Small but Severe: Candidiasis-Associated Esophageal (micro) Perforation: 1664

Esophageal candidiasis is an AIDS defining illness that is increasingly common with low CD4+ counts. Although generally manageable with oral anti fungals, development of serious associated complications can significantly increase the associated morbidity and mortality. A 28 year old male with history of AIDS complicated by oral thrush and anal condyloma presented with chronic productive cough for over two years. Cough was productive of yellow and green sputum and associated with upper abdominal ‘tightness'. The patient denied fevers, chills, dysphagia, or odynophagia. He denied recent travel, sick contacts, and hospitalizations. No history of incarceration, institutionalization or shelter stay. On exam, the patient was in no acute distress, had evidence of oral thrush and had decreased breath sounds in left lower lobe. Labs were notable for CD4+ 18 cells/mL, VL 52,400 copies/mL, WBC 11 K/uL with neutrophilic predominance and negative AFB sputum x3. Respiratory cultures were poly-microbial with presence of both gram positive cocci and bacilli as well as Candida albicans. A CT scan was significant for a multiloculated rim-enhancing hypodense lesion in the left lower lobe as well as a dilated and hyperemic esophagus with adjacent foci of air suggestive of esophageal perforation. Subsequent esophagram was notable for a shaggy esophagus compatible with candida esophagitis and findings consistent with microperforation related to ulceration from candidiasis. There was no extravasation of contrast. The patient was treated with empiric antibacterial and antifungal agents with improvement in symptoms. We present an atypical case of a solitary lung abscess that was likely secondary to esophageal microperforation from esophageal candidiasis. Esophageal perforation is a rare but previously described complication of candidiasis, specifically of the invasive variety. Lung involvement by Candida species typically presents as multiple lung abscesses due to the hematogenous fungal dissemination. Isolated collections or abscesses are more rare and have been described in association with anatomical disruption. Empyema due to fistula formation between the gastrointestinal tract and pleural cavity as well as Candida mediastinitis have been rarely described and carry very high morbidity and mortality rates. A high degree of clinical suspicion is required to diagnose and treat this entity as it is associated with several high risk complications.