VA AM Report 12.12.16: Lemierre’s, Ludwig’s, and disseminated GC.

Mondays are for coffee, Monday Night Football, and deep space infections of the neck. Thanks to Jin for bringing a case of the latter.

Ludwig’s Angina

Refers to any infection of the sub-mandibular space. Important to remember this, as theoretically fasciitis of the necrotizing type can occur in the neck. The classic origin of infection of is the 2nd and 3rd molar of the ipsilateral side, and it results in marked swelling, pain, erythema, and carries with it the potential for airway compromise. Ludwig was a 19th century physician who first described this aggressive infection, and ironically may have died from his eponymous condition at age 75. Other exam findings include trismus and superior/posterior displacement of hte tongue from the swelling in the floor of the mouth. The microbiology includes the anaerobic flora of the mouth.

Lemierre’s Disease

Techinically refers to a septic thrombophlebitis of the internal jugular vein, though per our own Joe Wong, ID attending, it is better to think of it as a continuum of any infection of the deep neck that may seed the vasculature leading to bacteremia, and as in this case, the potential for overwhelming sepsis. In fact, Harrison’s identifies it as syndrome to consider when a clear source of sepsis is not immediately clear. The classic bug here is Fusobacterium, and it can cause septic emboli, usually to the lung as it is a ride sided intravascular infection. Mortality has been quoted as high as 15% in this disease, so get on it quickly, and as in Ludwig’s think about the airway early and often.

Disseminated gonococcal disease

Brief word on DGI. We classically think of gonococcal arthritis as the manifestation of DGI, but generalized sepsis is also possible, and can be quite severe. It presents as does any other bacteremia with fevers, rigors, tachycardia and even shock. Treatment is the same, third generation cephalosporins, also reasonable to treat with azithromycin given increasing resistance worldwide.

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