[Noma/Cancrum oris: a neglected disease]

Noma is an aggressive orofacial gangrenous pathology that damages hard and soft tissues of the mouth and the face. Throughout the centuries it has been present around the globe, but nowadays it has practically disappeared from developed countries and mainly affects children from the most disadvantaged places, especially in Africa. Noma disease is a multifactorial process; malnutrition, debilitating diseases (bacterial or viral systemic diseases, HIV-associated immunosuppression, etc.) and intraoral infections are some of the factors implied. The characteristic tissue necrosis is produced by a polymicrobial infection. Fusobacterium necrophorum, Prevotella intermedia, Prevotella melaninogenica, Fusobacterium nucleatum, Bacteroides fragilis, Bacillus cereus, Trueperella pyogenes, spyrochetes, etc, are some of the species that have been isolated from the affected areas. Without treatment, noma is lethal in a short period of time, and the patients that survive show severe sequelae that hinder their life and interpersonal relationships. The aim of this paper is to unify the existing information and to promote wider knowledge and awareness among the population.

Prevalence of psychiatric morbidity and its associated factors among patients facially disfigured by cancrum oris in Nigeria a controlled study

OBJECTIVE

Little information is available about prevalence of psychiatric morbidity among adult patients who suffered from cancrum oris in Nigeria. The objective of this paper was to assess the prevalence of psychiatric morbidity among patients of cancrum oris in Nigeria.

METHOD

A cross sectional controlled study was conducted in 2005 comprising 200 adult patients of cancrum oris. Data was collected through self administered questionnaire from the patients. Psychiatric morbidity was assessed using General Health Questionnaire (GHQ) 28.

RESULTS

Prevalence of psychiatric morbidity was 37% which was about three times that of the control. Psychiatric morbidity was more prevalent among female patients. Other factors associated with high prevalence of psychiatric morbidity include being never married, no formal education and unemployed status.

CONCLUSION

Psychiatric morbidity is prevalent among cancrum oris patients with differences between both sexes. Being never married, no formal education and unemployed status were other associated factors.

Noma: life cycle of a devastating sore - case report and literature review

Noma (cancrum oris) is an orofacial gangrene, which during its fulminating course causes progressive and mutilating destruction of the infected tissues. The disease occurs mainly in children with malnutrition, poor oral hygiene and debilitating concurrent illness. Noma is well documented in the literature, but because most patients do not report to a doctor until the disease is at an advanced stage, its onset and progression remain a mystery. This case report, with a survey of recent relevant literature, highlights the different stages in the development of tissue necrosis, including onset and progression, with an emphasis on the need for early diagnosis and prompt treatment.

Necrotizing ulcerative periodontal diseases in children and young adults in Medellín, Colombia, 1965--2000

Previous findings that necrotizing ulcerative gingivitis (NUG) is a precursor to noma or cancrum oris were confirmed by the follow-up of these clinical conditions in a study of 45 Colombian patients: necrotizing ulcerative gingivitis (NUG, n = 29), necrotizing ulcerative periodontitis (NUP, n = 7) and noma (n = 9). Patients were diagnosed at the outpatient clinic of the School of Dentistry at the University of Antioquia, at the University Hospital Saint Vincent of Paul, at the Luz Castro de Gutierrez University Hospital, at the Red Cross Hospital and at the private office of one of the authors (Jiménez L., M) in Medellín, Colombia, from 1965 until 2000. Almost all the patients came from low socioeconomic groups and presented with predisposing and/or contributing factors, such as acute herpetic gingivostomatitis, measles, and leukemia (including acute lymphoblastic and chronic lymphoid leukemia). Malnutrition and poor oral hygiene were associated with the necrotizing process and favored progression from the gingiva to deeper periodontal tissues and other structures within the oral cavity or the facial tissues. No patients had human immunodeficiency virus (HIV) or AIDS, which makes these findings different from other reports. Noma can be prevented by vaccinating children against infectious diseases, by controlling malnutrition and by improving their oral hygiene. It is arrested by mechanical lesion debridement, improving oral hygiene and antibiotic therapy. Necrotizing ulcerative gingivitis may progress in some cases to ulcerative necrotizing stomatitis, necrotizing ulcerative periodontitis, and, finally, to noma. Microbial studies among new Colombian NUG, NUP and noma patients are necessary, using bacterial culturing and identification methods and molecular techniques such as PCR for viruses and bacteria, in order to establish the exact nature of these lesions.

[Noma in HIV-infected adults]

INTRODUCTION

Noma is a necrotic stomatitis, frequent in undernourished children in tropical countries. Its occurrence in adults is extremely rare and has recently been described during AIDS. We report two new cases.

