A radiographic. Leroy Roberts, Jr., M.D.4. Gregory Gibbons, M.D.t

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1 RdioGrphics Index terms: Adult esophgel cndidisis: Gstrointestinl rdiology umultive Index terms: ndldlsls Esophgitis Esophgus, rdiogrphy A rdiogrphic spectrum Leroy Roberts, Jr., M.D.4 Rebecc Gibbons, M.D.4 Gregory Gibbons, M.D.t Reed P. Rice, M.D.4 \Mllim M. Thompson, M.D.4t Bcuse of n Incresing number of Immunod.fIcI.ncy stt#{149}s from vrious cuses, the bility of 1h rdiologist to dignose ndid esophgltls Is gining In lmportnc. THIS EXHIBIT WAS DISPLAYED AT THE 71ST SIENTIFI ASSEMBLY AND AN- NUAL MEETING OF THE RADIOLOGIci SOIE1Y OF NORTH AMERIA NOVEMBER 17-22, 1985, HIAGO. ILLINOIS. IT WAS REOMMENDED BY THE GASTROINTES11NAL RADIOLOGY PANEL AND WAS AEPTED FOR PUBLIATION AFTER PEER REViEW AND REViSION ON SEPTEMBER 4, From the Deprtments of Rdiology ( ) nd Medicine, Gstroenterology Section (t), Duke University Medicl enter nd Veterns Administrtion Hospitl, Durhm, North rolin. fpresently t Dept. of Rdiology, University of Mmnesot School of Medicine, Minnepolis, MN. Address reprint requests to L. Roberts, Jr., M.D., Box 88, Deprtment of Rdiology, Duke University Medicl enter, Durhm, N Introduction ondid /b/cns is norml inhbitnt of the orophrynx nd gstrointestinl trct; it is not considered pthogen in the symptomtic ptient. In the pthologic stte (cndidlsis or monilisis), this fungus my proliferte nd colonize the esophgus, eventully invding the mucos nd producing bnorml esophgel motility, ulcerlion, edemtous folds, nd plques of debris. Unrecognized nd untreted It my result in fistul formtion, perfortion, stricture nd potentilly ftl disseminted cndidisis. Prompt recognition nd dequte tretment, however, usully result in rpid resolution of the infection (1,1.The purposes of this report, therefore, re to present the spectrum of rdiogrphic findings seen in cndid esophgifis nd to identify nd illustrte differentil considertions in the rdiogrphic dignosis. All of the cses of cndid esophgitis presented here were proved either by biopsy or culture. linicl Sefting nd Prisnttlon of ndldlsls cndid esophgilis occurs in ptients whose norml flor Is ltered by brod spectrum ntibiotic therpy; in ptients whose immune systems re suppressed becuse of dibetes mellitus, mlignnt neoplsms, or the dministrtion of immunosuppressive gents, chemotherpy or rdition therpy (1-), nd In ptients with immune deficiency sttes such s AIDS. It hs lso been described in individuls with scleroderm, strictures nd chlsi; nd It hs been reported to occur fter fundoplicllon (). Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 289

2 ndid esophgitis Roberts et l. The ptient with symptoms cused by cndid esophgitis initilly complins of dysphgi (difficult swllowing) nd of odynophgi (pin on swllowing); or of intense, retrosternl pin, which my hve burning chrcter, or both. Orl thrush is vriously reported to occur s concomitnt of cndid esophgitis in 2 to 8% of cses (1). Dignosis of ndidisis For mny yers, brium esophgogrphy remined the principl dignostic technique vilble for the evlution of the esophgus. In cndidisis, however, the incidence of flse negtive brium esophgogrms hs been reported to vry from 2 to 6% (. Levine et l., in recent study of cndid esophgitis, stted tht double contrst esophgogrphy is more sensitive (88%) thn single contrst exmintions (55%) for the detection of superficil mucosl lesions (). Nevertheless, currently, endoscopic evlution of the esophgus is the most specific nd sensitive (97%) method with which to estblish the dignosis of cndid esophgitis (5). The endoscopic ppernce, which is chrcteristic but not pthognomonic, consists of ptchy, cremy-white plques tht cover frible, erythemtous mucos. Direct smers re needed to estblish the dignosis with certinty. The presence of mycelil cndid is thought to be evidence of pthogenic, invsive form of the orgnism (V. Still mny ptients will continue to be exmined initilly by brium esophgogrphy, nd some ptients, such s those with AIDS whose endoscopy represents t lest theoreticl risk of disese trnsmission to other ptients, my not be considered cndidtes for the more invsive procedure. It is importnt, therefore, for the rdiologist to be fmilir with the common nd unusul mnifesttions of esophgel cndidisis. Usul Rdiogrphic Appernces of ndid Esophgitis The erliest chnge in the esophgus is impired penistlsis with decrese from the norml frequency nd mgnitude of the primry nd secondry wves, prticulrly in the distl esophgus. Spsm nd irritbility hve lso been observed fluoroscopiclly (). When the disese is superficil, the esophgel mucos my pper norml rdiogrphiclly, prticulrly on single contrst brium study (5) (Figures IA nd B). 29 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

