Nausea and vomiting caused by candida esophagitis in an elderly frail patient.

An elderly frail lady with features of malnutrition was investigated by endoscopy because of nausea and vomiting. Candida esophagitis was found, and there was symptomatic and endoscopic resolution after treatment with amphotericin B.

Introduction

Candida esophagitis usually occurs in patients with impaired immunity caused by debility, malnutrition, or medication. , The most common symptom is dysphagia, but other symptoms may occur including nausea and vomiting. , , Most patients have coexisting oral candidiasis. We report an elderly, disabled woman with candida esophagitis who presented with nausea and vomiting without features of oral candidiasis.

Case report

An 80‐year‐old female patient presented to the department of gastroenterology with complaints of nausea, vomiting, and appetite loss. She had a medical history of radiation therapy due to vocal cord cancer in her late twenties, carotid artery stenting at 67 years, laryngectomy due to laryngeal cartilage necrosis at 72 years, and idiopathic dilated cardiomyopathy and total arch replacement of the ascending aorta due to acute aortic dissection at 76 years. She was taking an antiplatelet agent (clopidogrel, 75 mg/day) and a proton pump inhibitor (PPI; omeprazole, 20 mg/day). She was also on a liquid diet (Ensure, Abbott, Tokyo, Japan) because of a 3‐month history of trismus. Her oral cavity was normal with no features of oral candidiasis. Blood tests revealed a hemoglobin level of 9 g/dl and a serum albumin level of 2.6 g/dl. Nasal gastrointestinal endoscopy (GIF‐H190N, Olympus Optical Co, Tokyo, Japan) revealed multiple white plaques in the lower esophagus (Fig. 1a) and atrophic gastritis. Esophageal biopsies confirmed esophageal inflammation with Candida albicans (Fig. 2). Treatment with amphotericin syrup, 400 mg, 4× daily for 1 week resulted in the resolution of symptoms as well as esophageal abnormalities (Fig. 1b).

Figure 1

(a) Endoscopic finding before treatment; multiple whitish plaques were identified. (b) Endoscopic finding after treatment; normal finding.

Figure 2

Biopsy specimens from the lesions, revealing inflammatory cells, mainly neutrophils, infiltrating the mature squamous cells at places infected with Candida albicans (bar = 30 μm).

Discussion

We attribute esophageal candidiasis to immunosuppression associated with frailty and malnutrition. The typical symptoms of esophageal candidiasis are a pain in swallowing, dysphagia, and retrosternal pain. Other symptoms may include abdominal pain, heartburn, diarrhea, nausea, vomiting, and weight loss. Most patients with esophageal candidiasis have coexisting oral candidiasis, but the absence of the latter does not exclude the diagnosis as illustrated by this patient. Candida esophagitis usually responds well to antifungal therapy. Amphotericin syrup was effective in this patient, but alternative medication could include fluconazole, itraconazole, voriconazole, and caspofungin. , Some of these drugs have significant side effects including drug interactions. This case suggests that nausea and vomiting are caused by candida esophagitis in an elderly frail patient and that antifungal drugs could improve these symptoms and the quality of life of the patient.