OBSERVATIONS

The first patient, a 37 year-old farmer, consulted for a mutilating ulcer of the commissure of the right lip. The second patient, a 25 year-old woman, consulted for an ulcerating and necrotic tumefaction of the left cheek. Anamnesis reconstructed the chronology of the lesions and a cutaneous biopsy revealed non-specific ulcers. The status of health of both patients was poor and they both exhibited positive HIV serology.

DISCUSSION

The diagnosis of noma is easy and based on clinical manifestations. The characteristic aspect is that of a mutilating ulcer of the face with conventional progression: tumefaction, followed by ulceration and finally elimination necrosis. This disease predominates in children. Its discovery in adults is a sign of poor prognosis because it may reveal an HIV infection at the AIDS stage.

CONCLUSION

It is important to draw the attention of practitioners on the interest of performing HIV serology when confronted with an adult exhibiting a noma, and to evoke a noma when confronted with a tumefaction of the face rapidly progressing towards necrosis.

[Noma: apropos of a case in a 9-year-old child at the Centre Hospitalier de Libreville (Gabon)]

The authors report the observation of a disease in fact the noma which one believed disappeared, it of it is nothing. This disease, summation of several factors, with frightening forecasts immediate and remote, must have before a whole preventive treatment by the improvement of the standard of living of the populations because its repair is so long, if difficult and so expensive that access will have well little there.

Is noma neonatorum a presentation of ecthyma gangrenosum in the newborn?

Noma neonatorum was suggested as a distinct entity characterized by a gangrenous process of the nose, oral cavity, eyelids and perineum that was almost universally fatal in premature infants with Pseudomonas sepsis. We report the first case of noma neonatorum in a 26-week-gestation twin born in the United States. Our case is consistent with previous descriptions of noma neonatorum; however, we question the distinction between noma neonatorum and a neonatal presentation of ecthyma gangrenosum.

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.

Cancrum oris (noma) in a patient with acute lymphoblastic leukaemia. A complication of chemotherapy induced neutropenia

Cancrum oris (noma) has been most commonly described in malnourished debilitated children with poor oral hygiene following systemic childhood infections such as measles, pertussis or scarlet fever. We describe a patient who developed this condition during a period of profound neutropenia following cytotoxic chemotherapy for acute lymphoblastic leukaemia.

Cancrum oris (noma) in children

Cancrum oris, noma or gangrenous stomatitis is a disease which affects primarily undernourished and immunosuppressed young children. Frequent in underdeveloped countries, it also is seen in rare cases of patients with AIDS and leukemia in America and in Europe. Once fatal, the disease is now better understood and today the repair of its terrible sequels is looked upon as a great surgical challenge. This paper reports a case of noma in a 3-year-old black African female admitted to this Service. In an already advanced stage of this illness with severe sequelae, she presented with partial amputation of the lips (upper and lower), right cheek, right side of the nose and maxilla. The choice of treatment of the infected area and eventual reconstruction is discussed.

Cancrum oris--a 35-year retrospective study

OBJECTIVES

To determine the factors predisposing to cancrum oris and its frequency, clinical features, treatment and outcome. Cancrum oris is a gangrenous condition of the face usually occurring in poorly nourished children in a Third-World setting.

DESIGN

Retrospective review of clinical data on children with cancrum oris.

SETTING

All children with cancrum oris seen over a 35-year period, from 1960 to 1995, at Red Cross War Memorial Children's Hospital (RXH) in Cape Town.

SUBJECTS

Twenty-six patients (16 female and 10 male) with cancrum oris. Their average age at presentation was 4 years and 4 months (range 1-15 years).

RESULTS

The peak incidence was between 1971 and 1975 (11 cases); subsequently only 1 new case was seen at RXH in every 5-year period. Most children were referred from rural areas. Associated conditions could only be determined in 11 of the 26 patients. In order of frequency, these were malnutrition, gastro-enteritis, measles and anaemia. Twenty-three of the 26 children had soft-tissue involvement affecting the lips, cheek, chin, nose or other structures. Eighteen had bony or cartilaginous involvement; the maxilla was affected in 15, the palate in 7, the vomer in 5, the mandible in 3 and the nasal septum in 7. Three children had bony involvement only, the soft tissues being spared. Operative records were available for 18 children. These 18 children had a total of 84 operations, with an average of 4.7 per child (range 0-12).

CONCLUSIONS

Cancrum oris is a devastating condition affecting malnourished children. Reconstruction is complex and demanding, involving both soft tissue (23 of 26 cases) and bone (18 of 26 cases). Most children require multiple procedures. Prevention is best effected by comprehensive primary health care.

Gangrenous stomatitis (cancrum oris): clinical features, etiologic factors, and complications

Gangrenous stomatitis (cancrum oris) is a lesion involving the orofacial structures that is primarily seen in areas where the socioeconomic standards are low and there is poor hygiene. The general clinical features, associated etiologic factors, and ensuing complications in eight consecutive cases diagnosed between 1991 and 1995 are presented and discussed.

