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 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~ Conclusion
 ~  References
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  Table of Contents  
Year : 2015  |  Volume : 33  |  Issue : 2  |  Page : 300-302

Ludwig's angina by Salmonella Typhi: A clinical dilemma

1 Department of Microbiology, Dr. Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India
2 Department of Advanced Ear, Nose, Throat Surgery, Dr. Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi, India

Date of Submission24-May-2014
Date of Acceptance23-Nov-2014
Date of Web Publication10-Apr-2015

Correspondence Address:
S Sharma
Department of Microbiology, Dr. Ram Manohar Lohia Hospital and Postgraduate Institute of Medical Education and Research, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.154889

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 ~ Abstract 

Salmonella Typhi has rarely been associated with focal abscesses; and in literature, there is no evidence of its association with abscesses in the neck spaces. Ability of Salmonella Typhi to invade and localise in the neck spaces not only poses a diagnostic challenge but also underscores the necessity to understand the mechanisms that facilitate Salmonella Typhi to establish infections at sites completely non-traditional to the organism.

Keywords: Life-threatening illness, Ludwig′′s angina, Salmonella Typhi

How to cite this article:
Mahajan R K, Sharma S, Madan P, Sharma N. Ludwig's angina by Salmonella Typhi: A clinical dilemma. Indian J Med Microbiol 2015;33:300-2

How to cite this URL:
Mahajan R K, Sharma S, Madan P, Sharma N. Ludwig's angina by Salmonella Typhi: A clinical dilemma. Indian J Med Microbiol [serial online] 2015 [cited 2021 Jan 25];33:300-2. Available from:

 ~ Introduction Top

Ludwig's angina is a fatal progressive gangrenous cellulitis and edema of the soft tissues of submandibular space of the neck and floor of the mouth. The majority of cases (90%) of Ludwig's angina are odontogenic in etiology, primarily resulting from infections of the second and third molars. The roots of these teeth penetrate the mylohyoid ridge such that any abscess, or dental infection, has direct access to this space. Infection can also spread contiguously to involve the pharyngomaxillary and retropharyngeal spaces, thereby encircling the airway. It is a potentially life-threatening illness because of the risk of upper airway obstruction and spread into the mediastinum. [1] Other causes include peritonsillar or parapharangeal abscesses, mandibular fractures, oral lacerations/piercing or submandibular sialadenitis, trauma, tonsillitis and oral malignancy. Predisposing factors include dental caries, recent dental treatment, systemic illness such as diabetes mellitus, malnutrition, alcoholism, human immunodeficiency virus (HIV), organ transplantation and other immunodeficiency states. Anaerobes and Gram-positive microaerophilic cocci are among the most frequent causative agents of the infection. [2] Without a treatment, it is frequently fatal from the risk of asphyxia with a mortality rate of 50%. The aggressive surgical intervention, the antibiotic introduction and the improvement of dental care have determined a significant reduction of the mortality rate to less than 10%. [3] Early detection may sometimes be difficult due to alteration and masking of the clinical features by the use of antibiotics. Here, we are reporting an extremely rare case of Ludwig's angina by  Salmonella More Details Typhi in an immunocompetent adult male without any predisposing factors and the patient was successfully managed in our hospital.

 ~ Case Report Top

A 25-year-old immunocompetent male from low socio-economic status presented in the ear nose throat (ENT) Department with chief complaints of inability to open the mouth, pain and swelling in the lower jaw and neck with difficulty in swallowing since 2 days. On examination, he was conscious, febrile (temperature: 39°C), pulse rate 160 per min and blood pressure was 100/60 mmHg. He had pallor, but icterus was absent. There was a diffuse, tender and indurated neck swelling in submandibular and submental space [Figure 1]. Neck extension was painful and limited. On oral examination, the dental hygiene was normal. The floor of the mouth was erythematous and indurated but tongue protrusion was normal. Routine haematological investigations revealed haemoglobin 9 gm%, total leukocyte count (TLC) 19,800/cu mm [Polymorphs 78%, Lymphocytes 19%, Eosinophils 2%] and platelet count of 2.5 lacs/cu mm. Liver function test, renal function test values and serum electrolytes were within reference ranges. Serology for HIV, hepatitis B surface antigen (HBsAg) and anti-hepatitis C virus (HCV) were non-reactive. A clinical diagnosis of Ludwig's angina was made, and abscess was aspirated and about 5 ml of pus sent for microbiological investigations. The patient was empirically started on intravenous ciprofloxacin and metronidazole. The pus sample received was processed as per standard microbiological techniques. Gram stain smear showed gram-negative bacilli along with pus cells. Ziehl Neelsen stain was negative for acid fast bacilli. The culture was positive for S. enterica subspecies enterica serovar Typhi [4] and was susceptible to ampicillin, cotrimoxazole, cephalosporins of third generation, chloramphenicol and ciprofloxacin by Kirby Bauer disc diffusion method. [5] Blood (two samples from different sites on one occasion) and urine cultures were sterile. No pathogenic organism was grown in stool culture. Also the Widal test was negative. An ultrasound abdomen showed no abnormality in the gall bladder. Since the isolate was found susceptible to ciprofloxacin, hence patient was continued on the same treatment of 500 mg Ciprofloxacin BD for 7 days and patient responded well to the treatment, swelling reduced drastically and he was discharged after 1 week of admission in the hospital.
Figure 1: Neck swelling in submandibular and submental space

