Medical Mystery of the Week

      You have recieved your COVID19 immunizations but still participate in Telemedicine.

You are shown a photograph of a 15-year-old boy (see below). You are given no other information.  






      What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?

DIAGNOSIS: Ludwig's angina. Ludwig's angina is a diffuse cellulitis in the submandibular, sublingual, and submental spaces characterized by its propensity to spread rapidly to surrounding tissues including the fascial planes of the neck (deep neck space infection, DNSI).
      Ludwig's angina usually arises from odontogenic infections (as in the presented case); less commonly, the source is a penetrating injury to the floor of the mouth, osteomyelitis or fracture of the jaw, otitis media, tongue piercing, or submandibular sialoadenitis or sialolithiasis.
      The infection is usually polymicrobial involving both aerobic and anaerobic organisms. Isolates can include Staphylococcus auerus, Staphylococcus epidermidis, Streptococcus viridans, Fusobacterium nucleatum, Fusobacterium necrophorous, and/or peptostreptococcus and actinomyces spp. The presence of crepitus on palpation and subcutaneous air on x-rays of the neck confirms the presence of an anaerobic component (see x-rays below).
      Ludwig's angina is a medical emergency, generally requiring immediate hospital admission and administration of intravenous antibiotics. Penicillin G, metronidazole or clindamycin are good choices for initial coverage.
      Complications of Ludwig's angina can include airway obstruction, carotid artery rupture or sheath abscess, thrombophlebitis of the internal jugular vein (Lemierre's syndrome), mediastinitis, empyema, necrotizing fasciitis, pericarditis, osteomyelitis, subphrenic abscess, and aspiration pneumonia. This potentially lethal infection has an overall mortality of about 8%, most often due to airway obstruction.

A patient with Ludwig's angina involving a gas forming (anaerobic) organism. Gas location is indicated by the arrow (left image) and the star (right image). Like the presented case, the source of infection in this patient was a periodontal abscess.