Esophageal Candidiasis (Esophageal Thrush)

What happens in esophageal candidiasis

Candida yeast lives harmlessly in the mouth and gut of most people, kept in check by the immune system and normal bacteria. When local or whole-body defenses fall, the yeast overgrows and attaches to the lining of the esophagus. It forms raised white or cream plaques, and the lining underneath becomes inflamed, red and sometimes ulcerated. That inflammation is what makes swallowing painful.

Esophageal candidiasis is the most common cause of infectious esophagitis. In people with HIV, it is an AIDS-defining illness, meaning it signals significant immune damage, typically a CD4 count below 200 cells/mm³.

Symptoms

• Painful swallowing (odynophagia): the most typical symptom, often sharp and behind the breastbone
• Difficulty swallowing or a feeling of food sticking
• Chest pain behind the breastbone, sometimes mistaken for heartburn
• Nausea, loss of appetite and weight loss in more severe cases
• Oral thrush: white patches in the mouth that can be wiped off. These are present in about two-thirds of people with esophageal candidiasis, but their absence does not rule it out.

Some people, especially those on inhaled steroids, have no symptoms, and the infection is found by chance during endoscopy.

Causes and risk factors

Weakened immunity

• HIV infection, especially untreated or advanced. See HIV/AIDS.
• Cancer treatment: chemotherapy and radiotherapy to the chest, head or neck
• Blood cancers such as leukemia and lymphoma
• Organ or stem cell transplants and immune-suppressing medicines
• Oral steroids or other immunosuppressants for autoimmune disease

Local factors

• Inhaled corticosteroids for asthma or COPD, especially at high doses or without rinsing after use
• Acid-suppressing medicines (proton pump inhibitors), which raise the pH of the stomach and esophagus
• Broad-spectrum antibiotics, which disturb normal bacteria
• Uncontrolled diabetes
• Conditions that slow the esophagus, such as achalasia or scleroderma
• Older age, dentures and dry mouth

How it is diagnosed

• Upper endoscopy (EGD): a thin camera passed through the mouth shows the typical white plaques that do not wash away. Brushings or a biopsy confirm yeast invading the lining and exclude other causes.
• Treatment trial: in a person with HIV who has oral thrush and painful swallowing, doctors often start antifungal treatment without endoscopy. If symptoms improve within about a week, the diagnosis is confirmed. If not, endoscopy is done.
• HIV test: recommended for anyone with esophageal candidiasis who does not have a clear alternative cause.
• Blood glucose and a review of medicines.

Other infections can cause similar symptoms, especially herpes simplex virus and cytomegalovirus esophagitis in people with weak immunity. Biopsy tells them apart. Eosinophilic esophagitis and reflux are non-infectious mimics.

Treatment

Antifungal medicines

• Fluconazole tablets are the first choice, usually for 14 to 21 days. Symptoms typically improve within a few days, but the full course is needed.
• If you cannot swallow tablets, fluconazole can be given intravenously at first.
• For infections that do not respond, often from fluconazole-resistant Candida species, alternatives include itraconazole solution, voriconazole, posaconazole, or IV echinocandins such as caspofungin or micafungin.
• Mouth rinses and lozenges that treat oral thrush are not enough for esophageal infection because the medicine does not stay in the esophagus long enough.

Your doctor will check for medicine interactions, because azole antifungals interact with many drugs, including some statins, blood thinners and HIV medicines.

Treating the underlying cause

• Starting or optimizing HIV treatment (antiretroviral therapy) is the most effective way to prevent recurrence in people with HIV.
• Controlling blood sugar in diabetes.
• Reviewing the need for acid suppressants and antibiotics.
• Rinsing the mouth and spitting after each use of a steroid inhaler, and using a spacer device.

Easing symptoms while treatment works

• Choose soft, cool or lukewarm foods and liquids such as yogurt, soups and smoothies.
• Avoid spicy, acidic, very hot, rough or dry foods, alcohol and smoking.
• Take small sips of water to keep hydrated.

Complications

Complications are uncommon with treatment but include:

• dehydration and weight loss from avoiding eating
• bleeding or, rarely, narrowing (stricture) of the esophagus
• spread into the bloodstream (invasive candidiasis) in people with severely weakened immunity

Outlook

Most people recover fully with a single course of antifungal medicine. Recurrence is common if the underlying cause persists. People with frequent recurrences and ongoing immune suppression may be offered longer-term preventive antifungal treatment, though this raises the risk of resistance.

Frequently asked questions

What are the symptoms of esophageal thrush?

The main symptoms are pain when swallowing, difficulty swallowing, and pain or burning behind the breastbone. Many people also have white patches in the mouth from oral thrush. Severe infection can cause loss of appetite and weight loss.

How is esophageal candidiasis treated?

It is treated with antifungal tablets, usually fluconazole, for 14 to 21 days. Mouth rinses and lozenges are not enough. If the infection does not respond, other antifungal medicines are used. Treating the underlying cause, such as HIV or uncontrolled diabetes, prevents it from coming back.

Can a steroid inhaler cause esophageal thrush?

Yes. Inhaled steroids for asthma or COPD can reduce local immunity in the mouth and throat, allowing Candida to grow. Using a spacer, rinsing your mouth with water and spitting after each dose, and using the lowest effective dose all reduce the risk.

Is esophageal candidiasis a sign of HIV?

It can be. In people with no other clear cause, such as cancer treatment, steroids or diabetes, it may be the first sign of HIV with significant immune damage. Doctors recommend an HIV test for anyone diagnosed with it unless another cause is obvious.

Is esophageal thrush contagious?

Not in the usual sense. Candida is already present in most people's bodies, and the infection develops because local or immune defenses are weakened. It is not spread through normal contact. The underlying risk factor matters far more than exposure.