3 Roberts et l. ndid esophgitis Figure IA Erly disese No rdiogrphic evidence of cndid esophgitis is seen in single contrst brium esophgogrm. This ptient hd endoscopiclly proved cndid esophgitis. A smll hitl herni nd mild distl esophgel stricture, presumbly secondry to gstroesophgel reflux, re demonstrted; the study is otherwise norml. Figure lb Erly disese No rdiogrphic evidence of cndid esophgitis is seen in single contrst brium esophgognm. This renl trnsplnt ptient hd endoscopiclly proved cndid esophgitis; the esophgogrm is norml. Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 291

4 ndid esophgitis Roberts et l. U. Erly in the course of cndid esophgitis, mucosl plques re the most frequent finding on brium studies; discrete ulcertions re found infrequently t this stge (Figures 2A nd B). Lter, erosions nd ulcertions my develop. It is combintion of erosions nd ulcertions together with intrmurl hemorrhge nd necrosis tht results in the shggy mrgin seen in esophgogrms (Figures nd 4). Figures 2A&B Erly disese Double contrst esophgogrms demonstrte n occsionl re of ulcertion with surrounding edem (rrows) in the distl third of the esophgus. This is n uncommon mnifesttion of cndid esophgitis. 2A 2B 292 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

5 Roberts et l. ndid esophgitis Figure Advnced disese A double contrst esophgogrm demonstrtes diffuse ulcertion, thickened folds nd mildly shggy borders in the distl esophgus. Figure 4 Shggy borders This is double contrst esophgogrm of womn who hd scleroderm nd cndid esophgitis. The esophgus is dilted nd hs shggy borders nd diffuse ulcertion. An re of nrrowing is present in the proximl third of the esophgus. Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 29

6 ndid esophgitis Roberts et l. U The lesion my involve the intrthorcic esophgus diffusely (Figure 5) or segmentlly (Figures 6A nd B), nd when segmentl, it shows.. predilection for the middle nd distl thirds of the esophgus (4). 5 6A 6B Figure 5 Diffuse cndid esophgitis Note the irregulr, nodulr mucosl pttern nd edemtous folds demonstrted in this single contrst brium esophgognm. Limited distensibility ws observed in the re of nrrowing in the middle third of the esophgus. Figures 6A&B Segmentl chnges Poor esophgel distensibility nd focl re of mucosl ulcertion nd edem re demonstrted in the distl third of the esophgus, in this single contrst brium esophgogrm. ndid esophgitis ws proved endoscopiclly in this ptient who ws receiving chemotherpy for mlignnt neoplsm. 294 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

7 Roberts et l. ndid esophgitis Though Andrew nd Thender initilly described cndid esophgitis s n extensive, inregulr invsion of the mucos (5), the disese my spred into the deeper lyers of the esophgus, producing chrcteristic chnges. The minor irregulrities of the esophgel mucos, which re seen in the erly stges of the disese, progress to the clssic cobblestone pttern, reflecting edem nd ssocited inflmmtory chnges (4) (Figure 7). Figure 7 obblestone pttern This double contrst esophgogrm demonstrtes the clssic mucosl cobblestone pttern observed in cndid esophgitis. Uncommon Rdiogrphic Appernces in ndid Esophgitis Less typicl rdiogrphic mnifesttions of cndid esophgitis my be seen (4,6-1). For exmple, discrete ulcers which re more frequently seen in rohn s disese or in virl, peptic or drug induced esophgitis, re occsionlly observed (6) (Figures 2A nd B; Figures 8-Il). Strictures, rel (Figures 12A-) or pprent (Figure 1), my be encountered, nd sometimes n brupt, symmetric esophgel defect tht resembles neoplsm my be seen (Figures 14A nd B) (6-8). Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 295

