Consideraţii clinice şi terapeutice în angina Ludwig

Introduction

Ludwig’s angina is a very serious disease, a life-threatening diffuse cellulitis, being a surgical emergency. It brings together a wide range of infections that are interested in sublingual, submaxillary and submandibular spaces, with bilateral involvement and potential broadcast mediastinal space, with direct implications for cardiac and respiratory functions. It can be determined by Gram-positive and Gram-negative pathogens, most frequently being determined by Staphylococcus aureus, Streptococcus spp., Prevotella spp. and Porphyromonas spp. (aerobic or anaerobic organisms). 

The purpose of this paper is to draw attention to the existence of this severe infection, on the factors that determined the difficulties in the therapy and prevention of this disease with a poor prognosis.

Materials and method

This study includes a total of five patients with Ludwig’s angina hospitalized in the “Elias” University Emergency Hospital in the period 1.01.2012 - 31.12.2016. In this group of patients we performed a statistical analysis in terms of the distribution of cases by calendar years, sex, age, origin, clinical manifestations and therapy.

Results and discussions

The distribution of the cases of Ludwig’s angina varies during this period: two cases in 2015 and only one case in 2012, 2014, and 2016, with no event in 2013. There were two cases at females and three cases at males, whose ages ranged from 19 to 35 years old. The distribution according to origin shows 90% of cases from rural area and 10% from urban areas.  Odontogenic infections were the common etiologic factor in two cases and three cases were post-dental extraction sepsis. The history of all patients retains the attention with the existence of dental infections, acute periodontitis, root debris, these factors and the existence of imunosupressed host constituting the triggers of the infection. As host immunosuppression predisposing factors were: chronic alcoholism (3 cases), diabetes (one case), and pulmonar infection (one case). The distance between primary dental disease and Ludwig’s angina varied between 24 hours and 3 days, the admission diagnosis being of Ludwig’s angina in 4 from 5 cases, one case being admitted with the observation of “sepsis”. From the clinical point of view, all patients clinically presented at admission: serious malaise, fever (38.5 to 39˚C), throbbing pain at the entrance gate, dysphagia (100%) with propulsion tongue to the floor of mouth, the swallowing, pulping wood of the floor mouth, ear pain reflex (60% cases), locoregional lymphadenopathy, dizziness, frontal headache, tachycardia, and two of the patients presented at admission early hypotension and oliguria.
The useful laboratory diagnostic tests drew our attention to the following results:

• a constant leukocytosis with values between 11000/mm³ and 19000/mm³, and neutrophils greater than 80%;
• erythrocyte rate sedimentation was in all cases greater than 50 mm/h; a moderate intrainfectious anemia;
• blood cultures remained sterile in all cases, because of the initiating of antibiotic treatment before admission.

The isolation of etiologic agents was realized intra vitam only in septic pus, that included mixed anaerobic flora, streptococci and Gram-negative bacilli. The bacteriological examinations were performed and blood culture system Oxoid Signal appropriate solid media incubated aerobic and anaerobic pathogens. The bacteria were identified by conventional methods and antibiotic susceptibility testing was performed by diffusion method or standard solutions.
The etiologic agents were isolated in four cases and were represented by anaerobic flora – triple combination of anaerobic bacteria: Fusobacterium + Peptostreptococcus spp. + Porphyromonas (one case):

• Gram-negative association + anaerobic and anaerobic BGN (one case);
• Porphyromonas (one case);
• Klebsiela + Streptococcus (one case).

The treatment is an urgency in all cases, being necessary a prompt evaluation and a serious clinical follow-up, in order to improve its prognosis and reduce the high mortality. Antibiotherapy is important to stop the diffusion of the infection and prevent the marrow dissemination, with the establishment of the mediastinitis and other complications. Being a very serious infection, it requires the use of intravenously antibiotic, active on oral microflora, broad spectrum antibiotics both to aerobic Gram-positive bacilli, Gram-negative, and on anaerobic bacilli. The length of treatment ranged from a minimum 14 days to 60 days, with an average of 21 days, depending on the virulence of the etiological agent. In all the cases, antibiotic therapy was performed with empiric treatment, with different combinations of parenteral broad-spectrum antibiotics and after that subsequently according to the antibiogram: penicillin G + chloramphenicol + metronidazole (one case), or cephalosporins IIIrd generation in combination with aminoglycoside and metronidazole (two cases).
Another used therapeutic option was amoxicillin + clavulanic acid associated with gentamicin and fluoroquinolones – ciprofloxacin (one case) or imipenem in combination with metronidazole (one case).
Together with antibiotic therapy, surgical treatment was practiced, necessary for the discharge of pus (drainage for decompression of facial spaces - airway management). Periodontal treatment was performed, local outbreaks of dental debridement, incision followed by excision, curative pathogenic and symptomatic medication. The clinical evolution of the patients was favorable under therapy in all those 5 cases, with lower fever, loss of local phenomena, improving of the general condition and with the normalization of biological samples.
The complications were determined because of the delayed addressability, which worsened the prognosis – airway obstruction (two cases), pericarditis (one case).

Conclusions

Ludwig’s angina is a serious infection through its particularly systemic potential and anatomic context. The etiology allows the dissemination into mediastinum with direct implications on the cardiac and respiratory functions. Being a surgical emergency, it requires a serious, complex and urgent therapy, with broad spectrum antibiotics associated with surgical drainage and pathogenic treatment.