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 ~ Discussion Top

The commonest infecting organisms in Ludwig's angina are derived from the oral flora with predominance of Streptococci, Staphylococci, Bacteroides and Fusobacterium spp. Other microorganisms such as Haemophilus influenzae, Pasteurella multocida and Enterobacteriaceae have been infrequently detected. [6] Ludwig's angina in majority of cases is odontogenic in origin. However, in this particular case, teeth were perfectly normal and patient could not recall any incidence of dental manipulation. There are a couple of reports where Salmonella species have been isolated from infections of neck spaces but all these cases have associated predisposing factors in the form of diabetes mellitus, malignancy, etc. Isolation of Salmonella Typhi from such a site is not evidenced in the literature.

The transient bacteremia of typhoidal Salmonella during the normal pathophysiological course allows the organism to localise at various sites/organ of the body. The localisation of typhoidal salmonella may follow a multiplicative cycle and cause clinical enteric fever or the organism may establish a latent/persistent infection. The form in which persistent bacilli exist and the mechanism that allow organism to establish persistent infection are the subjects of large scientific enquiry but the linkage between persistence and involvement of rare sites like neck spaces can be speculated upon. Intracellular pathogen like Salmonella Typhi trapped in ecological nook like submandibular lymph nodes has the advantage of long-term survival in a surreptitious manner without provoking inmical immune response. In this particular case, the organism probably settled in submandibular lymph nodes to cause latent infection but no justifiable explanation could be conceived as to what factors precipitated the state of latency developing into a full blown infectious clinical entity of Ludwig's angina. Perry in his work in arthritis has hypothesized that traumatic accidents cause capillary stasis, reduce oxygen tension and create a local nidus of infection. [7] Onley in his work on experimental animals have supported the concept that microtrauma in the presence of bacteraemia renders joints susceptible to Salmonella infections. [8]

In the subject case, no history of trauma could be elicited but the patient definitely conveyed his habit of breaking monkey nuts, almonds, etc., with his teeth. It is hypothesised that his behaviour could have been the cause of some microtrauma in the submandibular lymph nodes and during the stage of bacteraemia, the organism appear to have settled in the locally damaged lymph nodes and a further traumatic insult would have stimulated the organism to multiply rapidly developing into an acute neck abscess and manifesting as Ludwig's angina.

Neck space infections manifesting as Ludwig's angina are associated with considerable morbidity and mortality unless aggressive surgical interventions are instituted. In country like India where Salmonella Typhi infections are endemic but microbial culture facilities are inadequate, under-reporting of the organism appears logical against the actual number of localised infections. This is a cause of concern because strategies to control communicable diseases like Salmonella Typhi infection may require a fresh look and microbiology scientists need to debate on various demographic and therapeutic factors that may be pushing the pathogens like Salmonella Typhi to shift to locations that are relatively protected from the onslaught of immune attacks and drug penetration is not adequate.

 ~ Conclusion Top

the possibility of Salmonella Typhi as aetiological agent of Ludwig's angina in the absence of history of enteric fever may be extremely implausible clinically. Ludwig's angina being an emergency situation, the drainage/aspirations may not always be referred for investigation of cultures. Also the cultures may not yield any purposeful information if the patient is on antibiotics. Since these infections in our country are endemic, there is strong apprehension that localised infections are being under-reported or being missed altogether.

 ~ References Top

Saifeldeen K, Evans R. Ludwig's angina. Emerg Med J 2004;21:242-3.  Back to cited text no. 1
Candamourty R, Venkatachalam S, Babu R, Kumar GS. Ludwig's angina-An emergency: A case report with literature review. J Nat Sci Biol Med 2012;3:206-8.  Back to cited text no. 2
Britt JC, Josephson GD, Gross CW. Ludwig's angina in the pediatric population: Report of a case and review of the literature. Int J Pediatr Otorhinolaryngol 2000;52:79-87.  Back to cited text no. 3
Winn W Jr, et al. Konemann's color atlas and diagnostic text of microbiology. 6 th ed. Philadelphia: Lippencott Williams and Wilkins Publishers; 2006. p. 945-1021.  Back to cited text no. 4
Clinical Laboratory Standards Institute. Performance standards for antimicrobial disk susceptibility tests; Twenty second informational supplement. Wayne: Clinical Laboratory Standards Institute; 2013. CLSI document M02-A11.  Back to cited text no. 5
Kurien M, Mathew J, Job A, Zachariah N. Ludwig's angina. Clin Otolaryngol Allied Sci 1997;22:263-5.  Back to cited text no. 6
Perry CR. Septic arthritis. Am J Orthop (Belle Mead NJ) 1999;28:168-78.  Back to cited text no. 7
Olney BW, Papasian CJ, Jacobs RR. Risk of iatrogenic septic arthritis in the presence of bacteremia: A rabbit study. J Pediatr Orthop 1987;7:524-6.  Back to cited text no. 8


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