Ludwig’s Angina Complicated by Descending Necrotizing Mediastinitis and Superimposed Candida mediastinitis: Case Report and Literature Review

Abstract

Ludwig's angina is a rapidly spreading infection of the floor of the mouth and neck. A rare and dreaded complication of Ludwig's angina is extension of the infection to the mediastinum. We describe a unique case of Ludwig's angina presenting with descending necrotizing mediastinitis, with the subsequent development of Candida albicans and Candida krusei mediastinitis.A 57-year-old man presented with a three-day history of progressive neck swelling with odynophagia. Two days prior, he was treated at another facility with oral clindamycin. Upon his presentation to our Emergency Department, he was noted to have tachycardia (pulse 126/ minute), with trismus and purulent discharge from his oral cavity. He had numerous dental caries, and elevation of the floor of his mouth with visible necrotic tissue. The submental and submandibular regions were bilaterally swollen, with firm, erythematous skin extending from the neck to the upper chest wall.

Can Descending Necrotizing Mediastinitis be treated without surgical intervention? – A case report.

“…The cervical fascial layers are divided into a super cial and a deep layer, the deep layer itself consists of three layers (super cial, middle, and deep), which generate the different deep neck spaces, the dorsal part of the submandibular space offers access to the sublingual compartment and the parapharyngeal space, which is connected with the retropharyngeal space, and by this anatomical communicated route, spreading of in ammations, infectious processes may reach into the posterior visceral space and cause for example a Descending Necrotizing Mediastinitis [14][15][16]. Pharyngeal spaces communicated with the mediastinum leading to complication as pericardial and plural effusion as in our case [14,15].…”

“…a differential diagnosis for complications arising from infection in this space include cranial nerve nine to twelve palsies, Horner's syndrome, carotid artery rupture or sheath abscess and jugular vein suppurative thrombophlebitis (Lemierre's syndrome), infection can spread to the retropharyngeal and danger spaces, located between the posterior border of the pharynx or esophagus, and the anterior border of the spine. These spaces communicate with the mediastinum, leading to complications such as pleural or pericardial effusions, as well as descending necrotizing mediastinitis [13,14].…”

“…The mortality rate of Ludwig's angina is less than 10% but it can increase to reach more than 30% when complicated by descending necrotizing mediastinitis, so we can say that Ludwig's angina is a potentially life-threatening condition when it doesn't treated well [6,14].…”