Abstract
Ludwig angina is a rare but severe life-threatening cellulitis, classically of odontogenic origin, characterized by an extensive and a rapidly progressive inflammation of subcutaneous tissue of the face and severe systemic toxicity. Its prognosis is potentially worse in pregnancy given the higher vulnerability of both mother and fetus to infection and to the consequences of therapies. Early diagnosis and timely treatment are of paramount importance in the prognosis of this condition but could be however challenging as it is infrequently observed in current daily practice. Moreover, literature dealing with Ludwig’s angina in pregnancy is scarce, consisting mostly in isolated case reports from developed countries. The aim of this article was to improve awareness on Ludwig angina in pregnancy through a report of experience in 12 patients and a literature review on the diagnosis and treatment of this clinical entity. To this end, medical records of 12 patients with Ludwig angina in pregnancy were analysed retrospectively and the diagnosis and treatment approaches discussed through a literature review. Age of pregnancy ranged from 27 to 37 weeks. In all the patients, the cellulitis origin was a carious molar of the mandible. The infection spread extended to the neck (4 patients), the thorax (3 patients) and the temporal fossa (2 patients). One patient presented with necrotizing fasciitis extending from the submandibular and submental regions to the thorax. Bacteriological examination of pus which was possible and successful in 4 patients only, showed staphylococcus aureus (2 patients) staphylococcus SP (1 patient) and staphylococcus epidermidis (1 patient). Death occurred in 2 mothers and in 7 fetus giving mortality rates of 16.7% and 58.3% respectively. Direct causes of death in mothers were sepsis shock and air way compromise. In 6 out of the 7 mothers who had dead fetus, the infection extended beyond the mouth floor. Oral health care providers should be aware for proper treatment of dental infections. They should also be alert for early recognition and multidisciplinary treatment of Ludwig angina in pregnancy in collaboration with obstetricians, specialists of intensive care and infectious diseases.
Highlights
Infections continue to account for a major cause of maternal, fetal, and neonatal mortality and morbidity in developing countries as well as in the developed world [1]
This study aims to improve awareness on this clinical entity through a report of experience in 12 patients and a literature review on its diagnosis and treatment
The treatment started at the department of anaesthesia and intensive care and continued when the patient’s condition improved, at the department of oral and maxillofacial surgery. It consisted of respiratory support by face mask or cannulas; antibiotic therapy consisting in a combination of ceftriaxone (60mg/kg day), metronidazole (30mg/kg day) given intravenously until 2-3 days after normalization of the temperature and gentamycin (3mg/kg day) given during 5 days; incision and drainage of pus collections performed by multiple skin incision and blunt dissection under local anaesthesia; intravenous administration of 2mg/kg day of steroids during 2-3 days; administration of 40-60ml/kg day of saline serum and isotonic glucose serum; treatment of the source of the infection consisting classically in extraction of carious teeth performed as soon as the mouth opening authorized this
Summary
Infections continue to account for a major cause of maternal, fetal, and neonatal mortality and morbidity in developing countries as well as in the developed world [1]. Ludwig angina is of these, a condition named in reference to the German physician Karl Friedrich Wilhelmvon Ludwig who first described it in 1836. It is classically a poly microbial infection of odontogenic origin characterized by a severe systemic toxicity associated to an extensive and a rapidly progressive inflammation of the subcutaneous tissue which begins at the floor of the mouth and may progress to reach the pharyngeal space, the neck and the thorax [2, 3]. High threat for life in Ludwig’s angina imposes early diagnosis and timely treatment This may be challenging as the condition is infrequently observed in current daily practice. This study aims to improve awareness on this clinical entity through a report of experience in 12 patients and a literature review on its diagnosis and treatment
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