Ludwig’s angina describes fulminant cellulitis involving the oro- and hypopharynx, which typically stems from bacterial pathogens, whereas “pseudo-Ludwig’s angina” is ascribed to sublingual swelling due to noninfectious causes. There is a paucity of case reports implicating warfarin as the culprit for sublingual hematoma mimicking Ludwig’s angina; however, we describe a novel case of apixaban-induced pseudo-Ludwig’s angina, which was successfully managed with urgent surgical intervention and supportive care with antibiotic and glucocorticoid therapy.

A 42-year-old female presented to the Otolaryngology Department with a two year history of progressive dysphagia to solids. She did not have any comorbidities yet complained of fatigue and shortness of breath on exertion. When questioned about her menstrual cycle, the patient was unaware that she was having menorrhagia for several years. Her physical examination was normal with the exception of her skin pallor and platynychia (Figure 1). Hematological investigation revealed a hemoglobin level of 6.5 g/dL, hematocrit of 24%, mean corpuscular volume of 58.5 fL, a red cell distribution width of 19.1%, and a serum ferritin level of 9 ng/mL. Barium esophagogram demonstrated an esophageal web within the proximal esophagus at the level of the C6 vertebral body (Figure 2). A diagnosis of Plummer-Vinson syndrome was made and the patient was referred to gastroenterologist for therapeutic intervention.