A Case of Esophageal Candidiasis in an Adolescent Who Had Frequently Received Budesonide Nebulizing Therapy
A 13-year-old female adolescent visited our pediatric clinic presenting with nausea, dysphagia and abdominal pain. Her abdominal pain was localized to the epigastric area. The symptoms started 1 month ago, and became aggravated 2 weeks ago. The pain occurred intermittently, and became severe during the post-prandial period and at midnight, and was aggravated by a heavy meal. Her appetite was also decreased, but the body weight had not decreased. Her height was 152.3 cm (20th percentile), body weight was 41.6 kg (15th percentile), and body mass index was 17.9 (30th percentile). She had a history of frequent nebulizer therapy with budesonide for severe coughing at a private pediatric clinic although she had not been diagnosed with asthma or chronic bronchial disease. Every time she visited the pediatric clinic for the cough, she was prescribed nebulizer therapy with budesonide once a day for 2 or 3 consecutive days. This had occurred 3 times during the previous winter season. The dose of budesonide could not be confirmed. Her last budesonide nebulizer therapy was 2 months before she visited our clinic. Her history of use of antibiotics was unclear. The physical examination was nonspecific, except for mild epigastric tenderness. Blood studies were done, and they showed WBC 4,600/mm3 (polymorphonuclear neutrophils 54%, lymphocyte 36%, monocyte 7%), hemoglobin 12.9 g/dL, platelet 245,000/mm3, and C-reactive protein was negative. Electrolytes, total protein, albumin, calcium, phosphorus, cholesterol, liver enzymes, renal profiles, total bilirubin, direct bilirubin, CD3 and CD4 were within the normal range. In addition, serum Helicobacter pylori IgM and Ig G, and hepatitis B virus serologic tests were also negative, and human immunodeficiency virus was negative. Chest x-ray film showed no abnormality. Peptic ulcer disease was suspected clinically, so we planned an upper gastrointestinal endoscopic examination. On her first endoscopic examination, we found normal oral, gastric, and duodenal mucosa, but there were creamy white pseudo-membranes and multiple erosions on the whole of the esophageal mucosa (). Pathologic studies were performed on the esophageal biopsies of the lesion. KOH staining showed hyphae that suggested a fungal infection. Hematoxylin and eosin staining of the biopsy showed numerous hyphae and yeasts on the surface of the epithelia in the hyperkeratotic squamous epithelium of the esophagus (). Pathologically the lesion was consistent with candidal infection. So we were able to confirm candidiasis of esophagus. We thought that our patient was not in an immunocompromised state because she had no history of admission or operation, and was on no special medications except for budesonide. The patient's growth percentile was normal, and there was no immune-comprised clinical feature. So, we planned a wait-and-see approach without any antifungal treatment because the lesion could possibly heal naturally in an immunocompetent healthy host.\nAfter 1 month, a follow-up esophagoscopic examination was performed. The previous whitish creamy pseudo-membranes and erosions were still noted on the whole esophagus (). We decided to prescribe an antifungal agent, oral fluconazole, that is usually well tolerated and effective for esophageal candidiasis, in the dose of 6 mg/kg per day for 2 weeks. As she took the medicine, her dysphagia, nausea, and abdominal pain improved gradually.\nA follow-up esophagoscopic examination was performed 2 weeks after the cessation of the anti-fungal therapy. The whitish creamy pseudo-membranes and multiple erosions were no longer seen in the esophagus (). The esophageal mucosa was normal. Her symptoms also improved completely. She is now in excellent condition.