Successful Management of Ludwig's Angina Only to Encounter Perforated Viscus during Recovery

Repeat CT of the neck after the procedure revealed resolution of abnormal fluid in the neck, but a new finding of a nonocclusive thrombus of the right internal jugular vein for which the patient was started on continuous heparin infusion and later bridged to Coumadin. Given these findings, he was emergently given prothrombin complex concentrate and vitamin K, and taken urgently to the operating room by the general surgeon for an exploratory laparotomy, washout, and modified Graham patch of a perforated pyloric ulcer. Hisham reported a case of Ludwig's angina complicated by an adverse reaction to antibiotic treatment resulting in worsening systemic symptoms such as fevers, tachycardia, tachypnea, respiratory acidosis, and leukocystosis in addition to worsening edema within the naso- and oropharynx requiring urgent tracheostomy.3 Ludwig's angina and ketoacidosis as a first manifestation of diabetes mellitus after odontogenic infection was encountered and treated according to standard therapy for this disease with airway management, antibiotics, and surgical drainage.4 We report a case of Ludwig's angina complicated by intestinal perforation because of the development of stress ulceration despite ulcer prophylaxis requiring surgical intervention.