Pseudo-Ludwig's Phenomenon: A Rare Clinical Manifestation in Liver Cirrhosis

Abstract

Pseudo-Ludwig's phenomenon, an exceedingly rare clinical entity, is characterized by non-infectious upper airway obstruction resulting from spontaneous hematoma in the sublingual space. The condition is often described in patients on anticoagulants with grossly deranged coagulation profile. We describe a case of pseudo-Ludwig's phenomenon in a cirrhotic patient with significantly deranged hemostasis profile; the first to be reported in medical literature.

Isolated sublingual hematoma post internal carotid artery stenting for internal carotid artery stenosis in high-risk patients as uncommon and rare misadventure: A case report and review of literature

“…Bleeding into the sublingual space may elevate the tongue and increase the dead space in the floor of the mouth resulting in a non-infectious life-threatening upper airway obstruction. This picture was first reported in 1976, and known as pseudo-Ludwig's phenomenon [10] , [11] . Sublingual hematoma may be seen in trauma, tongue bite, biopsies at the level of the mouth floor, dental/osseodental procedures, intraoral suturing, or in patients with bleeding disorders.…”

Pseudo-Ludwig’s angina: spontaneous sublingual haematoma elicited by warfarin

“…Upper airway haematomas are rarely observed and reported in contrast to gastrointestinal, genitourinary, and central nervous system bleedings secondary to supratherapeutic INR in patients on warfarin. Oral anticoagulation-induced haematomas have been reported in various upper airway locations, including the sublingual space, retropharyngeal area, arytenoids and epiglottis [ 2 , 6 ] . An upper airway haemorrhage might be preceded by predisposing factors such as intense coughing and trauma, or it may manifest spontaneously.…”

“…In contrast to Ludwig’s angina, which refers to an acute and severe inflammation of the oro- and hypopharynx that is commonly caused by bacterial infections, pseudo-Ludwig’s angina is associated with spontaneous sublingual haematoma arising from non-infectious aetiologies [ 1 ] . A scarcity of case reports has established an association between sublingual haematoma and excessive anticoagulation, notably with warfarin or coagulopathy stemming from hepatic dysfunction [ 2 ] . Upper airway bleeding, spontaneous or with minor trauma, can occur secondary to supratherapeutic international normalised ratio (INR) and holds clinical significance due to the risk of life-threatening airway obstruction.…”

Spontaneous submental hematoma, a pseudo-Ludwig’s phenomenon in 101-year-old patient: case report and literature review

“…The floor of the mouth, though highly vascular, is rarely a site of hematoma formation. Floor of mouth hematomas have been described after trauma and dental implant procedures, anticoagulant-induced coagulopathy or uncontrolled hypertension [2] , [3] , [4] . Spontaneous hemorrhage in sublingual space due to uncontrolled hypertension is very unusual and only a few cases have been reported [5] , [6] , [7] , [8] , [9] , [10] .…”

“…Clinicians must study the coagulation profile and mange it accordingly. The diagnosis is essentially clinical [3] , [4] , [5] .…”