Gastrointestinal Tract (GIT) candidiasis

Gastrointestinal tract candidiasis is an opportunistic fungal infection of the mucosa of the oropharynx, esophagus, stomach, or intestines caused predominantly by Candida albicans, a commensal yeast that normally inhabits the human mucosal surfaces.

Under normal immune conditions Candida remains harmless. Disease develops when there is disruption of host immunity or normal flora balance, allowing fungal overgrowth and tissue invasion.

Common predisposing factors

• HIV/AIDS or other immunodeficiency states

• Diabetes mellitus (especially uncontrolled)

• Pregnancy

• Prolonged antibiotic use (destroys protective bacteria)

• Long-term corticosteroid therapy

• Chemotherapy / immunosuppressive therapy

• Malnutrition

• Prolonged hospitalization or ICU stay

• Use of contraceptive pills

• Indwelling medical devices (feeding tubes, catheters)

Pathophysiology

Candida species exist in yeast form (commensal) and hyphal form (pathogenic).

When immunity drops:

1. Candida converts into invasive hyphae

2. Adheres to mucosal epithelial cells

3. Produces enzymes (proteases & phospholipases)

4. Causes epithelial destruction → inflammation → pseudomembrane formation

5. May disseminate hematogenously in severe immunosuppression

Key concept:GIT candidiasis is usually a marker of systemic immune compromise.

Clinical Presentation

The disease may involve multiple body sites simultaneously.

A. Oral Candidiasis (Thrush)

• White adherent plaques on tongue, palate, buccal mucosa

• Plaques bleed when scraped

• Burning mouth sensation

• Loss of taste

• Angular cheilitis (cracks at mouth corners)

B. Esophageal (GIT) Candidiasis

• Painful swallowing (odynophagia)

• Difficulty swallowing (dysphagia)

• Retrosternal chest pain

• Reduced oral intake → weight loss

C. Cutaneous & Intertriginous Candidiasis

• Erythematous moist rash

• Satellite pustules around main lesion

• Common in groin, axilla, under breasts, diaper area

D. Nail Infection (Paronychia)

• Painful swelling around nail

• Pus discharge

• Worse after water exposure

• Nail dystrophy

E. Vulvovaginal Candidiasis

• Intense itching

• Thick curd-like white discharge

• Dysuria

• Dyspareunia

• Vulval erythema

Diagnostic Criteria

Diagnosis is clinical plus laboratory confirmation when needed.

Suggestive features

• White mucosal plaques (oral)

• Odynophagia in immunocompromised patient

• Satellite pustules in moist folds

• Curd-like vaginal discharge

• Nail fold inflammation with pus

Investigations

Treatment

A. Non-Pharmacological Management

• Improve oral hygiene

• Control blood sugar

• Reduce prolonged antibiotic use if possible

• Keep skin folds dry

• Avoid tight, moist clothing

• Rinse mouth after steroid inhaler use

• Nutritional support

B. Pharmacological Treatment

First-line (systemic therapy for GIT involvement)

Fluconazole (PO)150 mg once daily for 14 days

Alternative options (if resistant or severe)

• Fluconazole 200–400 mg daily (esophageal candidiasis)

• Itraconazole oral solution

• Voriconazole (refractory disease)

• Amphotericin B (severe disseminated infection)

Site-specific adjunct therapy

Complications

• Esophageal ulceration

• Stricture formation

• Malnutrition due to painful swallowing

• Disseminated candidemia (life-threatening)

• Recurrent vulvovaginal candidiasis

Prevention

• Proper diabetic control

• Avoid unnecessary antibiotics

• Maintain good genital hygiene

• Keep skin folds dry

• Nutritional improvement

• HIV patients: early ART initiation

• Rinse mouth after inhaled steroids

• Regular replacement of dentures

Prognosis

• Good in immunocompetent individuals

• Recurrent in diabetics & HIV patients

• Severe disease may indicate advanced immunosuppression

Key Clinical Pearls

• Odynophagia in an HIV patient = assume esophageal candidiasis until proven otherwise

• Oral thrush + dysphagia → start systemic antifungal immediately

• Recurrent vaginal candidiasis → screen for diabetes

• Persistent candidiasis → evaluate immune status