8 ndid esophgitis Roberts et l. U I Figure 8A Lrge, discrete ulcer This young womn ws on longterm steroid therpy when this pprently norml double contrst esophgogrm ws mde. Figure 8B Six months lter she ws seen with orl thrush nd cndid esophgitis. This double contrst esophgogrm shows segmentl mucosl irregulrity nd lrge, discrete ulcer. 296 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

9 Roberts et l. ndid esophgitis 9A Figures 9A&B Multiple mucosl ulcers Right (A) nd left (B) oblique double contrst esophgognms show few discrete mucosl ulcers (rrows) in this renl trnsplnt ptient who ws receiving immunosuppressive therpy. 9B Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 297

10 ndid esophgitis Roberts et l U I Figure 1 Punctte ulcertion This double contrst esophgogrm demonstrtes severe punctte ulcertion nd distl esophgel stricture cused by cndid esophgitis. Figure II Aphthoid ulcertion A single contrst esophgogrm demonstrtes smll phthoid ulcer in the distl esophgus (rrow) cused by cndid esophgitis. 298 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

11 Roberts et l. ndid esophgitis Figure 12A Stricture formtion This ptient hd cute myelogenous leukemi nd developed cndid esophgitis. This mitil esophgognm shows chrcteristic irregulrity of the esophgel wll nd thickening of the folds. Figure l2b The ptient ws treted with symptomtic relief, but 8 weeks lter gin developed dysphgi. The esophgogrm mde t tht time shows long esophgel stricture. Figure 12 This subsequent followup exmintion shows no chnge in the ppernce of the stricture. (Previously published in the BJR 1978; 51: nd reproduced here with permission.) Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 299

12 ndid esophgitis Roberts et l U EE U Figure 14B The gross pthologicl specimen neveled invsive cndidisis Figure 1 Apprent stricture Pin on swllowing prevented dequte distention of the esophgus, resulting in the ppennce of diffuse esophgel stricture. Diffuse edem ws not believed to be the cuse of this ppnent stricture. Figure 14A Asymmetric filling defect This is the single contrst esophgognm of ptient who hd leukemi nd complined of dysphgi nd odynophgi. It shows n brupt, symmetnc filling defect in the distl esophgus with thickened folds, ulcertion nd irregulr mucos, simulting mlignnt neoplsm. RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

13 Roberts et l. ndid esophgitis When, in n pproprite clinicl setting, isolted polypoid lesions (Figure I5A), or rrely, multiple nodules re observed on the bckground of n irregulr esophgel mucos, the In the ltter cse, it is usully necessry to excise lrge solitry polyp re observed (Figure I5B). dignosis of cndid esophgitis usully presents no problem. Occsionlly, however, few esophgel the polyp to exclude the possibility of n cncer. Figure ISA Polypoid defects This single contrst esophgogrm demonstrtes (multiple) polypoid defects in the distl esophgus tht represented focl res of cndid esophgitis nd necrotic debris. (Imge unshnpness is secondry to the ptient s dyspne.) Figure 15B Polypoid defects This double contrst esophgognm demonstrtes n inflmmtory polyp which ws due to ndid lbicns. Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 1

14 ndid esophgitis Roberts et l. Differentil Dignosis The rdiogrphic ppernce of cndid esophgitis, while suggestive, is not pthognomonic. A number of other entities must be considered in the differentil dignosis. They re listed in Tble I nd illustrted in Figures Figure 16 Reflux esophgitis This double contrst esophgognm demonstrtes n irregulr mucosl pttern in the distl esophgus in ptient with neflux esophgitis. Figure 17 Herpes esophgitis A double contrst esophgogrm demonstrtes discrete ulcer (rrow) in the mid esophgus. 2 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

