|Year : 2015 | Volume
| Issue : 3 | Page : 279-281
Gastric candidiasis with gastric adenocarcinoma intestinal type: A rare association
Kalaivani Selvi Subramanian, Sandhya Panjeta Gulia, M Lavanya, SP Arun Kumar
Department of Pathology, Sri Venkateswaraa Medical College and Research Centre, Puducherry, India
|Date of Web Publication||12-Jun-2015|
Dr. Kalaivani Selvi Subramanian
No. 2, I Cross, Rathna Nagar, Puducherry - 605 009
Source of Support: None, Conflict of Interest: None
Candidiasis of the gastrointestinal tract most commonly involves the esophagus and rarely involves the stomach and small bowel. The association of gastric carcinoma with candidiasis is even rare and only a very few case reports are available. We present here a 40-year-old female who presented with complaints of gastric outlet obstruction who on endoscopy showed a malignant ulcer involving the lesser curvature. The histopathological examination of biopsy from the ulcer showed adenocarcinoma intestinal type along with yeast and pseudohyphae forms of candida species.
Keywords: Gastric adenocarcinoma, gastric candidiasis, malignant ulcer
|How to cite this article:|
Subramanian KS, Gulia SP, Lavanya M, Arun Kumar S P. Gastric candidiasis with gastric adenocarcinoma intestinal type: A rare association. CHRISMED J Health Res 2015;2:279-81
|How to cite this URL:|
Subramanian KS, Gulia SP, Lavanya M, Arun Kumar S P. Gastric candidiasis with gastric adenocarcinoma intestinal type: A rare association. CHRISMED J Health Res [serial online] 2015 [cited 2020 Oct 23];2:279-81. Available from: https://www.cjhr.org/text.asp?2015/2/3/279/158716
| Introduction|| |
Candidiasis of gastrointestinal (GI) tract is commonly seen in immunocompromised patients. Esophagus is the most common site and it rarely involves the stomach and small intestine. ,, Candida infection in the stomach can be seen in patients with altered mucosal integrity like gastric ulcer, ingestion of corrosive chemicals, post-surgery, and any underlying malignancy. ,,, Again gastric candidiasis is most commonly observed in association with benign gastric ulcer, its association with adenocarcinoma is very rare and only a very few case reports are available. ,,,, We present here a 40-year-old immunocompetent patient who had coexisting gastric candidiasis and gastric adenocarcinoma.
| Case Report|| |
A 40-year-old female who is immunocompetent presented with complaints of fever, nausea, vomiting, early satiety, and epigastric fullness. She had no history of diabetes. Upper GI endoscopy showed a malignant ulcer in the lesser curvature measuring 6 cm × 4 cm with everted edges and covered by whitish slough. Biopsy was taken from the ulcer which showed ulceration of the mucosa with infiltration of the underlying tissue by atypical glands which are closely packed with features of adenocarcinoma intestinal type [Figure 1]a and b. There was also a fragment of ulcer slough, which showed infiltration by many yeast and pseudohyphae forms of Candida species which was also seen infiltrating the underlying tumor superficially [Figure 1]c. PAS stain was performed, which highlighted the organisms [Figure 1]d. Giemsa stain for Helicobacter pylori was negative. The patient was started on antifungal treatment and was planned for gastrectomy.
|Figure 1: (a and b) Gastric adenocarcinoma-intestinal type (hematoxylin and eosin [H and E], ×40, ×400). (c). Yeast and pseudohyphae forms of Candida species infiltrating the ulcer slough (H and E, ×100). (d) Periodic acid-Schiff (PAS) stain highlighting the fungus which is also seen invading the tumor superficially (PAS, ×100)|
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| Discussion|| |
The incidence of gastric candidiasis has been studied by few authors and found it to be low. Knoke and Bernhardt  found gastric Candida in only 6 out of 2537 outpatients; each of those patients had a previous gastric or esophageal resection. In a study by Minoli et al.  Candida was isolated as a stomach opportunistic germ in 23 patients (15.4%) among 149 patients who consecutively undergone gastroscopy. Oehlert and Preuss  demonstrated 121 cases of candidiasis in gastric mucosal biopsies in 20,401 patients. The incidence of candidiasis by Katzenstein and Maksem  in resected ulcers is 18%. Scott and Jenkins  found 19 cases of gastro-esophageal candidiasis giving an overall incidence of 4%, of which 20% of patients were with gastric cancer, 16% of patients were with benign gastric ulcers.
