Inhaled Steroids for Misdiagnosed Asthma Increase the ‎Frequency of Esophageal Moniliasis in Patients with ‎Achalasia

INTRODUCTION

Candida Albicans (esophageal moniliasis) is the most common cause of infectious ‎esophagitis so far. However, this kind of infectious esophagitis is linked to ‎immunocompromized conditions e.g. uncontrolled diabetes, HIV infection, ‎patients with advanced malignancy, and with prolonged heavy steroids use. ‎Furthermore, infrequently patients with achalasia and other obstructive lesions of ‎the esophagus with prolonged food stasis have been diagnosed with this infection ‎‎[1,2]. The case presented her is educational from different points. First, the ‎clinical inertia. This patient had years of complaints and per the current practice ‎guidelines [3] he should have been investigated by either imaging studies or ‎endoscopy years back for both the persistent pain and the progressive dysphagia ‎particularly with failure of empirical PPI therapy and persistence of complains. ‎Second, the misdiagnosis of asthma. In patients with achalasia, like our patient, ‎with stagnation of the food residues, recurrent aspirations with cough and ‎sometimes wheezes are occasionally misdiagnosed as asthma. This further ‎complicated the case because the inhaled steroids [4], as those given to our case, ‎are well known risk factors for the local fungal infection and this explains the ‎extensive affection seen in this patient. The extensive candidiasis shown in Figure ‎‎1 B should draw attention of clinicians to the odynophagic effect of this infection ‎among this category of patients

Case Presentation

A 55-year old male patient with hypertension on amlodipine had 4-5 years ‎history of central chest discomfort, dysphagia, with cough and was misdiagnosed ‎as GERD and asthma and given multiple courses of proton pump inhibitors ‎‎(PPIs) and due to cough was diagnosed as asthma and kept on inhaled steroid ‎‎(budesonide) in combination with a long-acting bronchodilator (formoterol ‎fumarate dihydrate). The patient when evaluated in our clinic 2-months ago did ‎not fulfill the diagnostic criteria of GERD and with the presence of the alaram ‎manifestation  dysphagia  a ‎decision for upper endoscopy was taken and it revealed ‎markedly dilated esophagus, tight lower esophageal sphincter and diffuse ‎esophageal moniliasis (Figure 1 A) that was confirmed in the films done for the ‎brushes and on histopathology specimens taken to rule out pseudoachalasia. The ‎patient was then examined by barium swallow that showed dilated esophagus ‎with smooth tapering lower end (Figure 1 B). The patient was treated for ‎esophageal moniliasis with oral antifungals for 2 weeks, followed by pneumatic ‎dilation by 30 mm balloon, and the inhaled steroids were discontinued‎.