Noma in children with severe combined immunodeficiency

Noma (cancrum oris): A scoping literature review of a neglected disease (1843 to 2021)

Background

Noma (cancrum oris) is an ancient but neglected and poorly understood preventable disease, afflicting the most disenfranchised populations in the world. It is a devastating and often fatal condition that requires urgent and intensive clinical and surgical care, often difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and identify research gaps that need to be addressed to evolve our understanding of how to address this disease.

Methods

We searched 11 databases and collected primary peer reviewed articles on noma in all languages, the final search was conducted on 24^th August 2021. The oldest manuscript identified was from 28^th March 1843 and the most recently published manuscript was from 3^rd June 2021. Search terms included cancrum oris and noma. Data was extracted using a standardised data extraction tool and key areas of interest were identified. The Preferred Reporting Items for Systemic review and Meta-Analyses requirements were followed.

Results

The review included 147 articles, the majority of the studies (n = 94, 64%) were case reports. Most manuscripts (n = 81, 55%) were published in the 2000s, 49 (33%) were from the 1900s and 17 (12%) from the 1800s. The main areas of interest identified were the history and epidemiology of the disease, noma’s clinical progression and aetiology, treatment regimens, mortality rates and the risk factors for the development of noma.

Conclusions

Noma has been reported in the literature for hundreds of years; however important gaps in our understanding of the disease remain. Future research should focus on determining the burden and distribution of disease; the true mortality rate, pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.

Noma is a devastating and often fatal condition that mainly affects children in severely disenfranchised communities. Noma is preventable and requires urgent basic medical care in the early stages of disease. Once the disease reaches the last stage, sequelae, survivors require expert surgical care, usually difficult to access as most cases of noma occur in resource-limited settings. We conducted a scoping review of the literature published on noma to understand the size and scope of available research on the disease and to identify research priorities that will evolve our understanding of how to eradicate this disease. Our review showed that noma has been reported in the literature for hundreds of years; however several major gaps in knowledge still exist. There is appreciation among the small community of clinicians and researchers involved in noma care and research that these gaps in knowledge impact on the ability to develop and implement sound evidence-based policies and activities aimed at eradicating noma from communities that continue to be afflicted by this ancient disease. The main focus of future research should be to study the burden and distribution of disease; the true mortality rate, and the pathogenic cause(s) and the factors that influence prognosis and outcomes after treatment.

Autosomal recessive diseases among the Athabaskans of the southwestern United States: recent advances and implications for the future

Genetic and linguistic data suggest that the Na-Dene, of which the Athabaskans are the largest group, are part of a later immigration into the Americas than the first Amerind immigration. Whether a second and third immigration can be separated seems unlikely but continued cross-Bering Strait exchanges may have masked what was a greater separation in the past. The movement of tribes into Siberia appears to have involved a genetic bottleneck leading to at least one disease allele shared by Eskimo/Aleuts and Navajos and a second possibly shared by the Navajo and a Siberian population, but not the same Siberian population that share deep linguistic affinities with the Navajo. A second bottleneck appears to have occurred with the migration of Athabaskans from Northwest North America to the Southwestern United States along the Rocky Mountains. This bottleneck is reflected in several rare recessive diseases shared by the Navajo and Apache. Finally, the Navajo were captured and imprisoned under conditions which led to severe population loss. This, and the "hiding away" of a small number of Navajos in what is now the Western portion of the reservation, led to a Navajo-specific bottleneck(s) resulting in an increased frequency of several rare recessive diseases among the Navajo. Prejudice against human genetic research is high among the Southwestern Athabaskans but attempts to bridge the gap are now occurring. The involvement of Navajo scientists in this process is especially encouraging.

