Refractory hemorrhagic esophageal ulcers by Candida esophagitis with advanced systemic sclerosis

Abstract

A 64-year-old woman diagnosed with rheumatoid arthritis (RA) and systemic sclerosis (SSc) was admitted to our hospital with chief complaints of uncontrolled bleeding from esophageal ulcers and an inability to consume meals. For RA and SSc, she was treated with prednisolone and abatacept and was taking vonoprazan as prophylaxis for steroid-induced gastric ulcers. She was diagnosed with severe Candida esophagitis, with multiple large and small ulcers with bleeding, based on esophagogastroduodenoscopy and pathological findings. We performed comprehensive treatment; abatacept was discontinued, and total parenteral nutrition was initiated along with antifungal therapy. Improvement in the esophageal ulcers was observed. Although severe Candida esophagitis is a rare condition, we should keep in mind that severe Candida esophagitis can occur in patients with an immunosuppressive compromised host and esophageal movement disorders such as SSc. Regular follow up by endoscopy and prophylactic treatment to prevent severe esophagitis may be necessary.

Figure 1

Computed tomography (CT), esophagogastroduodenoscopy (EGD), and pathologic images. (a) CT shows an extremely dilated esophagus (white arrows) with liquid and blood components (white arrowhead). (b) EGD shows multiple large and small ulcers with white plaques, with extravasation and oozing in the upper posterior wall lesion. (c, d) Hematoxylin and eosin and periodic acid–Schiff staining show the severe destruction of the esophageal mucosa with lymphocyte invasion in which infiltrated mycelium (black arrows) are seen. (e) EGD shows reextravasation and oozing of the esophageal ulcers. (f) EGD shows improved esophageal ulcers after the therapies.