15 Roberts et l. ndid esophgitis Figure 18 Acute custic ingestion A double contrst esophgogrm demonstrtes diffuse, prominent folds in the esophgus with occsionl nodulnity in ptient who hd ingested cid. Figure 19 Intrmurl pseudodiverticulosis This finding my result from ny severe esophgitis, but is most often ssocited with reflux on cndid esophgitis. Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics

16 ndid esophgitis Roberts et l. I Figure 2 Squmous ppillomtosis This double contrst esophgognm demonstrtes diffuse cobblestone pttern. (ourtesy of Hrvey M. Goldstein, M.D., Southwest Texs Methodist Hospitl, Sn Antonio, TX,) III uuiiiuu iiiuuui ll (UllU ny to incresed glycogen (11). (ountesy of Dune Mezw, M.D., Willim Beumont Hospitl, Royl Ok, MI.) Figure 22 Severe squmous metplsi Ares of discrete ulcertion nd fold thickening s well s nrrowing of the proximl esophgus re seen in this ptient who hd Brrett s esophgus with severe squmous metplsi. (ourtesy of Herbert Kressel, M.D., Hospitl of the University of Pennslvni, Phildelphi, PA.) 4 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

17 Roberts et l. ndid esophgitis S Figure 2 Brrett s esophgus The chnges of Brrett s mucos re illustrted in this double contrst esophgogrm. Figure 24 Superficil spreding crcinom A double contrst esophgogrm demonstrtes thickened folds nd nodulr defects in the esophgus in this ptient with proved crcinom. Figure 25 Epidermolysis bullosum Note the short stricture nd diffuse nrrowing of the esophgus shown in this esophgognm. Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 5

18 ndid esophgitis Roberts et l. ) A 26B Figures 26A&B Vrices The nodulr ppernce chrcteristic of vnices (A) often becomes more pprent with better distention of the esophgus (B). 6 RdioGrphics #{149}Mrch, 1987 #{149}Volume 7, Number 2

19 Roberts et l. ndid esophgitis. Summry With the incresing use of cncer chemotherpy nd orgn trnsplnttion requiring immunosuppressive therpy, nd with the mcidence of immunodeficiency sttes such s AIDS incresing, it is to be expected tht cndid esophgitis will occur with incresing frequency. Though fiberoptic endoscopy is more specific nd more sensitive pproch to the dignosis of cndid esophgitis thn brium esophgogrphy, it is lso more invsive, nd mny ptients will continue to be exmined rdiologiclly, t lest initilly. The rdiologist continues, therefore, to ply significnt role in suggesting the dignosis nd it is incumbent on him to fmilirize himself with the spectrum of common nd unusul rdiogrphic mnifesttions of this disese. References 1. Mthieson R, Dutt 5K. ndid esophgitis. Dig Dis Sci 198; 28(4): Gefter WB, Lufer I, Edell 5, Gohel VK. ndidisis in the obstructed esophgus. Rdiology 1981; 18: Levine MS. Mcones AJ Jr. Lufer I. ndid esophgitis: Accurcy of rdiogrphic dignosis. Rdiology 1985; 154: Lewicki AM, Moore JP. Esophgel monilisis: A review of common nd less frequent chrcteristics. AJR 1975; 125(1): , Andrew L, Thender G. Roentgenogrphic ppernces of esophgel monili. Act Rdiol 1956; 46(4): Orringer MB, Slon H. Monilil esophgitis: An incresingly frequent cuse of esophgel stenosis? Ann Thorc Surg 1978; 26(4): Gibson MJ, Hrris M. An unusul cse of monilil oesophgltls. Br J Rdlol 1967; 4: Kelvin FM, lrk WM, Thompson WM. Huch T. hronic oesophgel stricture due to monilisis. Br J Rdlol 1978; 51: Lufer I. Rdiology of esophgitis. Rdiol lin North Am 1982; 2(4):687-#{24} Ho S. ullen JB, Gry RR. An unusul mnifesttion of esophgel monilisis. Rdiology 1977; 12: Volume 7, Number 2 #{149}Mrch, 1987 #{149}RdioGrphics 7