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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 59-61

Trench mouth: Is it a disease of the past? Diagnostic clincher: The underrated “urgent smear”


1 Department of ENT, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Department of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission20-Nov-2018
Date of Acceptance19-Jan-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Jaise Jacob
Department of ENT, Pondicherry Institute of Medical Sciences, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_39_18

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  Abstract 


Vincent's infection is a progressive painful infection with ulceration, swelling, and sloughing of the dead tissue from the oral cavity and oropharynx caused by the fusiform bacillus (Fusobacterium fusiforme) and spirochetes (Borrelia vincentii). However, it is rare in the vocal cords. We present a case of Vincent's angina of the larynx in an otherwise immunocompetent patient. This case report is to highlight clinician's diagnostic challenge, the need for crucial interdisciplinary interaction with microbiologist, and the significance of “urgent smear” (which is most often overlooked) for timely curative patient care.

Keywords: Borrelia vincentii, Fusobacterium fusiforme, oropharynx, Vincent's angina


How to cite this article:
Jacob J, Savery N, Thomas K, Elan S, Kanungo R, Kurien M. Trench mouth: Is it a disease of the past? Diagnostic clincher: The underrated “urgent smear”. J Curr Res Sci Med 2019;5:59-61

How to cite this URL:
Jacob J, Savery N, Thomas K, Elan S, Kanungo R, Kurien M. Trench mouth: Is it a disease of the past? Diagnostic clincher: The underrated “urgent smear”. J Curr Res Sci Med [serial online] 2019 [cited 2019 Nov 23];5:59-61. Available from: http://www.jcrsmed.org/text.asp?2019/5/1/59/260637




  Introduction Top


Trench mouth or Vincent's angina is a noncontagious anaerobic infection of oral cavity and oropharynx associated with overwhelming proliferation of spirochete (Borrelia vincentii) and fusiform bacillus (Fusobacterium fusiforme), presenting as ulceration, swelling, and sloughing off of dead tissue.[1] The classical presentation is as necrotizing ulcerative gingivitis. This disease is uncommon with a prevalence of <1%.[2],[3] It is extremely rare in the vocal cords and has not been reported in the past 70 years. Predisposing factors include smoking, viral respiratory infections, and immunodeficiency disease such as HIV/AIDS.[1] It has also been reported as infection of adolescents and young adults, especially in institutions and armed forces.[2],[3],[4]


  Case Report Top


A 47-year-old male presented with a history of throat pain, difficulty in swallowing to both solids and liquids, and voice change of 3 days duration. In fact, he was throwing away liquids which made the treating physician consider hydrophobia as a differential diagnosis!! However, in the absence of definitive history of a dog bite, and the presence of throat pain, change in voice along with a low-grade fever, malaise, and the fetid odor, consultation with otolaryngologists was urgently sought. Ear, nose, and throat examination revealed markedly congested tonsil and posterior pharyngeal wall. Urgent soft-tissue X-ray of the neck was taken and was normal [Figure 1]. Laryngoscopy showed congestion of both vocal cords with ulcers in the left vocal cord along with pooling of saliva in the postcricoid region [Figure 2].
Figure 1: X-ray soft-tissue of the neck

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Figure 2: Ulcerative lesions in the right vocal cord

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Routine blood investigations, including sugars, were normal. An urgent gram stain of the throat swab was requested. This was reported to have numerous fusospirochetal bacteria with polymorphonuclear cells and few Gram-positive cocci. The smear report was conveyed to the treating clinicians. The patient was immediately started on crystalline penicillin 24 million units/day dose delivered as 8 million units eight hourly following which symptoms subsided dramatically the next day. Repeat laryngoscopy on the 4th day revealed regressed ulcers with normal laryngeal mucosa [Figure 3]. The treatment was continued for a week.
Figure 3: Vocal cord on the 4th day of penicillin therapy