Noma (cancrum oris)

Noma is an opportunistic infection promoted by extreme poverty. It evolves rapidly from a gingival inflammation to grotesque orofacial gangrene. It occurs worldwide, but is most common in sub-Saharan Africa. The peak incidence of acute noma is at ages 1-4 years, coinciding with the period of linear growth retardation in deprived children. Noma is a scourge in communities with poor environmental sanitation. It results from complex interactions between malnutrition, infections, and compromised immunity. Diseases that commonly precede noma include measles, malaria, severe diarrhoea, and necrotising ulcerative gingivitis. The acute stage responds readily to antibiotic treatment. The sequelae after healing include variable functional and aesthetic impairments, which require reconstructive surgery. Noma can be prevented through promotion of national awareness of the disease, poverty reduction, improved nutrition, promotion of exclusive breastfeeding in the first 3-6 months of life, optimum prenatal care, and timely immunisations against the common childhood diseases.

Update on general health risk of periodontal disease

OBJECTIVES

To review the potential of periodontal infections to cause nonoral diseases. Therapeutic recommendations are provided to help patients and dental practitioners prevent systemic complications from periodontal infections.

FINDINGS

Systemic diseases from oral bacteria are mostly caused by transient bacteraemias, which can occur spontaneously from dental foci of infection, from mastication, brushing, flossing or other daily manipulations, or from dental treatments. Examples of systemic infections that may involve oral microorganisms include infective endocarditis, aspiration pneumonia, HIV-related disseminated candidiasis and cancrum oris, septicaemia associated with cancer chemotherapy and radiotherapy, necrotising faciitis and various other life-threatening infections. Inflamed gingiva constitutes a significant reservoir for herpes viruses, which have the potential to cause serious systemic diseases in immunocompromised patients. Periodontal disease may also aggravate chronic insulin insensitivity and thus interfere with glycaemic control in diabetic patients. Controversy surrounds the involvement of periodontal infections in coronary heart disease.

CONCLUSIONS

Cumulative evidence suggests that periodontal disease can be an important cause of morbidity and mortality of various systemic diseases, especially in individuals exhibiting compromised host defence. Maintaining a healthy dentition and periodontium by means of daily oral hygiene practice and regular professional care is the most effective way of preventing systemic diseases from oral infections.

Noma: a forgotten disease

According to recent reports from the WHO, noma (or cancrum oris), a hideous, ancient disease primarily affecting children living in poverty in parts of sub-Saharan Africa, is increasing. Noma often starts as an ulcer on the oral mucosa or as ANG and commonly after a bout of measles or other disease. It quickly develops into a massive necrosis, moving from the inside outward, often involving major portions of the face. Early treatment with antibiotics, rehydration, correction of electrolytic imbalances, and administering nutritional supplements will halt the disease. The high mortality rate, however, indicates that many children are not given care or brought for care in time. Surviving victims often display severe facial deformities that demand extensive reconstructive surgery. Current research has elucidated parts of the pathogenesis of noma. The WHO started the international Action Network Against Noma in 1992, with its official launch on the World Health Day in 1994: a five-point action plan was presented and current work follows that plan.

Prenatal diagnosis and carrier detection for Athabascan severe combined immunodeficiency disease

OBJECTIVES

Severe combined immunodeficiency disease occurs at a high incidence among Athabascan-speaking Navajo and Apache children (SCIDA). We linked the SCIDA gene to chromosome 10p and recently identified a common nonsense mutation in Artemis/SCIDA. In this study we compared polymorphic markers linked to SCIDA and the point mutation which creates an NspI site on exon 8 for prenatal diagnosis and carrier detection.

METHODS

We tested five amniocentesis samples, two cord blood and two blood samples from eight at-risk families using polymorphic DNA markers tightly linked to SCIDA. We amplified the region of exon 8 of Artemis/SCIDA and evaluated the products for the NspI site in each sample plus samples from 30 unrelated healthy Navajos.

RESULTS

We correctly predicted that three were affected and six were unaffected. Two of the unaffected appear to be carriers based on our haplotype analysis. Retrospective analysis for the gene mutation confirmed the DNA analysis. Finally, 10% of the normal Navajo controls were carriers.

