SHARE @ Advocate Health - Midwest - Scientific Day: TEE-ing Up a Diagnosis: An Unexpected Presentation of Ludwig Angina Following Routine Cardiac Imaging
 

Affiliations

Advocate Christ Medical Center

Abstract

Introduction/Background:

Iatrogenic esophageal perforation (IEP) is a rare but serious complication that may occur during transesophageal echocardiography (TEE). The high mortality of this condition implores rapid identification for urgent antibiotic administration and potential surgical repair.

Description:

A 66-year-old female with gastric arteriovenous malformations and paroxysmal atrial fibrillation with recent left atrial appendage (LAA) closure presented with submandibular pain, swelling, and acute onset dysphagia. IEP was suspected as TEE had been performed within the preceding 24 hours for routine assessment of the LAA closure device. CT neck and esophagram were obtained exhibiting submandibular edema and gas locules without contrast extravasation concerning for Ludwig angina (diffuse cellulitis of bilateral submandibular, sublingual, and submental spaces) rather than perforation. Broad spectrum IV antibiotics were administered, and the patient underwent emergent incision and drainage. The patient was discharged without complication on oral amoxicillin-clavulanate and doxycycline.

Discussion:

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 prompted workup. CT neck without frank perforation and esophagram without contrast extravasation ruled out acute traumatic injury. As a result, an alternative diagnosis was considered, such as an infectious process. The patient was diagnosed with Ludwig angina in context of symptoms and additional imaging findings and was subsequently treated with empiric antibiotics and surgical intervention. Formulating a broad multisystem differential remains crucial to the expedient recognition of less common but highly morbid conditions. Developing and maintaining a broad knowledge base across multiple systems and critical pathologies remains essential for all clinicians to combat diagnostic bias and promote appropriate intervention. Pathologies may have a diverse range of symptoms and even mimic the characteristic presentation of unrelated disease mechanisms. Although critical to identify, the relative infrequency of IEP substantiates alternative diagnoses, such as infection of the oral cavity, e.g. Ludwig angina. This patient was successfully treated before incurring further sequelae and has recovered.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

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May 21st, 11:41 AM May 21st, 1:15 PM

TEE-ing Up a Diagnosis: An Unexpected Presentation of Ludwig Angina Following Routine Cardiac Imaging

Introduction/Background:

Iatrogenic esophageal perforation (IEP) is a rare but serious complication that may occur during transesophageal echocardiography (TEE). The high mortality of this condition implores rapid identification for urgent antibiotic administration and potential surgical repair.

Description:

A 66-year-old female with gastric arteriovenous malformations and paroxysmal atrial fibrillation with recent left atrial appendage (LAA) closure presented with submandibular pain, swelling, and acute onset dysphagia. IEP was suspected as TEE had been performed within the preceding 24 hours for routine assessment of the LAA closure device. CT neck and esophagram were obtained exhibiting submandibular edema and gas locules without contrast extravasation concerning for Ludwig angina (diffuse cellulitis of bilateral submandibular, sublingual, and submental spaces) rather than perforation. Broad spectrum IV antibiotics were administered, and the patient underwent emergent incision and drainage. The patient was discharged without complication on oral amoxicillin-clavulanate and doxycycline.

Discussion:

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 prompted workup. CT neck without frank perforation and esophagram without contrast extravasation ruled out acute traumatic injury. As a result, an alternative diagnosis was considered, such as an infectious process. The patient was diagnosed with Ludwig angina in context of symptoms and additional imaging findings and was subsequently treated with empiric antibiotics and surgical intervention. Formulating a broad multisystem differential remains crucial to the expedient recognition of less common but highly morbid conditions. Developing and maintaining a broad knowledge base across multiple systems and critical pathologies remains essential for all clinicians to combat diagnostic bias and promote appropriate intervention. Pathologies may have a diverse range of symptoms and even mimic the characteristic presentation of unrelated disease mechanisms. Although critical to identify, the relative infrequency of IEP substantiates alternative diagnoses, such as infection of the oral cavity, e.g. Ludwig angina. This patient was successfully treated before incurring further sequelae and has recovered.

 

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