Cotton wool-like plaques due to Candida in ulcerative colitis

A 62-year-old man with a long history of ulcerative colitis and who was taking 2250 mg of mesalazine and 50 mg of azathioprine daily, developed intermittent abdominal pain and prolonged diarrhea. He was referred to our hospital with a suspicion of exacerbated ulcerative colitis. A physical examination revealed a man in acute distress with mild tenderness to palpation in the mid abdomen. Oral prednisolone was prescribed at a dose that was to be gradually decreased from 80 mg. After 5 weeks, when the dose of prednisolone had decreased to 30 mg, he developed high fever and abdominal colic pain. In his stool examination, Pseudomonas aeruginosa, Clostridium difficile, and some Candida species were present. Serum cytomegalovirus (CMV) antigen was also positive. Colonoscopy revealed multiple ulcers, marked granular change, and edema throughout the colon. White plaques as well as cotton wool-like plaques on a background of inflamed mucosa were seen in the transverse colon ([Fig. 1 a]). The lesions seemed to be an aggregation of filaments when magnified ([Fig. 1 b]). Samples were collected which led to the diagnosis of candidiasis ([Fig. 2]). Intravenous antifungal medication was administered, and the whitish plaques and inflammation disappeared within 2 months.

Fig. 1 A 62-year-old man with a long history of ulcerative colitis developed intermittent abdominal pain and prolonged diarrhea. After 5 weeks of treatment with prednisolone, he developed high fever and abdominal colic pain. a Colonoscopic imaging in the transverse colon revealed cotton wool-like plaques on a background of inflamed mucosa. b The lesions seemed to be an aggregation of filaments when magnified (under narrow-band imaging).

Fig. 2 On microscopic imaging, numerous Candida fungi were seen in the sample.

Acute infectious colitis mimics ulcerative colitis with the presence of diffuse lesions or focal colitis, thus necessitating differential diagnosis [1]. In ulcerative colitis, C. difficile and CMV infections are common while other infections such as Salmonella, Campylobacter, and Listeria monocytogenes have also have been reported [2] [3]. There are some reports describing candidiasis of the digestive tract in immunocompromised hosts [4], however, candidiasis in patients with ulcerative colitis has rarely been reported [5]. Patients with ulcerative colitis undergoing treatment with steroids or immunosuppressive agents, and who develop prolonged diarrhea or high fever, should undergo colonoscopy to evaluate whether this is due to a relapse of ulcerative colitis or to infection.

Endoscopy_UCTN_Code_CCL_1AD_2AZ

• References

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• 4 Kumamoto CA. Inflammation and gastrointestinal Candida colonization. Curr Opin Microbiol 2011; 14: 386-391
• 5 Kudo T, Aoyagi Y, Fujii T et al. Development of Candida albicans colitis in a child undergoing steroid therapy for ulcerative colitis. J Pediatr Gastroenterol Nutr 2010; 51: 96-99