CONCLUSIONS

We demonstrate the feasibility of prenatal diagnosis and carrier detection for SCIDA in the families at risk as well as the availability of a rapid screening test for the SCIDA founder mutation that can be used in all Navajo and Apache newborns and at-risk fetuses.

A founder mutation in Artemis, an SNM1-like protein, causes SCID in Athabascan-speaking Native Americans

Athabascan SCID (SCIDA) is an autosomal recessive disorder found among Athabascan-speaking Native Americans and is manifested by the absence of both T and B cells (T(-)B(-)NK(+) SCID). We previously mapped the SCIDA gene to a 6.5-cM interval on chromosome 10p. SCIDA fibroblasts were found to have defective coding joint and reduced, but precise signal joint formation during V(D)J recombination. After excluding potential candidate genes, we conducted a combined positional candidate and positional cloning approach leading to the identification of nine novel transcripts in the refined SCIDA region. One of the transcripts showed significant homology with the mouse and yeast SNM1/PSO(2) and was recently reported (Artemis) to be responsible for another T(-)B(-)NK(+) SCID condition (radiation sensitive SCID) in 13 patients of primarily European origin. In our evaluation of this gene, we have identified a unique nonsense mutation in 21 SCIDA patients that is closely correlated to the founder haplotypes that we had previously identified. This nonsense founder mutation results in the truncation of the deduced protein product. The wild-type construct of the primary transcript can effectively complement the defective coding joint and reduced signal joint formation in SCIDA fibroblasts. The above results indicate that this SNM1-like gene (Artemis) is the gene responsible for SCIDA. We also discovered three additional alternative exons and detected at least six alternatively spliced SCIDA variants (SCIDA-V1, 2, 3, 4, 5, and 6) coexisting with the primary transcript in trace amounts. Finally, we found that the SCIDA primary transcript (Artemis) encodes a nuclear protein.

Oro-facial gangrene (noma/cancrum oris): pathogenetic mechanisms

Cancrum oris (Noma) is a devastating infectious disease which destroys the soft and hard tissues of the oral and para-oral structures. The dehumanizing oro-facial gangrenous lesion affects predominantly children ages 2 to 16 years, particularly in sub-Saharan Africa, where the estimated frequency in some communities varies from 1 to 7 cases per 1000 population. The risk factors are poverty, malnutrition, poor oral hygiene, residential proximity to livestock in unsanitary environments, and infectious diseases, particularly measles and those due to the herpesviridae. Infections and malnutrition impair the immune system, and this is the common denominator for the occurrence of noma. Acute necrotizing gingivitis (ANG) and oral herpetic ulcers are considered the antecedent lesions, and ongoing studies suggest that the rapid progression of these precursor lesions to noma requires infection by a consortium of micro-organisms, with Fusobacterium necrophorum (Fn) and Prevotella intermedia (Pi) as the suspected key players. Additional to production of a growth-stimulating factor for Pi, Fn displays a classic endotoxin, a dermonecrotic toxin, a cytoplasmic toxin, and a hemolysin. Without appropriate treatment, the mortality rate from noma is 70-90%. Survivors suffer the two-fold afflictions of oro-facial mutilation and functional impairment, which require a time-consuming, financially prohibitive surgical reconstruction.

Bone marrow transplantation for T-B- severe combined immunodeficiency disease in Athabascan-speaking native Americans

