Non responding Ludwig’s angina due to starvation and PEM: review of literature and a case report


  • Mohammad Shakeel Department of ENT, Era’s Lucknow Medical College & Hospital, Lucknow, India
  • Rajeev Krishna Gupta Department of ENT, Era’s Lucknow Medical College & Hospital, Lucknow, India



Ludwig’s angina, Starvation, Immunosuppression


Relationship between starvation and immunosuppression was initially suggested on the basis of increased rate of infectious disease during famine. Latter on this was confirmed by thorough studies of immune response in starved and malnourished patients. There are numerous defense mechanisms to protect human host from infection. Starvation leads to immunosuppression due to its damaging effects over these defense mechanisms, thereby increasing chance of opportunistic infections e.g. Ludwig’s angina. Not only this, it also alters the natural course and drug response of disease. Ludwig’s angina is infection of submandibular space which lies between mucous membrane of floor of mouth on one side and superficial layer of deep cervical fascia on other.  It is surgical emergency that is potentially life threatening unless early recognized and aggressively treated. Although most reported cases follow an odontogenic infection, it can occur in persons with no co-morbid disease and individuals with starvation and protein energy malnutrition also are at increased risk of developing it due to immunosuppression. Here we report a case of female who was starved for 14 days as she fell in well and presented with Ludwig’s angina, resistant to standard treatment protocol. The aim of this paper was to review literature supporting relationship between starvation and immunosuppression and present a case of starved female presenting with Ludwig’s angina resistant to treatment. We emphasize about the proper history tacking after counselling in cases resistant to treatment. It is important to assess the nutritional status of the patient in every case of Ludwig’s angina. This is important because Ludwig’s angina associated with other etiologies also develop restricted mouth opening thereby decreasing oral intake which further leads to nutritional deficiency and PEM.


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