Liver cirrhosis as a predisposing factor for esophageal candidiasis

Abstract

Summary Background Esophageal candidiasis (EC) often occurs in human immunodeficiency virus (HIV)‐infected patients, but is uncommon in non‐HIV‐infected patients. It is known that malignancy, diabetes mellitus, previous gastric surgery, and medications (antibiotics, proton pump inhibitors, and steroids) are risk factors for esophageal candidiasis in non‐HIV‐infected patients. However, the relationship between liver cirrhosis and esophageal candidiasis was unclear. This study aimed to elucidate the role of liver cirrhosis in esophageal candidiasis. Methods A retrospective chart review study was conducted on non‐HIV‐infected patients with esophageal candidiasis who presented to Tri‐Service General Hospital from January 2009 to December 2012. The diagnosis of EC was primarily based on endoscopic findings. The incidence of EC in cirrhotic and noncirrhotic patients was compared. Furthermore, differences in baseline characteristics, clinical variables, and mortality after antifungal treatment between the two groups were analyzed. Results In this study, 43,217 non‐HIV‐infected patients were enrolled, 3017 of whom had liver cirrhosis. The incidence of EC in cirrhotic patients was higher than that in noncirrhotic patients (0.8% vs. 0.36%; relative risk = 2.2; p < 0.001). Multivariate logistic regression analysis identified liver cirrhosis as an independent risk factor for EC (odds ratio, 1.74; 95% confidence interval, 1.06–2.87; p = 0.029). Moreover, cirrhotic patients tended to be asymptomatic compared with noncirrhotic patients (45.8% vs. 9%; p < 0.01). The most common coexisting endoscopic finding was reflux esophagitis (83.9%). However, antifungal treatment did not decrease the mortality of patients with EC during hospitalization. Conclusion Liver cirrhosis is an independent risk factor for EC. EC may be asymptomatic in cirrhotic patients. Although antifungal treatment did not improve the outcome in this study, a prospective study is still required to investigate this issue.

Liver cirrhosis as a predisposing risk factor for esophageal candidiasis: Bystander or culprit?

“…Early prevention of these second infections is suggested. However, whether esophageal candidiasis affected the outcomes of patients with liver cirrhosis was not reported by Ou et al [1]. Instead, they found no difference in the mortality during hospitalization between patients with and without antifungal treatment, and also found that antifungal treatment did not decrease the mortality in cirrhotic patients with esophageal candidiasis.…”

“…Candida esophagitis is the most common infectious disease of the esophagus and the most common gastrointestinal opportunistic disorder among individuals infected with human immunodeficiency virus (HIV). Ou et al [1] conducted a study using a retrospective chart review of non‐HIV‐infected patients with esophageal candidiasis and particularly aimed to elucidate the role of liver cirrhosis in esophageal candidiasis. I have long thought that retrospective chart reviews are usually poorly done and are subject to all sorts of biases and confounding issues.…”

“…I have long thought that retrospective chart reviews are usually poorly done and are subject to all sorts of biases and confounding issues. The editorial allowed me to review the article presented by Ou et al [1] and feel that it shared many of these problems. Actually, most of the clinical relevant data of esophageal candidiasis were gathered from HIV‐infected patients.…”

“…In the current study [1], the diagnosis of esophageal candidiasis was primarily based on endoscopic findings. Overall, 3017 of 43,217 non‐HIV‐infected patients had liver cirrhosis.…”

“…The prevalence of esophageal candidiasis in non‐HIV‐infected patients is approximately 0.3% [5]. Although it is not a major issue, for the first time, Ou et al [1] reported that the incidence rate of esophageal candidiasis in cirrhotic patients was 0.8%, which was likely overestimated because not all patients with liver cirrhosis were systemically evaluated by endoscopic examination and not all of the diagnoses were confirmed by histopathology.…”