A distinct form of autosomal recessive T-B- severe combined immunodeficiency disease occurs with a high frequency among Athabascan-speaking Native Americans (SCIDA), including Navajo and Apache Indians from the southwestern US and Dene Indians from the Canadian Northwest Territories. The SCIDA gene has been linked to markers on chromosome 10p although its identity and role in the pathogenesis of this disease are unknown. We report our experience in treating 18 Navajo and Dene children with SCIDA between 1984 and 1999; 16 underwent bone marrow transplants (BMT). All children were symptomatic within 2 months of birth, had the T-B- NK(+)SCID phenotype and 67% presented with oral and/or genital ulcers. Three children had evidence of maternal engraftment prior to transplant. Two children died shortly after diagnosis. Three children required more than one BMT and 12 are alive with T cell reconstitution at a median follow-up of 7 years. Three children developed normal B cell immunity, two of whom received ablative conditioning therapy with either radiation or busulfan. Three of the four children who died received therapy with either radiation or busulfan and two of eight long-term survivors who were also recipients of cytotoxic chemotherapy have failed to develop secondary teeth. These results demonstrate the efficacy of BMT in treating infants with this distinct form of SCID, although B cell reconstitution remains a problem even with HLA-matched donors. Without conditioning, T cell engraftment is likely when closely HLA-matched donors are used. With T cell depletion of haplocompatible marrow, conditioning with immunosuppressive therapy may be necessary; however, children with SCIDA who were treated with intensive immunosuppressive and myeloablative therapy had a poor outcome.

Oral manifestations of primary immunological diseases

BACKGROUND

Primary immunodeficiencies have many oral manifestations. The clinical presentation of these diseases demonstrates the roles of different immune cells for the maintenance of oral health.

METHODS

The authors reviewed selected literature describing systemic and oral manifestations of the primary immunodeficiencies published between 1966 and 1999.

RESULTS

The authors found that oral candidiasis and herpetic infections are seen frequently in patients with T-cell deficiencies, while patients with B-cell deficiencies are most susceptible to bacterial infections. Periodontitis and oral candidiasis are found in some, but not all, phagocyte deficiencies.

CONCLUSIONS

These findings demonstrate that T cells, B cells and phagocytes all have roles in oral immunity.

CLINICAL IMPLICATIONS

Acquired conditions that affect the immune system such as diabetes, alcoholism and acquired immunodeficiency syndrome, as well as certain medications, will affect oral defense mechanisms. The effects that acquired immunodeficiencies will have on oral health can be predicted from the oral manifestations of primary immunodeficiencies.

A survey of cases of cancrum oris seen in Ile-Ife, Nigeria

AIM

To review the records of child patients with cancrum oris who presented at a teaching hospital in Nigeria.

SETTING

Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria.

SAMPLE AND METHODS

The study was carried out through review of records of child patients diagnosed as having cancrum oris or post-cancrum oris defects between 1982 and 1996. Age, gender, site distribution, treatment and its outcome were recorded.

RESULTS

One hundred and forty-two cases were diagnosed during the study period. Mean age was 4.65 years (range 2-16 years). The maxillary quadrants were affected more often than the mandibular. Seventeen patients completed treatment satisfactorily, but 55 failed to do so. All patients had evidence of malnutrition.

CONCLUSIONS

The findings of this and other studies demonstrate the need for major initiatives to address the underlying causes of cancrum oris and to promote the utilization of health care.

Noma (cancrum oris): questions and answers

Noma (cancrum oris) is an infectious disease which destroys the oro-facial tissues and other neighboring structures in its fulminating course. It affects predominantly children aged 2-16 years in sub-Saharan Africa where the estimated frequency in some communities may vary from one to seven cases per 1000 children. The key risk factors are poverty, malnutrition, poor oral hygiene, deplorable environmental sanitation, close residential proximity to livestock, and infectious diseases, particularly measles. Malnutrition acts synergistically with endemic infections in promoting an immunodeficient state, and noma results from the interaction of general and local factors with a weakened immune system as the common denominator. Acute necrotizing gingivitis (ANG) is considered the antecedent lesion. Current studies suggest that evolution of ANG to noma requires infection by a consortium of microorganisms with Fusobacterium necrophorum and Prevotella intermedia as the suspected key players. Without appropriate treatment, mortality rate is 70-90%. Survivors suffer the two-fold affliction of oro-facial disfigurement and functional impairment. Reconstructive surgery of the resulting deformity is time-consuming and financially prohibitive for the victims who are poor.

