Abstract
Introduction
Fungal esophagitis is the result of an opportunistic pathogen that causes esophageal inflammation. AIDS patients are highly susceptible to esophageal infections, especially fungal infections, because of reduced cellular immunity. In this article, we present a case in which CT (computed tomography) was used to diagnose fungal esophagitis with esophageal mediastinal fistula, with the aim of highlighting the importance of utilizing CT for the diagnosis of esophagitis.
Case Report
Clinical features
A 59-year-old man who had experienced difficulty eating for 1 month and had been experiencing fever with chest pain for 4 days was referred to our hospital.
The patient was having difficulty eating, especially dry food. Four days earlier he suddenly experienced chest pain, chest tightness, and fever peaking at 39°C. Before presenting to our hospital, local hospitals had treated him for coronary heart disease. Chest CT scans and enhancements showed a slight thickening of the walls in the middle and lower esophagus, with mediastinal pneumatosis under the carina, and esophageal mediastinum fistula. Mediastinal abscesses were also detected, and multiple pulmonary embolisms were found in the right lower pulmonary arteries (Fig. 1A–C). Upper gastrointestinal (GI) examination was negative. Gastroscopy shows that milky white patches were presented throughout the entire esophagus, and could not be flushed with water (Fig. 1D). An anti-HIV test was positive, and additional laboratory test results included erythrocvte sedimentation rate (ESR) 90 mm/h, C-reaction protein (CRP) 153.49 mg/L, routine blood WBC 7.8 × 109/L, neutrophils 83.40%, hemoglobin (HGB) 107 g/L, and
Results
The patient was given a relatively standard treatment regimen of cephalosporin as an antibacterial agent, heparin as an anticoagulant, and voriconazole as an antifungal agent. After 1 week, a review of the patient's gastroscopy was relatively normal.
Discussion
Fungal esophagitis is an inflammatory disease caused by esophageal fungal infections, with pathogenic yeast, particularly C. albicans, being the primary causative agents. And main manifestation is the formation of ulcerative pseudomembranes in esophageal mucosa. The most common examination approach is GI examination, whereas gastroscopy and the etiological examination of oral pharyngeal swabs were used to confirm the diagnosis of fungal esophagitis.
In the present case, CT features were characterized by a thickening of the esophagus wall, as well as mediastinal air accumulation and blurring in the mediastinal adipose space that were diagnosed as an esophageal mediastinal fistula, uniform medial enhancement of the mediastinal mediastinal lymph nodes, and a partial “separation-like” or “Garland-like” strengthening mass that was diagnosed as an abscess; multiple embolisms were present in the right lower pulmonary artery branch. To date, only two cases reported in the literature 1,2 have employed CT examinations as a diagnostic approach for such infections, and in both instances, patients were initially misdiagnosed as having esophageal cancer. There was no report of esophageal perforation in the literature. We believe that there may be two reasons for this outcome. First, these previous cases lacked severe complications, such as the presence of an esophageal mediastinal fistula. Second, only GI and gastroscopy were initially performed in the clinic, without CT scans, resulting in an incorrect diagnosis.
There are differences between the presentations of esophageal cancer, reflux esophagitis, eosinophilic esophagitis (EoE), cytomegalovirus esophagitis, and esophagus wall thickening in patients with cirrhosis. Esophageal cancer often manifests as esophageal wall thickening in the middle and lower segments, and luminal narrowing over a relatively wide range, but generally does not coincide with the presence of esophageal fistulae, which can arise at sites of the postoperative anastomosis area or after radiotherapy. Gastroscopy of reflux esophagitis typically reveals severe erosive damage to the mucous membranes and redness in the esophagus. GI examinations show longitudinal mucosal thickening and serrated protuberances, often associated with esophageal hiatal hernias and with rare instances of perforation. Although the clinical and gastroscopic features of EoE are similar to those of fungal esophagitis, its conical narrowing of esophagus over a wide range is apparent on barium swallow angiography, 3 with distinct CT features, including circular thickening wall, potential perforation, and dissection in individual case reports, which is correlated with allergy. Cytomegalovirus esophagitis is the common complication of AIDS. Its typical features under GI examinations include esophageal spasm, marked irregular thickening of mucous folds, and the presence of small or large superficial ulcers. Esophagus wall thickening with a multisegmental distribution was concentric and homogeneous in all patients with cirrhosis. 4
Conclusions
Fungal esophagitis is a relatively common clinical diagnosis. In addition to conventional X-ray and gastroscopy examinations, which are used for the diagnosis of fungal esophagitis, CT scan is also recommended, if necessary. Contrast-enhanced CT can be used to rule out other complications. A reasonable diagnosis can be made based on the imaging characteristics and the clinical history of the patient, therefore, CT is of certain value in improving clinical awareness and differential diagnosis.
Footnotes
Acknowledgment
The authors are grateful to Word Designs for language editing.
Author Disclosure Statement
No competing financial interests exist.