Ludwig's Angina Masquerading As Angioedema

Abstract

Angioedema (AE) can be a medical emergency. Acquired AE is a side effect of ACE inhibitors, but other conditions mimic the facial swelling and upper airway obstruction found in AE. We present an adult with facial swelling, airway compromise, and initial diagnosis of AE secondary to ACE inhibitors, who was subsequently found to have Ludwig's angina (LA). LA is a cellulitis with the potential to obstruct the airways, often requiring tracheotomy. Patient's lisinopril was discontinued, ecallantide administered, triple antibiotics were initiated, and tracheostomy was eventually required. Surgical incision and drainage led to defervescence of his fever. This patient was hospitalized for facial swelling unresponsive to antihistamines, prednisone, and epinephrine. Respiratory compromise required mechanical ventilation. Patient became febrile despite antibiotics and did not respond to 30mg of ecallantide. Surgical incision revealed purulent material positive for methicillin-resistant Staphylococcus. Laboratory evaluation revealed normal complement, C1q, C1 esterase, and serum tryptase. His fever and facial swelling promptly resolved after I & D and he was discharged after removal of his tracheostomy. We believe this is the first reported case of Ludwig's angina presenting as facial edema and airway compromise similar to AE. Our patient suffered from poor dentition, likely accounting for his cellulitis. The danger in LA is swelling that spreads internally, often compromising the upper airway. In this case, expedient consultation with ENT resulted in a favorable surgical treatment. Clinicians should be diligent to evaluate other causes of AE even if the medical history suggests ACE inhibitor-induced AE.