections of the esophagus are unusual in the
general population and the majority of patients with
such infections have impaired host defenses. For all
immunocompromised patients, the most frequently
identified esophageal pathogens are Candida,
cytomegalovirus, and herpes simplex virus.4
Esophagomediastinal fistula is a rare condition
that develops mainly as a complication of trauma or
surgery of the chest. However, it can also develop in
immunocompromised patients, arising as a compli-
From the Division of Gastroenterology, Department of Internal
Medicine and Radiology, College of Medicine, The Catholic
University of Korea, Seoul, Korea.
Reprint requests: Byung-Wook Kim, MD, Division of Gastro-
enterology, Department of Internal Medicine, Our Lady of Mercy
Hospital, No. 665, Pupyong-dong, Pupyong-gu, Inchon, 403-016,
Republic of Korea; fax 82-32-510-5680.
Copyright © 2000 by the American Society for Gastrointestinal
Endoscopy
0016-5107/2000/$12.00 + 0 37/54/108922
doi:10.1067/mge.2000.108922
772 GASTROINTESTINAL ENDOSCOPY
VOLUME 52, NO. 6, 2000

Esophageal candidiasis: esophageal fistula and stricture
B-W Kim, S-H Cho, S-E Rha, et al.
A
Figure 2. Chest CT showing abnormal air density space
next to the distal esophagus (arrow) and a thickened
esophagus wall.
Figure 3. Photomicrograph of the esophageal biopsy speci-
men in which a number of hyphae are evident (PAS stain,
orig. mag. ×200).
cation of infections such as tuberculosis. There are
reports of esophagomediastinal fistula as a compli-
cation of tuberculosis.5,6 Sclerotherapy is another
cause of esophagomediastinal fistula.
Benign esophageal strictures are usually caused
by an inflammatory process, the most common of
which is gastroesophageal reflux.7 Other causes
include caustic stricture caused by the ingestion of
lye or other chemicals, medication-induced stric-
tures, and those resulting from disease processes
such as tuberculosis, and Crohn’s disease. Several
viral infections, including herpes simplex and
cytomegalovirus, also can cause esophageal stric-
tures. However, the occurrence of an esophageal
stricture in association with candida esophagitis
has rarely been reported in English language publi-
B
Figure 1. Before anti-fungal treatment. A, Endoscopic view
of the opening into the esophagomediastinal fistula (arrow) in
the distal esophagus. Open arrow indicates esophageal
lumen. B, Barium-contrast esophagogram demonstrating
esophagomediastinal fistula (arrow) with leakage of contrast
into the mediastinum and “shaggy” appearance of the wall of
the proximal and mid esophagus.
VOLUME 52, NO. 6, 2000
GASTROINTESTINAL ENDOSCOPY 773

B-W Kim, S-H Cho, S-E Rha, et al.
Esophageal candidiasis: esophageal fistula and stricture
A
Figure 5. Esophagography after dilatation showing the nar-
rowest region to be about 9 mm in diameter (arrows).
cations. This case suggests that severe candida
esophagitis may result in esophagomediastinal fis-
tula and esophageal stricture. To our knowledge,
this is the first reported case of esophageal candidi-
asis complicated by esophagomediastinal fistula
and esophageal stricture.
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