The gene for severe combined immunodeficiency disease in Athabascan-speaking Native Americans is located on chromosome 10p

Severe combined immunodeficiency disease (SCID) consists of a group of heterogeneous genetic disorders. The most severe phenotype, T-B- SCID, is inherited as an autosomal recessive trait and is characterized by a profound deficiency of both T cell and B cell immunity. There is a uniquely high frequency of T-B- SCID among Athabascan-speaking Native Americans (A-SCID). To localize the A-SCID gene, we conducted a genomewide search, using linkage analysis of approximately 300 microsatellite markers in 14 affected Athabascan-speaking Native American families. We obtained conclusive evidence for linkage of the A-SCID locus to markers on chromosome 10p. The maximum pairwise LOD scores 4.53 and 4.60 were obtained from two adjacent markers, D10S191 and D10S1653, respectively, at a recombination fraction of straight theta=.00. Recombination events placed the gene in an interval of approximately 6.5 cM flanked by D10S1664 and D10S674. Multipoint analysis positioned the gene for the A-SCID phenotype between D10S191 and D10S1653, with a peak LOD score of 5.10 at D10S191. Strong linkage disequilibrium was found in five linked markers spanning approximately 6.5 cM in the candidate region, suggesting a founder effect with an ancestral mutation that occurred sometime before 1300 A.D.

Maternal mosaicism for a novel interleukin-2 receptor gamma-chain mutation causing X-linked severe combined immunodeficiency in a Navajo kindred

X-linked severe combined immunodeficiency disease (SCID) results from mutations of IL2RG, the gene encoding the interleukin-2 receptor gamma chain, also known as the common gamma chain (gamma c). A distinct form of autosomal recessive SCID occurs at an increased frequency among the Navajo Native American population. The disease gene responsible for autosomal Navajo SCID remains to be determined. We report the occurrence of X-linked SCID in a Navajo Native American kindred with two affected brothers. X-linked SCID was suggested by the presence of circulating B cells and the absence of surface gamma c expression in a cell line derived from an affected male. A C-to-T transition was demonstrated in exon 5 of the IL2RG gene, resulting in the substitution of tryptophan for arginine at position 224. This change was not present in the peripheral blood lymphocytes of the mother, thus proving the occurrence of a new mutation in the maternal germline. This report underscores the importance of establishing a specific genetic diagnosis for SCID cases and illustrates the inherent difficulties in providing genetic counseling in cases involving mosaicism.

Noma (cancrum oris) in human immunodeficiency virus/acquired immune deficiency syndrome patients: report of eight cases

PURPOSE

This article describes the clinical features and management of noma (cancrum oris) in HIV/AIDS patients.

PATIENTS AND METHODS

Eight HIV/AIDS patients were studied. Clinical presentation was different in all of the cases. Conservative debridement under local anesthesia with an antibiotic was performed.

RESULTS

Satisfactory resolution of the acute phase of this dangerous infection was achieved.

CONCLUSION

Minimal but thorough debridement of necrotic tissue along with lavage with povidone-iodine is effective in controlling this infective process. However, long-term sequelae of noma are not possible because of the underlying HIV infection from which the patients inevitably soon succumbs.

Orofacial manifestations in the primary immunodeficiency disorders

Primary immunodeficiencies are increasingly recognized yet there is little data concerning the oral manifestations of such disorders. This article reviews the current literature and details the oral aspects of well-characterized primary immunodeficiencies.

Noma neonatorum: an unusual case of noma involving a full-term neonate

Noma neonatorum is a gangrenous process that occurs in the oral, nasal or anal area and occasionally the eyelids and scrotum of the newborn. The disease is caused by Pseudomonas aeruginosa and usually affects premature ill babies during the first few weeks of life. A full-term neonate with nasal and scrotal noma is uncommon and is therefore reported.