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  Discussion Top


Vincent's angina, manifests with both local and systemic symptoms. Patients present with the complaints of high-grade fever, headache and sore throat. When tonsils are involved, physical findings of cervical lymphadenopathy and a membrane on the tonsil are seen. When removed, an ulcer is noted which usually heals in 7–10 days.[5] Rapid presumptive diagnosis can be clinched by microscopic examination of the Gram stained smear prepared from the swab collected from the ulcerative lesion. The presence of many spirochetes, fusiform bacilli, and polymorphonuclear leukocytes is a presumptive evidence of this disease.[6] Isolation by culture is not attempted due to the presence of other anaerobic oral bacteria which make specific identification difficult. Management consists of improved oral hygiene, oral debridement, metronidazole, and penicillin therapy.[1],[3],[5],[7] A study by Dufty et al. stated that the duration of treatment must depend on what the individual can tolerate and the extent of the infection.[2] A case published by Malek et al. described complete resolution of symptoms following treatment with metronidazole and mouth rinses for 7 days.[8] Cancrum oris is a rare complication.[1]

To date, two cases of Vincent's angina of the larynx have been reported in the literature. Thefirst patient was a 17-year-old male with ulcerated lesion on the right side of hypopharynx (lateral wall and the pyriform fossa) in addition to multiple ulcers in the tongue and oral cavity.[9] The second patient had ulcerations of the vocal cord.[4] In our patient, the presence of a significant sore throat with fetid odor associated with marked congestion of oropharyngeal and laryngeal mucosa along with ulcers in the vocal cords, suggested the possibility of Vincent's angina. Diphtheria was not considered clinically as a differential diagnosis because of the absence of characteristic membrane and cervical lymphadenopathy. The Gram stain report was considered as critical alert by the microbiologist, which enabled us to start penicillin therapy immediately. Spirochetes are fastidious organisms and difficult to culture. Hence, the dependence on smear report is of paramount importance, an issue which is most often not considered by clinicians. These findings along with dramatic response to crystalline penicillin could be considered diagnostic of this uncommon severe infection.


  Conclusion Top


Vincent's angina commonly affects the oral cavity and oropharynx, while laryngeal involvement is extremely uncommon. This rare case is being presented to emphasize the clinician's diagnostic challenge, strength of imperative interdisciplinary consultation with the microbiologist, and the significance of “urgent smear” (which is almost forgotten in recent times) for effective, ethical and curative patient care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understood that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Skully C, Sebastian Bagab J. Benign oral and dental disease. In: Scott-Brown W, Gleeson M, editors. Scott-Brown's Otolaryngology, Head and Neck Surgery. 7th ed. London: Hodder Arnold; 2008. p. 1819.  Back to cited text no. 1
    
2.
Dufty J, Gkranias N, Donos N. Necrotising ulcerative gingivitis: A literature review. Oral Health Prev Dent 2017;15:321-7.  Back to cited text no. 2
    
3.
Dufty J, Gkranias N, Petrie A, McCormick R, Elmer T, Donos N, et al. Prevalence and treatment of necrotizing ulcerative gingivitis (NUG) in the British armed forces: A case-control study. Clin Oral Investig 2017;21:1935-44.  Back to cited text no. 3
    
4.
Bouty R. Vincent's angina among the troops in France. BMJ 1917;2:685-6.  Back to cited text no. 4
    
5.
Shirley W, Woolley A, Wiatrak B. Pharyngitis and adenotonsillar disease. In: Cummings C, Flint P, editors. Cummings Otolaryngology – Head and Neck Surgery. 5th ed. Philadelphia, Pa.: Mosby Elsevier; 2010. p. 2377.  Back to cited text no. 5
    
6.
Baron E. Specimen collection, transport and processing-bacteriology. In: Jorgensen J, Pfaller M, editors. Manual of Clinical Microbiology. 11th ed. Washington: ASM Press; 2015. p. 300.  Back to cited text no. 6
    
7.
Macdougall C, Penicillins cephalosporins and other beta lactam antibiotics. In: Brunton L, editor. Goodman and Gilman the Pharmacological basis of Therapeutics. 13th ed. New York: McGraw-Hill; 2011. p. 1028.  Back to cited text no. 7
    
8.
Malek R, Gharibi A, Khlil N, Kissa J. Necrotizing ulcerative gingivitis. Contemp Clin Dent 2017;8:496-500.  Back to cited text no. 8
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9.
Wagers A. Vincents infection of the mouth, throat and larynx. Report of a case. Laryngoscope 1938;48:122-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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