S3154 A Case of Proton-Pump Inhibitor-Refractory Candida-Associated Peptic Ulcer Disease Successfully Treated With Anti-Fungal Medication

Introduction: Candida infection of gastrointestinal tract commonly involves the esophagus. There is only few cases of Candida-associated peptic ulcer disease (PUD) reported. Currently recommended treatment for this condition is proton-pump inhibitor (PPI). We present a rare case of PPI-refractory Candida-associated PUD successfully treated with antifungal medications. Case Description/Methods: A 78-year-old woman with a past medical history of adrenal insufficiency on chronic steroid use and a history of transverse colon adenocarcinoma status post right hemicolectomy. Her medications included hydrocortisone, fludrocortisone and pantoprazole. She presented to the hospital with chief complain of abdominal pain. The pain was located in the upper abdomen, non-radiating, constant and worse with food intake. She also reported of multiple episodes of diarrhea associated with black tarry stools. Initial blood-work revealed WBC 10.2 th/uL, Hb 4 gm/dL, hematocrit 14.9%, platelet 472 th/uL, PT 12 sec, INR 1.02, PTT 27.5 sec, Cr 0.5 mg/dL, BUN 8mg/dL, lipase 11 IU/L. The patient received 3 units of packed RBC and was started on Protonix drip. Subsequent EGD revealed gastritis and multiple non-bleeding clean based duodenal ulcers. Biopsy of antral lesions showed detached fragments of fungal organisms, morphologically consistent with Candida species. Both gastric and duodenal ulcers biopsies were negative for Helicobacter. Of note, EGD from 2 months prior also showed multiple non-bleeding clean based duodenal ulcers, for which reason pantoprazole was started. Due to her persistent abdominal pain and EGD finding, the patient was initiated on oral fluconazole for 2 weeks. Her symptoms started to improve and subsequently resolved. Repeated EGD in 4 month showed complete resolution of both gastritis and duodenal ulcers. Discussion: Candida-associated PUD are rare and usually occur in patients with immunocompromised state. Since these diseases are uncommon, there is no established guideline for management. Recent literatures have shown favor in using of PPI without antifungal medication for treatment of Candida-associated PUD. However, there is very limit data on these studies and few cases of PPI failure have been reported. We present a case of EGD and biopsy-proven resolution of PUD secondary to Candida infection after starting fluconazole. Therefore, we suggest that early initiation of antifungal medication after failing initial PPI therapy might improve the outcome and decrease complications from Candida-associated PUD.