Management of Non-Candida White Esophageal Plaques

Diagnostic Approach

Histopathologic confirmation is essential to definitively exclude Candida, as diagnosis requires demonstration of characteristic yeast forms in tissue with culture confirmation, according to the Centers for Disease Control and Prevention 1, 2, 3.
Endoscopic appearance alone cannot accurately predict non-Candida etiologies; specimen acquisition for laboratory study is mandatory, as recommended by the American College of Radiology 4.
Obtain multiple biopsies from at least 2 levels, as inflammatory conditions can be patchily distributed, according to the American Gastroenterological Association 5.

Herpes simplex virus (HSV) and cytomegalovirus (CMV) are common infectious causes in both immunocompromised and immunocompetent patients, as reported by the American College of Gastroenterology 4, 5.
Eosinophilic Esophagitis (EoE) presents with white exudates along with edema, rings, furrows, and strictures on endoscopy, and requires ≥15 eosinophils per high-power field on biopsy in the absence of other causes, according to the American Gastroenterological Association 5.
Lymphocytic Esophagitis is characterized by dense peripapillary lymphocytic infiltrate and spongiosis without significant eosinophils or neutrophils, and may present with white plaques, as reported by the American College of Gastroenterology 5.

Perform endoscopy with multiple biopsies (minimum 2 levels) for histopathology, as recommended by the American College of Gastroenterology 4, 5.
If HSV Esophagitis is confirmed, initiate antiviral therapy (acyclovir or valacyclovir), as recommended by the Infectious Diseases Society of America 4.
If EoE is confirmed, implement dietary elimination therapy, high-dose proton pump inhibitors, or topical corticosteroids, as recommended by the American Gastroenterological Association 5.

Immunocompromised patients have a broader differential that includes opportunistic infections beyond Candida, and require a lower threshold for endoscopy with extensive biopsy sampling, as recommended by the Centers for Disease Control and Prevention 4, 6.
Persistent symptoms despite treatment may require re-evaluation of diagnosis with repeat endoscopy and biopsies, and assessment for treatment resistance, non-compliance, or alternative diagnoses, as reported by the American College of Gastroenterology 5.