DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20170542

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

Mohammad Shakeel, Rajeev Krishna Gupta

Abstract


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.


Keywords


Ludwig’s angina, Starvation, Immunosuppression

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References


Chandra RK. Nutrition and immunity: Lessons from the past and new insights into the future. Am J Clin Nutr. 1991;53:1087–101.

Cason J, Ainley CC, Wolstencroft RA, Norton KR, Thompson RP. Cell-mediated immunity in anorexia nervosa. Clin Exp Immunol. 1986;64:370–5.

Polack E, Nahmod VE, Emeric-Sauval E, Bello M, Costas M, Finkielman S, et al. Low lymphocyte interferon-gamma production and variable proliferative response in anorexia nervosa patients. J Clin Immunol. 1993;13:445–51.

Suskind RM, Thanagkul O, Damrangsak D, Leitzmann C, Suskind L, Olson RE. The malnourished child: clinical, biochemical, and hematological changes. In: Suskind RM, editors. Malnutrition and the Immune Response. NewYork: Raven Press; 1977: 1-8.

Chandra RK, Gupta SP. Increased bacterial adherence to respiratory and buccal epithelial cells in protein-energy malnutrition. Immunol Infect Dis. 1991;1:55-7.

Von Ludwig WF. Uber eine in neuerer Zeit wiederholt hier vorgekommene Form von Halsentz¨undung. Medicinisches Correspond-enzblatt des W¨urttembergischen ¨arztlichen Vereins. Stuttgart. 1836;6:21–5.

Bansal A, Miskoff J, Lis RJ. Otolaryngologic critical care. Critical Care Clin. 2003;19:55–72.

Kremer MJ, Blair T. Ludwig angina: forewarned is forearmed. J Am Assoc Nurse Anesth. 2006;74:445-51.

Spitalnic SJ, Sucov A. Ludwig’s angina: case report and review. J Emergency Med. 1995;13:499–503.

Winters S. A review of Ludwig’s angina for nurse practitioners. J Am Acad Nurse Pract. 2003;15:546-9.

Genco RJ. Current view of risk factors for periodontal disease. J Periodontol. 1996;67:1041-9.

Miller W, Furst I, Sandor G. A retrospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109:1873–9.

Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, González-Valdepeña H, Bluestone CD. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. 1995;112:375-82.

Shears P. Epidemiology and infection in famine and disasters. Epidemiol Infect. 1991;107:241–51.

Chandra RK. Immunocompetence in undernutrition. J Pediatr. 1972;81:1194-200.

Schrimshaw NS, Taylor CE, Gordon JE. Interactions of nutrition and infection. Monogr Ser World Health Organ.1968;57:3-329.

Simon J. A physiological essay on the thymus gland. London: Renshaw; 1845.

Chandra RK. Rosette-forming T lymphocytes and cell-mediated immunity in malnutrition. Br Med J. 1974;3:608-9.

Wade S, Parent G, Daniel FB, Maire B, Fall M, Schneider D, et al. Thymulin (Zn-FTS) activity in protein-energy malnutrition: new evidence for interaction between malnutrition and infection on thymic function. Am J Clìn Nutr. 1988;47:305-11.

Chandra RK, Gupta S, Singh H. Inducer and suppressor T cell subsets in protein-energy malnutrition. Analysis by monoclonal antibodies. Nutr Res. 1982;2:21-6.

Chandra RK. Numerical and functional deficiency in T helper cells in protein-energy malnutrition. Clin Exp Immunol. 1983;51:126-32.

Cushing SD, Berliner JA, Valente AJ, Territo MC, Navab M, Parhami F, et al. Minimally modified low density lipoprotein induces monocyte chemotactic protein 1 in human endothelial cells and smooth muscle cells. Proc. Natl Acad Sci. 1990;87:5134-8.

Boring L, Gosling J, Chensue SW, Kunkel SL, Farese RV Jr, Broxmeyer HE, et al. Impaired monocyte migration and reduced type 1 (Th1) cytokine responses in C-C chemokine receptor 2 knockout mice. J Clin Invest. 1997;100:2552–61.

Plump AS, Smith JD, Hayek T, Aalto-Setälä K, Walsh A, Verstuyft JG, et al. Severe hypercholesterolemia and atherosclerosis in apo-lipoprotein E-deficient mice created by homologous recombinant in ES cells. Cell. 1992;71:343–53.

Zhang SH, Reddick RL, Piedrahita JA, Maeda N. Spontaneous hypercholesterolemia arterial lesions in mice lacking apolipoprotein E. Science. 1992;258:468–71.

Plump AS, Scott CJ, Breslow JL. Human apolipoprotein A-I gene expression increases high density lipoprotein and suppresses atherosclerosis in the apolipoprotein E-deficient mouse. Proc Natl Acad Sci. 1994;91:9607–11.

Nakashima Y, Plump AS, Raines EW, Breslow JL, Ross R. ApoE-deficient mice develop lesions of all phases of atherosclerosis throughout the arterial tree. Arterioscler Thromb. 1994;14:133–40.

Sommer A. Vitamin A status, resistance to infection and childhood mortality. Ann NY Acad Sci. 1990;587:17-23.

Zeba AN, Sorgho H, Rouamba N, Zongo I, Rouamba J, Guiguemde RT, et al. Major reduction of malaria morbidity with combined vitamin A and zinc supplementation in young children in Burkina Faso: a randomized double blind trial. Nutr J. 2008;7:7.

Srisinha S, Edelman R, Suskind R, Charupatana C, Olson RE. Complement and C3 proactivator levels in children with protein-energy malnutrition and effect of dietary treatment. Lancet. 1973;1:1016-20.