Ludwig's angina and mediastinitis due to Streptococcus milleri ...

Eur Respir J
1990, 3, 728-731
CASE REPORT
Ludwig's angina and mediastinitis due to Streptococcus milleri:
usefulness of computed tomography
X. van der Brempt*, G. Derue*, F. Severin**, L. Colin***, J-P. Gilbeaut, F. Heifer*
Ludwig's angina and mediastinitis due to Streptococcus milleri: usefulness of
computed tomography. X. van der Brempt, G. Derue, F. Severin, L. Colin,
J-P. Gilbeau, F. Helier.
ABSTRACT: Despite Intensive use of antibiotics, Ludwig's angina
remains a potentially lethal Infection because of the risk of upper airway
obstruction and spread Into the mediastinum. We present two patients
who survived mediastinitis complicating Ludwig's angina due to
Streptococcus milleri. Computed tomography performed early In the
course of the disease detected pus collections and directed appropriate
drainage procedures.
Eur Respir J., 1990, 3, 728-731.
Ludwig's angina (LA) is a rapidly spreading cellulitis
involving sublingual and submaxillary spaces [1]. Two
major complications of LA are life-threatening upper
airway obstruction and infectious seeding of the mediastinum,
which were responsible for a high mortality
rate before the antibiotic era: more than 50% in LA [2],
and from 50% (with surgical drainage) to 86% (without
surgical drainage) in mediastinitis [3]. We report
two cases of LA and mediastinitis of dental origin.
Although the detection of the cervical and mediastinal
collections is usually difficult in such cases, the early
use of computed tomography (CT) allowed appropriate
surgical drainage and probably contributed to the
survival of our patients.
Case 1
A mildly retarded 17 yr old girl was admitted because
of fever and dysphagia. She complained of toothache for
several days. Two days before entry, temperature rose
to 39.5°C.
Physical examination showed bilateral submandibular
swelling, trismus and oedema of the floor of the
mouth. Pulse rate was 120 b·min· 1 • Temperature was
36.8°C and the patient was not dyspnoeic.
Abnormal laboratory findings included erythrocyte
sedimentation rate 70 mm·h- 1 , fibrinogen level 622
mg·dl· 1 , white blood cell count 11,800·mm- 3 with 10,000
neutrophils. Chest X-ray showed slight enlargement of
the superior mediastinum. Ampicillin (2 g i.v. every 6 h)
was given as well as indomethacin (100 mg·day· 1 for 2
days) and a single dose of methylprednisolone (125 mg)
for the incipient upper airway obstruction.
On the second day, cellulitis extended to the anterior
chest wall with subcutaneous emphysema. A left pleural
rub was heard and the abdomen was tender and silent.
• Dept of Internal Medicine, •• Dept of Bacteriology,
•u Intensive Care Unit and ' Dept of Radiology,
Hopital de Jolimont, Haine-Saint-Paul, Belgium.
Correspondence: Dr G. Derue, H()pital de Jolimont,
Rue Ferrer, B-7161 Ha.ine-Saint-Paul, Belgium.
Keywords: Computed tomography; Ludwig's angina;
mediastinitis.
Received: August 9, 1989; accepted after revision
February 17, 1990.
Fig. I.- Chest X-ray, subject I, day 2. Enlargement of the superior
mediastinum (arrowheads); right pleural effusion (arrow); enlargement
of the cardiac area; swclling of the cervical soft tissues_
Fig. 2. -Cervical X·ray, subject I, day 2. Gas bubbles are visible in
front of the trachea (arrow); enlargement of the root of the tongue; loss
of the normal cervical lordosis-

a
c
LUDWIG'S ANGINA AND MEDIASTINITIS 729
Fig. 3. - CT scan of subject 1, day 3 (without contrast medium). a) CT scan of the neck at the level of the subglonic trachea. Infectious process
infiltrates the anterior pan of the neck with gas production and abnormal densities of fat, partially blurring the thyroid and vessels margins. b) CT
scan of the chest at the level of the carina. Gas bubbles in the anterior compartment of the mediastinum; posterior right pleural collection. c) CT
scan of the chest at the level of the right inferior pulmonary vein. Gas is visible in the retrostemal space. Right pleural collections are visible in
the interlobar and posterior pleural space.
Chest X-ray showed a right pleural effusion, gas bubbles
in the pretracheal space and enlargement of the cardiac
area (figs 1 and 2).
On the third day, a loud pericardial friction rub
was noted. Temperature was 37 .6°C. Blood cultures
remained sterile. Cervical echography failed to demonstrate
an abscess formation, whereas CT showed free
gas in the pretracheal space and in the retrostemal space,
an abnormal density of fat due to infiltration by the
infectious process with partial blurring of the normal
cervico-mediastinal structure, and a right pyothorax
(fig. 3). Echocardiogram was normal.
The patient was transferred to the intensive care unit.
After endotracheal intubation, surgical drainage of the
cervical, mediastinal and pleural collections were
performed according to the CT data. Cultures yielded
Streptococcus milleri sensitive to penicillin and its
derivatives.
b
Despite an acute respiratory distress syndrome,
the patient's condition slowly improved. Her carious
teeth were extracted and she was discharged after 77
days.
Case 2
A 49 yr old alcoholic man presented 7 days after
multiple dental extractions with stridor, swelling of
the cervical region, trismus and elevation of the
floor of the mouth. Temperature was 39.6°C. Erythrocyte
sedimentation rate was 70 mm·h- 1 , fibrinogen
level 579 mg·dt-1, white blood cell count 19,800·mm- 3 •
Chest X-ray showed a normal mediastinum
and bilateral basal pulmonary infiltrates. The patient
was treated with amoxycillin (1 g i. v. every 6 h)
and metronidazole (500 mg i.v. every 8 h);

