Unusual Case of Ludwig Angina Caused by Clostridium sporogenes in an Immunocompromised HIV-Positive Patient with Alcoholism and Dental Abscess.

BACKGROUND Ludwig angina is a cellulitis of the soft tissues of the neck and floor of the mouth. It is most commonly caused by Viridans streptococcal species, but other bacterial species have been shown to lead to this severe infection. Clostridium sporogenes is an anaerobic gram-positive, spore-producing bacillus found in soil and the human gastrointestinal tract. This report is of a case of a 49-year-old HIV-positive man with alcoholism and poor dental hygiene leading to a molar abscess who presented with Ludwig angina due to C. sporogenes. CASE REPORT A 49-year-old man presented with severe left molar pain, fever, and worsening neck swelling for 5 days. His medical history was significant for AIDS; he was not on antiretroviral therapy. Computed tomography of the neck was positive for extensive subcutaneous emphysema of the left sublingual space. Ludwig angina was diagnosed, and he was taken urgently for incision and drainage of the bilateral neck fascial space. On day 6 of hospitalization, 1 of 2 blood cultures grew C. sporogenes. He left the hospital on day 13 and was readmitted 6 days later with progression of the disease and alcohol withdrawal. CONCLUSIONS This case illustrates the need for rapid diagnosis and treatment of Ludwig angina and the importance of considering commonly pathogenic and rarely pathogenic bacteria when considering the underlying bacterial cause of an infection in an immunocompromised patient. To the best of our knowledge, this is the first case of Ludwig angina caused by C. sporogenes reported in the medical literature.

Adolescent Patient with Cystic Fibrosis Presents with Suspected Ludwig Angina.

A 15-year-old boy attended Emergency Department with a complaint of difficulty in breathing due to dental infection. A pulmonologist was consulted regarding the severity of the cystic fibrosis. The patient was admitted and intravenous (IV) fluids and antibiotics were given. The infected mandibular right first permanent molar tooth # 30 was extracted under IV ketamine dissociative anesthesia in the hospital setting.

The empirical use of aminoglycosides in Ludwig's angina based on bacterial analysis of 63 cases.

PURPOSES: To determine if the empirical use of aminoglycosides is justified in Ludwig's angina based on microscopy, culture and sensitivity results. METHODS: A retrospective analysis was done on patients that presented with Ludwig's angina to the Maxillofacial and Oral surgery department at the University of Pretoria. Demographical data was extracted from patient files. Pus specimens that were submitted as part of the initial surgical intervention were analysed. RESULTS: Sixty-three patients were included in the study with the majority, 76.19% (n=48/63), comprising males. The mean patient age was 38.6 years (range 6 months to 78 years). The majority of infections (87.3%) had an odontogenic aetiology (n=55/63). Forty-four percent of the patients had immunosuppressive co-morbidities (n=28/63). Streptococci contributed 71.26% (n=62/87) of the cultured bacteria. Similar bacteria were cultured in the immunocompromised and the immunocompetent patients (p=0.672). Ninety-two percent (n=57/62) of the streptococci cultured were sensitive to penicillin. The addition of aminoglycosides to the study sample would not have made a statistically significant difference (p=0.1556). CONCLUSION: Based on the findings of this study, the empirical use of aminoglycosides is not warranted in either immunocompromised or immunocompetent patients with Ludwig's angina.

Facial Swelling After Dental Work Done: A Case of Ludwig's Angina.

Ludwig's angina is a fast-spreading cellulitis located on the floor of the oropharynx and neck (Tami, Othman, Sudhakar, & McKinnon, 2020). Patients may present with a wide range of symptoms depending on the severity of the condition (Reynolds & Chow, 2007). Emergency nurse practitioners need to promptly identify, diagnose, and treat patients with this problem, with close attention to the patient's airway. A compromised airway is the leading cause of mortality from this condition (McDonnough et al., 2019). The diagnosis is generally made with a comprehensive history and physical examination, laboratory values, and imaging studies such as computer tomography (Bridwell, Gottlieb, Koyfman, & Long, 2021). Management includes admission to the hospital, broad-spectrum antibiotics, and specialist surgical consultation (Bridwell et al., 2021).

Ludwig's Angina.

Ludwig's angina is a severe diffuse cellulitis that presents an acute onset and spreads rapidly and bilaterally. It can affect the submandibular, sublingual or submental spaces resulting in a state of emergency. Early diagnosis and urgent management could be a life-saving procedure. We report a case of wide spread sialadenitis infection extending to the neck with trismus and elevation of the floor of the mouth that caused an obstruction of the airway and resulted in an inspiratory dyspnea and a stridor. The patient was directed to maintain the airway by elective tracheostomy. An appropriate use of parenteral antibiotics, airway protection techniques, and potential surgical drainage of the infection remain the standard protocol of treatment in advanced cases of Ludwig's angina. The aim of this case report is to emphasize on the importance of early diagnosis and appropriate management of Ludwig's angina.

