Recommended Citation
Fletcher N, Bonaguro A, Sejpal M, Naqvi A, Memon N. TEE-ing up a diagnosis: an unexpected presentation of Ludwig’s angina following routine cardiac imaging. Presented at: CHEST 2025 Annual Meeting; October 21, 2025; Chicago, IL.
Presentation Notes
Presented at: CHEST 2025 Annual Meeting; October 21, 2025; Chicago, IL.
Abstract
Introduction: Iatrogenic esophageal perforation (IEP) is a serious adverse event of transesophageal echocardiogram (TEE) requiring prompt identification for urgent antibiotic administration and potential surgical repair. However, the relative infrequency of this complication implores the consideration of alternative diagnoses. We present a unique case of Ludwig’s angina following TEE initially concerning for IEP. Case Presentation: A 66-year-old female with gastric arteriovenous malformations and paroxysmal atrial fibrillation with recent left atrial appendage occlusion (LAAO) device placement presented to the emergency department for bilateral submandibular pain and swelling with acute onset dysphagia. IEP was suspected as TEE had been performed within the preceding 24 hours for routine assessment of the LAAO device. Urgent CT of the neck revealed mouth floor and submandibular space edema with gas locules without loculated abscess concerning for Ludwig’s angina (rapidly spreading cellulitis involving the sublingual and submaxillary spaces1) and narrowing of the laryngeal airway. Broad spectrum intravenous antibiotics were administered and subsequent esophagram demonstrated no contrast extravasation. ENT and thoracic surgery services were consulted and the patient underwent emergent incision and drainage. Intraoperative cultures revealed Streptococcus mitis and Veillonella. This patient was ultimately discharged without further complication on oral amoxicillin-clavulanate and doxycycline following 5-day hospital admission. Discussion: Transesophageal echocardiography (TEE) accounts for 5-10%2 of the nearly 8 million echocardiograms performed annually in the United States3. Fortunately, severe complications are rare, with IEP occurring during an estimated 0.03% of procedures4. In this case, TEE course was unremarkable with only minimal blood-tinged secretions observed post-procedure and the patient was discharged following a 2-hour observation and an unimpeded swallow challenge. The new onset of profound dysphagia, oral bleeding, increased volume of blood-tinged secretions, and pain necessitated further workup. Imaging demonstrated no frank perforation or contrast extravasation characteristic of IEP, prompting consideration of alternative diagnoses, such as an infectious process. Ludwig’s angina, like IEP, is a condition with a low annual incidence. A recent study identified Ludwig’s angina in only 0.2-0.4% of patients admitted to the emergency department with concern for oral or dental infections5. Over 90% of Ludwig’s angina cases are odontogenic in nature6, and indeed, CT of the neck demonstrated bilateral dental carries in the maxilla and mandible despite the absence of patient-reported dental issues and a benign oral examination. This patient was successfully treated before incurring further sequelae and has fully recovered. This case represents the first reported presentation of Ludwig’s Angina in close temporal proximity to TEE. Conclusions: Developing and maintaining a broad knowledge base across organ systems and critical pathologies remains essential for all clinicians to combat diagnostic bias and promote appropriate intervention. Pathologies often have a diverse range of presentations and may even mimic the characteristic clinic picture of other disease mechanisms. Although critical to identify, the relative infrequency of IEP substantiates alternative diagnoses, such as infection of the oral cavity, e.g. Ludwig’s angina. Although unrelated, TEE helped lead to discovery of the underlying infection with further investigation of this patient’s symptoms following the procedure.
Type
Poster
Affiliations
Advocate Christ Medical Center