730
methylprednisolone (40 mg every 8 h) was added
because of upper airway oedema.
Eighteen hours after entry, subcutaneous emphysema
was noted with persistent stridor and increased dyspnoea.
Chest X-ray showed enlargement of the superior
mediastinum. The patient was transferred to the intensive
care unit. Pharyngeal haemorrhage and aspiration of
blood required endotracheal intubation.
On the third day, er showed a mandibular abscess
extending to the pretracheal space and the anterior
mediastinum with bilateral pulmonary infiltrates. Surgical
drainage of the cervical and mediastinal collections
allowed aspiration of foul-smelling pus. Cultures
yielded Streptococcus milleri.
Despite a cardiac arrest with resuscitation, the
patient's condition improved slowly and he was
discharged after 67 days.
Discussion
Causative organisms of LA are mostly commensals of
oropharyngeal mucosae (streptococci, anaerobes). Mixed
aero-anaerobic infections are common [1, 4]. In the two
reported cases, the only isolated pathogen was
Streptococcus milleri, but cultures were obtained after
the beginning of treatment with antibiotics and we
cannot be sure that S. milleri was the only causative
micro-organism. This microaerophilic bacterium was first
isolated in dental abscesses [5], but it may cause
other suppurative infections including sinusitis,
meningitis, arthritis, endocarditis, peritonitis, perineal
hidradenitis, perirenal abscess and empyema [6-8]. It is
one of the most common pathogens isolated in frontal
brain [9] and liver abscesses [10]. S. milleri is susceptible
in vitro to penicillin, clindamycin and chloramphenicol;
it is resistant to tetracyclines in 36% of the cases
and always resistant to metronidazole [6].
The most common aetiological factor of LA is dental
infection, which is responsible for 85% of cases [11].
Other causes include nasopharyngeal surgery or trauma,
tonsillitis (post-anginal sepsis) and rarely submandibular
sialadenitis, erysipelas, furuncles or infected thyroglossal
duct cysts [4, 12].
In a recent review on LA, spread of infection into the
neck and mediastinum occurred in 5 of 141 cases (4%)
[11]. This spread is influenced by several factors: 1) the
anatomy of the cervical fascia allows cervical infections
to spread easily into the mediastinum, by creating
longitudinal spaces: the pretracheal space, the retropharyngeal
space ("the danger space", which communicates
freely with the mediastinum), the visceral compartment
containing carotid arteries, jugular veins and vagus
nerves [12-14]; 2) the inspiratory negative intrathoracic
pressure occurring during spontaneous ventilation
might favour aspiration of infected material (air,
saliva, bacteria) from the neck into the mediastinum [13];
3) spread of cervical infections is more frequent in
diabetics, alcoholics and in other conditions of
immunodepression and poor nutrition [11, 15]; 4)
inadequate initial management and treatment can
X. VAN DER BREMPT ET AL.
worsen the prognosis, e.g. insufficient or delayed
surgical drainage, or use of antibiotics inactive against
anaerobic flora. Corticosteroids were used in our cases
and in some others [16-18] in order to reduce the upper
airway oedema. Although no controlled studies are
available concerning their efficacy or harmfulness,
steroidal and nonsteroidal anti-inflammatory agents
might be deleterious in a clearly infectious process
because of their immunosuppressive action [19].
The complications of mediastinitis include empyema
(often bilateral), pneumothorax, pulmonary abscess,
aspiration pneumonia, pericarditis with or without
effusion, septic oesophageal perforation, erosion of the
aorta, subphrenic abscess and retroperitonitis [4, 12, 13,
15].
Other complications of LA include thrombophlebitis
of the internal jugular vein, rupture of the carotid
artery, metastatic abscesses and necrosis of the tongue
[4, 11, 13].
Because of the rapid spread of this infection through
the cervical and mediastinal compartments, and the
possible insidious initial course of the disease, CT should
be performed as soon as possible. Conventional X-ray
films of the neck and chest may show gas in the tissue,
air-fluid levels, loss of the normal cervical lordosis
or mediastinal widening [13, 16], but they do not delineate
the extension of the infection. In contrast, in our
cases and in some others [16, 20--23], CT adequately
detected pus collections and mediastinal extension.
CT findings included pleural and pericardial
effusions [22, 23], osteomyelitis of the rib [22],
retropharyngeal, parapharyngeal and mediastinal abscesses
or air collections [16, 20--22], usually ill-defined and
infiltrating the normal cervico-mediastinal structures.
These findings allowed adequate surgical drainages,
which are mandatory when mediastinitis is present.
Although the number of patients is too small to draw
definite conclusions, the early use of CT appears to
improve the prognosis of these patients.
Acknowledgements: The authors thank Dr J. Orehek
and Dr. W. Merrill for their suggestions concerning the
manuscript.
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Angine de Ludwig et midiastinite dues a Streptococcus rnilleri.
Inter et d' une tomographie computerisee. X. van der Brempt, G.
Derue, F. Severin, L. Colin, J-P. Gilbeau, F. Helier.
RESUME: Malgre !'usage intensif des antibiotiques, l'angine
de Ludwig reste une infection potentiellement mortelle a cause
du risque d'obstruction des voies aeriennes superieures et de
dissemination vers le mediastin. Nous presentons deux patients
ayant survecu a une mediastinite compliquant une angine de
Ludwig a Streptococcus milleri. Un scanner cervico-thoracique
pratique precocement permit la detection des collections
purulentes et guida les manoeuvres de drainage appropriees.
Eur Respir J., 1990, 3, 728-731.