challenges to classic esophageal candidiasis looks are usually deceiving objectives we undertook the first case control study of histologically confirmed esophageal candidiasis ecmethods a computer search from july 2012 through february 2015 identified 1011 esophageal specimens including 40 cases of ec and 20 controlsresults the ec incidence was 52 it was associated with immunosuppression and endoscopic white plaques and breaks smoking was a predisposing factor and alcohol was protective ec had no unique symptoms and 54 of endoscopic reports did not suspect ec important histologic clues included superficial and detached fragments of desquamated and hyperpink parakeratosis acute inflammation intraepithelial lymphocytosis dead keratinocytes and bacterial overgrowth thirty percent had no neutrophilic infiltrate pseudohyphae were seen on he in 925 n3740 upfront periodic acidschiff with diastase pasd on all esophageal specimens would have generated 6833349 in patient charges our targeted pasd strategy resulted in 1304487 in patient charges cost saving809 5528862conclusions we describe the typical morphology of ec and recommend limiting pasd to cases where the organisms are not readily identifiable on he and with at least one of the following 1 ulcer 2 suspicious morphology andor 3 clinical impression of ec