Translate this page into:
Candida Esophagitis Incidentally Detected by 18F-FDG PET/CT in Metastatic Lung Adenocarcinoma
Address for correspondence: Néstor Martínez-Amador, Department of Nuclear Medicine. Marqués de Valdecilla University Hospital. Molecular Imaging Group (IDIVAL). University of Cantabria. Santander. SPAIN. E-mail: nemartinez@humv.es
This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher.
Abstract
The diagnostic significance of esophageal 18F-FDG uptake in oncologic patient is challenging. It may represent normal physiological uptake, inflammation, infection, or neoplasia. We present a patient with a recent diagnosis of non-small cell lung cancer stage IV and esophageal mild uptake on 18F-FDG PET/CT scan. Biopsy of esophageal mucosa demonstrated Candida esophagitis.
Keywords
18F-FDG PET/CT
Candida albicans
esophagitis
infection
lung cancer
A 57-year-old man, heavy smoker (two packs per day for more than 40 years), complained of acute disorientation and unsteady gait. Brain contrast-enhanced computed tomography (CT) and gadolinium-enhanced magnetic resonance imaging (MRI) showed multiple metastases in brain parenchyma, mesencephalus, and cerebellum. Chest X-ray and whole-body CT revealed ill-defined nodule of 1 cm in size located in left lung upper lobe and enlarged left axillary lymph node (1.3 cm in diameter). Histological analysis of the lymph node was reported as metastatic adenocarcinoma. Samples were negative for ALK and EGFR mutations. An 18F-FDG (FDG) positron emission tomography /computed tomography (PET/CT) scan was requested for staging. FDG PET/CT showed increased metabolism in the lung nodule (SUVmax 2.05) and left axilla lymphadenopathy (SUVmax 4.39). Moreover, PET/CT showed diffuse FDG uptake along the proximal and middle third of the esophagus (SUVmax 3.58) [Figure 1]. The patient had no clinical or biochemical signs of immunodeficiency.
Upper gastrointestinal endoscopy revealed multiple raised white plaques throughout all the esophagus [Figure 2]. Biopsy confirmed Candida albicans esophagitis and therapy with oral Fluconazole (200 mg/day for 14 days) was established. Endoscopy was not repeated at the end of fungal treatment.
Based on the radiological and FDG PET/CT findings, cranial radiotherapy, and chemotherapy was started. Three months later, a new FDG PET/CT performed for treatment monitoring showed a decrease of FDG uptake in the lung nodule (SUVmax 1.80) and left axillary lymphadenopathy (SUVmax 3.24). In addition, a decrease both in the extent and intensity of FDG uptake in the esophagus (SUVmax 1.89) was observed [Figure 3].
Esophageal FDG uptake is likely multifactorial, including malignant and non-malignant conditions. Thus, incidental detection of esophageal uptake has been associated with swallowed saliva, active smooth muscle, metabolic active mucosa, lymphatic tissue uptake, Barrett's esophagus and inflammatory or infectious esophagitis.[1234567] Esophagitis may be caused by fungal (Candida albicans), bacterial (Helicobacter pylori, Mycobacterium tuberculosis), and viral (herpes simplex, citomegalovirus, HIV) infections. Candida albicans infection is often observed in immunocompromised patients.[28] Patients with solid tumor are susceptible to fungal infections, being Candida the most common pathogen isolated in the gastrointestinal tract. In this context, unexpected visualization of esophageal FDG uptake must be investigated by endoscopy. Biopsy should be considered based on endoscopic findings.
Financial support and sponsorship
Nil.
Conflict of interest
There are no conflicts of interest.
References
- Visual PET/CT scoring for nonspecific 18F-FDG uptake in the differentiation of early malignant and benign esophageal lesions. Am J Roentgenol. 2008;19:515-21.
- [Google Scholar]
- Intense esophageal FDG activity caused by Candida infection obscured the concurrent primary esophageal cancer on PET imaging. Clin Nucl Med. 2005;30:314-9.
- [Google Scholar]
- Significance of incidental 18F-FDG accumulations in the gastrointestinal tract in PET/CT: Correlation with endoscopic and histopathologic results. J Nucl Med. 2004;45:1804-10.
- [Google Scholar]
- Importance of diffuse versus focal F-18 fluoro-deoxy-glucose uptake in oesophagus. Indian J Nucl Med. 2011;26:211.
- [Google Scholar]
- Candida esophagitis mimicking esophageal malignancy on 18FDG PET/CT. Turk J Gastroenterol. 2015;26:63-4.
- [Google Scholar]
- PET/CT detection of unexpected gastrointestinal foci of 18F-FDG uptake: incidence, localization patterns, and clinical significance. J Nucl Med. 2005;46:758-62.
- [Google Scholar]
- Diagnostic contribution of positron emission tomography with 18F fluorodeoxyglucose for invasive fungal infections. Clin Microbiol Infect. 2011;17:409-17.
- [Google Scholar]