Grand Rounds

Ludwig’s Angina with Internal Jugular Vein Thrombosis - How to Manage?

Dhruv Gandhi, Devina Pande, Reepa Agrawal, Ira Shah
Department of Pediatric Infectious Diseases, BJ Wadia Hospital for Children, Mumbai, India

Address for Correspondence: Dhruv Gandhi, 5B/13 Shyam Niwas, Breach Candy, Mumbai-400026, Maharashtra, India. Email: dhruvgandhi2610@gmail.com

Keywords: Lemierre's syndrome, Head and neck infection, Head and neck surgery, Penicillin, Anticoagulants, Neck swelling.

Clinical Problem:
An 8-year-old boy presented in September 2024 with intermittent fever, right-sided neck swelling near jaw, difficulty in swallowing and opening the mouth 5 days after a dental procedure. He was diagnosed in January 2024 with a type II Abernathy malformation and an intrapulmonary shunt with situs solitus. On presentation, weight was 20 kg (10^th-25^th percentile according to Indian Academy of Pediatrics (IAP) growth charts) and height was 120 cm (10^th-25^th percentile according to IAP growth charts). On examination, he had painful neck movements, trismus (1.5-finger mouth opening) and pus was visualised in the oral cavity draining near the left lower molar. There was a right-sided firm, non-tender swelling in the submandibular region. Other general and systemic examinations were normal. Investigations of the patient are shown in Table 1. Computerized tomography (CT) of the neck showed a deep neck space collection extending into the right carotid and retromandibular spaces with no skull-base or mediastinal extension. Head and neck ultrasound showed diffuse inflammatory changes in the right face, right-sided prevertebral collection, bilateral submandibular collection and a right internal jugular vein (IJV) partial thrombus. Abdominal ultrasound showed a liver hematoma and aneurysmal dilatation of the portal vein at the porta hepatis. Intraoral pus swab from the gingivolingual sulcus near the left lower molar grew pansensitive Candida albicans and Streptococcus mitis. He underwent an incision and drainage of the swelling through an intraoral approach and removal of the infected left lower molar, right lower molar and left lower canine. Pus aspirated from the swelling did not grow any organism. He was given intravenous (IV) vancomycin, ceftriaxone, metronidazole and chlorhexidine mouthwash for 5 days. However, he developed persistent fever spikes and right facial swelling. He underwent an incision and drainage of the facial swelling. Pus culture did not show any growth. In view of clinical suspicion of Ludwig’s angina with Lemierre syndrome, antibiotics were changed to IV penicillin G (50,000U/kg/dose every 4-hours) and IV clindamycin (40 mg/kg/day every 6-hours) for 2 weeks followed by 2 weeks of oral penicillin and oral clindamycin. For the IJV thrombus, he was not started with any anticoagulation as his clotting parameters were deranged (Table 1). He was discharged on day 17 of admission. On follow-up 2-weeks later, pain and fever had subsided and the facial wound had healed. Subsequently, oral penicillin was not available and he received amoxicillin-clavulanate and clindamycin for 4 weeks and was asked to follow-up in the outpatient department. He was referred to the liver clinic for his Abernathy malformation.

Table 1. Investigations of the patient.

Parameters	At presentation	Day 2	Day 4	Day 5	Day 9	Day 15	At 4-week follow-up	Reference Ranges
Hemoglobin (gm/dL)	11.0	11.1	11.6	11.4	9.4	9.4	11.9	11.5-15.5
White blood cell count (cells/cumm)	19,740	19,700	22,410	18,820	8,770	7,990	7,460	5000-13,000
ANC (cells/cumm)	16,187	16,768	16,808	-	-	-	3,130	2000-8000
ALC (cells/cumm)	2,132	2,562	3,810	-	-	-	3,160	1000-5000
Platelets (105 cells/cumm)	1.23	1.71	3.12	-	-	-	1.96	1.50-4.50
CRP (mg/dL)	111	-	-	35.4	20.2	5.0	10.4	0.3-10
PT (seconds)	21.3	-	21.2	-	-	-	14.4	10.3-13.1
INR	1.91	-	1.9	-	-	-	1.25	0.8-1.2
aPTT (seconds)	-	-	37	-	-	-	-	25-35

Note: ANC- Absolute neutrophil count, ALC- Absolute lymphocyte count, CRP- C-reactive protein, PT- Prothrombin time, INR- International Normalised Ratio, aPTT- Activated partial thromboplastin time.

How to manage Ludwig’s angina and internal jugular vein thrombosis?