Complications of dental infections due to diagnostic delay during COVID-19 pandemic.

We present three cases who presented to the emergency department with severe complications of dental infections: Ludwig's angina, necrotising fasciitis and peritonsillar abscess. All of our cases presented at the beginning of COVID-19 pandemic, with complications of dental infections. They delayed their dental treatment due to the pandemic. The airway management was difficult in our cases. Their mortality risk increased due to complications. We aimed to draw attention to complicated odontogenic infections which are rarely seen in emergency department in the past, however started to show up increasingly particularly at the beginning of the COVID-19 pandemic.

Ludwig's angina in a COVID positive patient-An atypical case report.

The management of odontogenic infections is established and several guidelines have been proposed for its effective treatment. Outbreak of COVID-19 has posed serious challenge in the management of odontogenic infections, further complicated by immunocompromised status of the patient, where adequate evaluation and prompt attention is mandatory to avoid untoward consequences. Ludwig's angina being a life threatening infection by itself, association or simultaneous presentation with COVID-19 infection can add further complexity in the management for a maxillofacial surgeon. Here we present a case report of Ludwig's angina in a patient who tested positive for Coronavirus infection and how we treated her successfully.

Severe Ludwig's angina caused by an unknown insect bite.

Hereby, we report a case of a 75-year-old man who presented with a 3-day history of facial swelling and choking sensation. The only history of note was an insect bite on the left parotid gland area 3 days prior. The patient was later diagnosed with insect-bite-induced Ludwig's angina. Enterococcus faecalis was detected on blood cultures and was presumed the source of infection. Intravenous antibiotics and corticosteroids were initiated. The patient was intubated and was subsequently made to undergo a tracheostomy insertion to establish a definitive airway. He was admitted to the intensive care unit and when his condition improved, he was transferred to the ward for full recovery. The patient spent a total of 66 days in hospital before being discharged. This case suggests that Ludwig's angina can be caused by insect bites. However, further similar cases are needed to be documented to explore this theory.

Diagnosis and management of Ludwig's angina: An evidence-based review.

BACKGROUND: Ludwig's angina is a potentially deadly condition that must not be missed in the emergency department (ED). OBJECTIVE: The purpose of this narrative review article is to provide a summary of the epidemiology, pathophysiology, diagnosis, and management of Ludwig's angina with a focus on emergency clinicians. DISCUSSION: Ludwig's angina is a rapidly spreading infection that involves the floor of the mouth. It occurs more commonly in those with poor dentition or immunosuppression. Patients may have a woody or indurated floor of the mouth with submandibular swelling. Trismus is a late finding. Computed tomography of the neck soft tissue with contrast is preferred if the patient is able to safely leave the ED and can tolerate lying supine. Point-of-care ultrasound can be a useful adjunct, particularly in those who cannot tolerate lying supine. Due to the threat of rapid airway compromise, emergent consultation to anesthesia and otolaryngology, if available, may be helpful if a definitive airway is required. The first line approach for airway intervention in the ED is flexible intubating endoscopy with preparation for a surgical airway. Broad spectrum antibiotics and surgical source control are keys in treating the infection. These patients should then be admitted to the intensive care unit for close airway observation. CONCLUSION: Ludwig's angina is a life-threatening condition that all emergency clinicians need to consider. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Management of pediatric head and neck infections in the emergency department.

Head and neck infections can spread to nearby structures, compromising the airway and progressing to life-threatening events. Pediatric head and neck infections can be difficult to recognize; emergency clinicians must know the signs and symptoms of head and neck infections for early diagnosis and urgent management in order to prevent complications and decrease hospitalization rates. This issue reviews presenting signs and symptoms of pediatric head and neck infections, discusses when diagnostic studies are indicated, and offers evidence-based recommendations for management. Conditions reviewed include mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis.

Ludwig's Angina in Pregnancy: A Case Report.

BACKGROUND: Physiologic changes in pregnancy may predispose pregnant women to oral health problems. However, most women are not counselled on oral health during pregnancy. Lack of proper oral health care predisposes pregnant women to odontogenic infections, which can lead to severe complications. CASE: A 34-year-old multiparous woman presented at 400 weeks gestation with a 3-day history of severe, progressive neck swelling, jaw pain, and trismus. She was diagnosed with Ludwig's angina secondary to an untreated dental cavity. She required emergency fiberoptic intubation to secure her airway, urgent delivery via cesarean section, and subsequent surgical drainage performed by otolaryngology. CONCLUSION: Ludwig's angina during pregnancy is associated with severe morbidity. Dental care should not be denied or postponed due to pregnancy, and dental infections should be treated promptly. Health care providers should counsel women on the importance of maintaining good oral health during pregnancy.

Sialolithiasis with abscess: An uncommon presentation of a Ludwig's angina mimic.

Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.