Infection is usually primarily within the submandibular space, and the sublingual and submental spaces can also be involved. It presents with an acute onset and spreads very rapidly, therefor early diagnosis and immediate treatment planning is vital and lifesaving. The external signs may include bilateral lower facial swelling around the jaw and upper neck. Signs inside the mouth may include elevation of the floor of mouth due to sublingual space involvement and posterior displacement of the tongue, creating the potential for a compromised airway. Additional symptoms may include painful neck swelling, drooling, tooth pain, dysphagia, shortness of breath, fever, and general malaise. Stridor, trismus, and cyanosis may also be seen when an impending airway crisis is nearing. Causes
The most prevalent cause of Ludwigs angina is dental related, accounting for approximately 75% to 90% of cases. Infections of the lower second and third molars are usually implicated due to their roots extending below the mylohyoid muscle. Periapical abscesses of these teeth also result in lingual cortical penetration, leading to submandibular infection.Other causes such as oral ulcerations, infections secondary to oral malignancy, mandible fractures, sialolithiasis-related submandibular gland infections, and penetrating injuries of the mouth floor have also been documented as potential causes of Ludwigs angina. Patients with systemic illness, such as diabetes mellitus, malnutrition, compromised immune system, and organ transplantation are also commonly predisposed to Ludwigs angina.
In absence of other viable treatment options, artesunate may be used. Children
Artesunate is safe for use in children. Artesunate + sulfadoxine/pyrimethamine should be avoided in the newborns due to sulfadoxine/pyrmethamine effects on bilirubin. Parenteral artesunate dosing for treatment of severe malaria in children less than 20 kg should be higher than that of adults in order to increase exposure. When artesunate cannot be given orally or intramuscularly due to an individuals weakness or inability to swallow, rectal administration may be given as pre-referral treatment as long as parenteral administration is initiated after transfer to a more advanced facility. Adverse effects
Artesunate may cause serious side effects including hemolytic anemia (a condition in which red blood cells are destroyed), and severe allergic reactions.Artesunate is generally safe and well tolerated. Artesunate-based regimens are less likely to cause vomiting and tinnitus than quinine plus anti-malarial antibiotic therapy. The best recognised adverse effect of the artemisinins is that they lower reticulocyte counts. This is not usually of clinical relevance.With increased use of I.V. artesunate, there have been reports of post-artesunate delayed haemolysis (PADH). Delayed haemolysis (occurring around two weeks after treatment) has been observed in people treated with artesunate for severe malaria. Contraindications
Artesunate is typically a well tolerated medicine. Known contraindications include a previous severe allergic reaction to artesunate.Drugs that should be avoided while on artesunate are the drugs that inhibit the liver enzyme CYP2A6. These drugs include amiodarone, desipramine, isoniazid, ketoconazole, letrozole, methoxsalen and tranylcypromine. Mechanisms of action
The mechanisms of action of artesunate remains unclear and debatable.