Candida species is a common commensal of GI tract and its mere presence does not imply a pathogenic role. The criteria for the diagnosis of candidiasis are finding of infiltration by yeasts and hyphae of tissue or ulcer slough in histological sections of biopsies. Surface fungi should be ignored; and this criteria was also used by Scott and Jenkins in his study for diagnosis of gastroesophageal candidiasis.  This case also showed infiltration of the ulcer slough by yeast and pseudohyphae forms of Candida species which was also seen infiltrating the underlying tissue superficially at places.
In a study by Loffeld et al.,  he showed fungal colonization in 19% of gastric ulcers. However, none of them had tissue invasion. The author concluded that the fungus in gastric ulcer is probably a secondary phenomenon; gastric ulcer may be colonized with fungus, but invasion is rare.
There are conflicting results regarding association of candidiasis with gastric ulcer. Oehlert and Preuss  found in majority of those patients with ulcer who also had candidiasis there was at the same time atrophic or dysplastic gastric mucosa at the edge of the ulcer. He also commented that candidiasis in biopsy material from gastric ulcer should thus be interpreted as suspicious of carcinoma, until and unless further studies confirm or exclude it. Whereas in a study by Scott and Jenkins  candidiasis was present in 27% of patients with esophageal cancer, 20% of patients with gastric cancer, 16% of patients with benign gastric ulcers, and 15% of patients with esophagitis. Hence, he suggested that the presence of candidiasis in a gastric ulcer should not raise the suspicion of malignancy and the presence of associated local pathology in nearly all patients in his study suggested that the candidiasis is secondary to mucosal damage.
Most of the cases of gastric candidiasis reported so far are associated with benign ulcers and other benign local pathologies. Association of gastric candidiasis with gastric malignancy is very rare with very few case reports available in literature. Chyung et al.  reported a case of Candida infection with gastric carcinoma in a 72-year-old female with diabetic mellitus. Scott and Jenkins  reported two cases of gastric adenocarcinoma presented with gastric candidiasis. And this is a case of immunocompetent patient with gastric adenocarcinoma intestinal type presenting with gastric candidiasis.
| Conclusion|| |
The association of gastric candidiasis with gastric adenocarcinoma in an immunocompetent patient presenting with gastric ulcer is very rare. Tissue or necrotic slough infiltration should be considered as presence of candidiasis and should be treated with antifungal medication.
| References|| |
Badarinarayanan G, Gowrisankar R, Muthulakshmi K. Esophageal candidiasis in non-immune suppressed patients in a semi-urban town, southern India. Mycopathologia 2000;149:1-4.
Kodsi BE, Wickremesinghe C, Kozinn PJ, Iswara K, Goldberg PK. Candida esophagitis
: A prospective study of 27 cases. Gastroenterology 1976;71:715-9.
Knoke M, Bernhardt H. Endoscopic aspects of mycosis in the upper digestive tract. Endoscopy 1980;12:295-8.
Katzenstein AL, Maksem J. Candidal infection of gastric ulcers. Histology, incidence, and clinical significance. Am J Clin Pathol 1979;71:137-41.
Loffeld RJ, Loffeld BC, Arends JW, Flendrig JA, van Spreeuwel JP. Fungal colonization of gastric ulcers. Am J Gastroenterol 1988;83:730-3.
Scott BB, Jenkins D. Gastro-oesophageal candidiasis. Gut 1982;23:137-9.
Chyung JW, Yoo CY, Cheung DY, Hur H, Jeon HM. Candida infection in a patient with gastric carcinoma; 1 case report. J Korean Gastric Cancer Assoc 2009;9:31-5.
Minoli G, Terruzzi V, Butti GC, Benvenuti C, Rossini T, Rossini A. A prospective study on Candida
as a gastric opportunistic germ. Digestion 1982;25:230-5.
Oehlert W, Preuss B. Incidence and significance of candidiasis in biopsy material of gastric ulcers. Dtsch Med Wochenschr 1980;105:1773-6.