Ludwig's Angina and a Complicated Course of Streptococcus constellatus Management

IntroductionLudwig's angina is a rapidly progressive and life-threatening cellulitis of the soft tissue of the floor of the mouth and neck. Streptococcal and Staphylococcal infections are the most common causes, arising from poor dentition, oral procedures, alcoholism, diabetes or vascular disease, immunocompromised states such as malignancy, or malnutrition. Treatment involves securing the airway, broad spectrum antibiotic coverage, and surgical drainage for any abscess or drainable collection of fluid.CaseA 22-year-old transgender woman with a history of pre-diabetes, hypertension, asthma, hyperlipidemia, and alcohol use disorder reported poor dentition with dysphagia, drooling, and pain in ears and throat for about 1 week. She was taking amoxicillin after being seen at an urgent care 4 days prior for cough, fever, chills, and suspected pharyngitis and tonsillitis. Her oropharynx and tonsils were erythematous with tongue protrusion, dysphonia, poor dentition, diffuse swelling and induration in the submandibular area with tenderness to palpation, and limited neck range of motion. She was placed on mechanical ventilation and broad spectrum antibiotics. She was then taken for an incision and drainage (I & D) of submental and submandibular abscesses followed by removal of 5 teeth with dental carry debridement. Subsequent chest tube insertions into the pleura and mediastinum were performed for fluid collection as well as repeated I & D procedures. We found bilateral otomastoiditis with an abscess on the right extending to the sternocleidomastoid, drained abscesses on the right mastoid, and performed a tympanostomy on the left. Infection spread to the cerebellum necessitated initiation of high dose ceftriaxone. Her condition improved after a 45-day stay and she was sent to a long-term acute care hospital.ConclusionThis Ludwig angina case illustrates the tendency of S. constellatus to form abscesses elsewhere. The steroid hormone treatments, elevated cortisol state of Cushing's Syndrome, and severe metabolic syndrome provided ample opportunity for this infection to persist and spread to the mediastinum, pleura, and central nervous system. Source control is critical, as well as early and frequent evaluations by Otolaryngology and Oromaxillofacial surgery to provide extraction, drainage, and additional measures if needed.