# Persistent Esophageal Parakeratosis With Recurrent Candida Esophagitis in a Virally Suppressed Person With HIV

## TL;DR

A person with HIV experienced persistent esophageal changes resembling cancer, but tests showed no malignancy, highlighting the need for careful diagnosis and tailored management.

## Contribution

This case highlights the rare presentation of esophageal parakeratosis in a virally suppressed HIV patient and emphasizes diagnostic and management considerations.

## Key findings

- Serial biopsies showed parakeratosis without malignancy despite alarming endoscopic appearance.
- Symptoms improved partially with acid suppression, antifungal treatment, and micronutrient supplementation.
- Esophageal manometry was considered to evaluate motility due to ongoing dysphagia.

## Abstract

Esophageal parakeratosis is an uncommon histopathologic finding that can closely mimic malignancy endoscopically and has been linked to micronutrient deficiency states and chronic reflux. We report a 57-year-old man with well-controlled HIV (stable viral suppression and robust CD4 count) who developed progressive dysphagia with malignant-appearing esophageal plaques over a long segment of the mid-to-distal esophagus. Serial biopsies repeatedly showed parakeratosis/hyperkeratosis without dysplasia or malignancy, with intermittent Candida on histology. Despite the alarming appearance, cross-sectional imaging revealed no mass or nodal disease. Management included high-dose acid suppression, short courses of fluconazole for Candida esophagitis, and empiric zinc and riboflavin supplementation; the endoscopic extent of keratinization reduced but persisted, and dysphagia fluctuated without a fixed stricture. Given ongoing symptoms and easy passage of the scope, esophageal manometry was arranged to evaluate a motility contribution, and surveillance endoscopy was planned. This case emphasizes the importance of repeat histology before committing to oncologic pathways, consideration of micronutrient supplementation, cautious use of long-term proton-pump inhibition in patients at risk for Candida, and individualized surveillance where formal guidance is lacking.