Esophageal candidiasis successfully treated with replacement of inhaled corticosteroid

Background: Over the last few decades, inhaled corticosteroids (ICS) became the cornerstone in the treatment of persistent asthma. Esophageal candidiasis is a rare complication resulting from ICS administration, but it is probably underdiagnosed. We have recently described a prevalence of 5.7% in severe asthma patients. It was also shown that the device and type of ICS used can influence the occurrence of this complication.

Methods: We describe two patients who recovered from esophageal candidiasis after replacing budesonide dry powder with ciclesonide pressurized metered-dose inhaler (HFA).

Results: We report two cases of female patients aged 65 and 46 years with difficult-to-control asthma who had to use budesonide aeroliser 2000mcg/day associated with formoterol 60mcg/day to maintain asthma partially controlled. The patients complained of abdominal pain and heartburn and therefore underwent EGD, which revealed esophageal candidiasis. The diagnosis was confirmed by esophagus biopsy. They were both treated with fluconazole, with no improvement of the symptoms and the endoscopic lesions. We repeated the antifungal treatment once more, but it was again ineffective. Budesonide was then replaced with ciclesonide 1280mcg/day. The asthma continued stable and the infection was healed, without antifungal administration.

Conclusion: Ciclesonide is delivered as an inactive prodrug, which is cleaved to the active molecule by intracellular esterases located in the lungs. This and other pharmacodynamic and pharmacokinetic properties may limit the amount of active molecule outside the lung and may reduce the incidence of side effects. This could explain why our patients recovered from esophageal candidiases. We showed that replacement of budesonide aeroliser with ciclesonide aerosol without antifungal treatment can be enough to eliminate Candida infection.