The Journal of Emergency Medicine, Vol. 49, No. 4, pp. e121–e122, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.04.025

Visual Diagnosis in Emergency Medicine

A CURIOUS CASE OF COLD LUDWIG’S ANGINA Silpa Yalamanchili, MD* and Wayne Bond Lau, MD, FACEP† *Department of Internal Medicine and †Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Reprint Address: Wayne Bond Lau, MD, FACEP, Department of Emergency Medicine, Thomas Jefferson University Hospital, 1020 Sansom Street, 239 Thompson Building, Philadelphia, PA, 19107

A 54-year-old man with a history of adrenocortical carcinoma, hypertension, and diabetes presented to the emergency department 6 h after the onset of anterior neck swelling. The patient denied any difficulty tolerating his secretions or dyspnea. He denied fevers, chills, pruritis, rash, or hives. He recalled no exposures to new medications, foods, clothing, or chemicals. Twelve hours before the onset of his symptoms, he had underwent outpatient computed tomography (CT) scan with i.v. and oral contrast. He denied any symptoms immediately after scan completion. The patient was afebrile, with a pulse of 67 beats/min, blood pressure of 144/75 mm Hg, and a comfortable respiratory rate of 18 breaths/min. His oxygen saturation was 98% on room air. Physical examination revealed an obese man, breathing comfortably without stridor, drooling, or wheezing. He exhibited pronounced nontender, diffuse anterior neck fullness. There was no sublingual edema or erythema, and his anterior neck was free of induration or brawny erythema. His oral cavity was clear of lesions, ulcers, petechiae, or bullae. There was no uvular deviation or tonsillar exudate. He exhibited no rash. A complete blood count and comprehensive metabolic panel returned normal results. A noncontrast CT scan of the neck was performed, and revealed the images seen in Figures 1–4.

DIAGNOSIS Contrast-Induced Sialadenitis Sialadenitis, or ‘‘iodide mumps,’’ is a rare complication of i.v. contrast administration. Since 1956, there have been approximately 30 cases of ionic-contrast induced siala-

Figure 1. Antero-posterior scout film, revealing broadly the patient’s neck girth.

RECEIVED: 3 March 2015; ACCEPTED: 16 April 2015 e121

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S. Yalamanchili and W. B. Lau

Figure 2. Transverse neck film. Arrows indicate platysmal thickening and significant fat stranding surrounding the submandibular glands.

denitis and only 4 cases of sialadenitis from the use of non-ionic contrast material (1). This entity typically presents as a bilateral, painless enlargement of the submandibular or parotid glands. Patients are usually nontoxic appearing, with a history of contrast exposure or prior similar episode (2). Onset of symptoms varies from within a few minutes of exposure to 3 5 days after exposure (3). Contrast-induced sialadenitis is a benign, selflimited process that resolves with supportive treatment alone (4). Antihistamines and corticosteroids have been used to treat this reaction, although there is no established benefit in doing so (2). The etiology of iodide mumps is

Figure 4. Lateral neck film demonstrating enlargement of the lingual tonsils with associated moderate narrowing of the supraglottic airway.

unclear, but seems to be related to the accumulation of iodide in the salivary glands, inducing inflammation and ductal obstruction. Although previously thought to be associated with renal insufficiency, contrast-induced sialadenitis is now reported to occur with at least equal frequency in patients with normal renal function. The use of non-ionic contrast material has not eliminated the risk of developing sialadenitis, as evidenced in four prior case reports. Our patient had received Ultravist 300, a non-ionic contrast material, 12 h before developing symptoms. Upon presentation, he was treated with i.v. 125 mg methylprednisolone, 50 mg diphenhydramine, and 20 mg famotidine. The patient was admitted to the observation unit and discharged the following day in stable condition, with instructions to complete a steroid taper and followup with otolaryngology. REFERENCES

Figure 3. Transverse neck film demonstrating pronounced enlargement of the bilateral submandibular glands, left greater than right.

1. Sussman RM, Miller J. Iodide ‘‘mumps’’ after intravenous urography. N Engl J Med 1956;255:433–4. 2. Shacham Y. A rare case of acute contrast-induced sialadenitis after percutaneous coronary intervention. Isr Med Assoc J 2013;15:652–3. 3. Christensen J. Iodide mumps after intravascular administration of a nonionic contrast medium. Acta Radiol 1995;36:82–4. 4. Erdogan D. Nonionic contrast media induced sialadenitis following coronary angiography. Anadolu Kardiyol Derg 2006;6:270–1.

A Curious Case of Cold Ludwig's Angina.

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