Challenges to "Classic" Esophageal Candidiasis: Looks Are Usually Deceiving.
We undertook the first case control study of histologically confirmed esophageal candidiasis (EC).



A computer search from July 2012 through February 2015 identified 1,011 esophageal specimens, including 40 cases of EC and 20 controls.



The EC incidence was 5.2%; it was associated with immunosuppression and endoscopic white plaques and breaks. Smoking was a predisposing factor, and alcohol was protective. EC had no unique symptoms, and 54% of endoscopic reports did not suspect EC. Important histologic clues included superficial and detached fragments of desquamated and hyper-pink parakeratosis, acute inflammation, intraepithelial lymphocytosis, dead keratinocytes, and bacterial overgrowth. Thirty percent had no neutrophilic infiltrate. Pseudohyphae were seen on H&E in 92.5% (n = 37/40). "Upfront" periodic acid-Schiff with diastase (PAS/D) on all esophageal specimens would have generated $68,333.49 in patient charges. Our targeted PAS/D strategy resulted in $13,044.87 in patient charges (cost saving = 80.9%, $55,288.62).



We describe the typical morphology of EC and recommend limiting PAS/D to cases where the organisms are not readily identifiable on H&E and with at least one of the following: (1) ulcer, (2) suspicious morphology, and/or (3) clinical impression of EC.
Department of Pathology, The Ohio State University Wexner Medical Center, Columbus.
Mohammed I
MI
Alsomali
Department of Pathology, The Ohio State University Wexner Medical Center, Columbus.|Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH.
Michael A
MA
Arnold
Department of Pathology, The Ohio State University Wexner Medical Center, Columbus.
Wendy L
WL
Frankel
Division of Anatomic Pathology, Mayo Clinic, Rochester, MN.
Rondell P
RP
Graham
Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus.
Phil A
PA
Hart
Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ.
Dora M
DM
Lam-Himlin
Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA.
Bita V
BV
Naini
Department of Pathology, Johns Hopkins Hospital, Baltimore, MD.
Lysandra
L
Voltaggio
Department of Pathology, The Ohio State University Wexner Medical Center, Columbus.
Christina A
CA
Arnold
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002177:Candidiasis / Q000175:diagnosis* / Q000453:epidemiology / Q000473:pathology*; D016022:Case-Control Studies; D004941:Esophagitis / Q000453:epidemiology / Q000382:microbiology / Q000473:pathology*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D013194:Staining and Labeling / Q000191:economics / Q000379:methods; D055815:Young Adult
Desquamated; Esophageal candidiasis (EC); Hyper-pink; Parakeratosis; Periodic acid–Schiff with diastase (PAS/D); Pseudohyphae