Noma: a review

Cancrum oris or noma is a condition not well known in western Europe and North America. It is, however, a relatively common cause of mortality and disability in children of undeveloped areas of Africa, Asia, and South America. This paper describes the experience at Galmi Hospital, in the sub-Saharan region of South Africa in the Niger Republic, with 50 operative patients out of a group of 300 who were referred. An extensive review of the literature is presented describing the epidemiological impact of the disease, the characteristics of the lesions, the pathogenesis, symptoms, sequelae, differential diagnosis, and preoperative preparation. Additionally, we review approaches to anesthesia, methods of reconstruction, and the most common causes of complications and mortality. Numerous photographs illustrating the devastating consequences of this problem are presented.

Oral manifestations of infectious diseases

The oral manifestations of infectious diseases is a major topic since the prevalence rate has increased, and usually poses diagnostic and therapeutic dilemmas to the oral clinician. The clinical features of the most common and important oral infectious diseases are discussed.

Noma: clinical and evolutive aspect

Noma is a gangrenous stomatitis affecting children from developing countries. It may leave dreadful mutilations around the mouth, leading to esthetic disabling sequels and permanent trismus. Iconography of the acute stage and of sequels is presented in this paper, and pathogenesis of the disease is discussed.

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.

[Noma: presentation of a case]

The noma has been rarely seen during these last decades. It is of an infections etiology, primarily affecting malnourished or immunodeficient children. It is easily confused with neoplastic tumors, tuberculosis, mycosis or gangrene ecthyma which may condition errors in treatment with severe undesirable side-effects. It has recently been associated to AIDS. A case is reported, comments are included on the diagnostic method, medical and surgical treatment and the results obtained.

Cancrum oris-like lesions

Cancrum oris is predominantly seen in children in underdeveloped countries where widespread malnutrition, dehydration and epidemic infections are present. In the western world, it is sometimes found in immunosuppressed adults with predisposing conditions such as leukaemia and infection associated with malnutrition. Early diagnosis and an intensive therapeutic approach are the key to a favourable prognosis of noma-like necro-ulcerative lesions. The prognosis is significantly improved if the predisposing condition can be removed. Two cases are presented and the treatment is discussed.

Noma and noma neonatorum

Noma and noma neonatorum are rare gangrenous diseases that result in mutilating loss of tissue in the oronasal region. Noma usually occurs in patients between the ages of 2 and 5 years who are malnourished, have suffered a precedent illness, or are in some way immunodeficient, or all of the above. The gangrenous slough is thought to be caused by a mixed infection of oral bacterial pathogens. The disease may be fatal when it occurs in a severely debilitated patient. Noma neonatorum produces somewhat similar appearing lesions in the neonate. The infectious organism is usually Pseudomonas and the disease is generally accompanied by a life-threatening pseudomonal sepsis. Both diseases are rare in North America. Patients with noma and noma neonatorum were treated at the Children's Hospital and Medical Center, Seattle, WA. We present these cases and a literature review.

Cancrum oris in an adult Caucasian female

This paper reports a case of cancrum oris in an adult Caucasian female who had no obvious pre-disposing cause. It highlights the difficulties in making this diagnosis in a part of the world unaccustomed to seeing the disease and it illustrates that early surgery and reconstruction can be undertaken. To our knowledge, this is the first published case of cancrum oris reconstructed with the use of micro-vascular free tissue transfer.

Bacterial gangrene on the cheek of a comatose patient--necrotizing fasciitis or noma

A 68-year-old Japanese woman with sepsis developed a gangrene on her left cheek from a small wound in contact with a gastric tube. Klebsiella pneumoniae was cultured from the sputum, wound, and the blood and was assumed to be responsible for this condition, possibly through thrombosis of an artery.

Hodgkin's disease presenting in the maxilla. A case report

A rare case of intra-oral, extra nodal, maxillary Hodgkin's disease (Stage I), with no other discernible tissue involvement is described and discussed. The pertinent literature is reviewed.

Noma in children with severe combined immunodeficiency

Three Native American children with severe combined immunodeficiency developed noma, a necrotizing gingivostomatitis not previously reported in this country. The similarity between the clinical findings and those observed in monkeys with simian AIDS prompted us to evaluate our patients and their families for human retroviral infection. Antibodies to HTLV-I or HTLV-III/LAV proteins were not identified in patients nor in their family members. Standard bacterial and viral cultures similarly failed to identify a suspect pathogen.

Infectious oral necrosis (cancrum oris) in Nigerian children: a review

The devastating orofacial gangrenous disease known as cancrum oris (noma) is still commonly seen in underprivileged Nigerian children. These children are usually victims of such stressors as chronic malnutrition, numerous endemic communicable diseases and severe adverse physical conditions which may lead to depletion of their adaptive resources or produce physiological maladaptation to additional stressors. Measles is the most common infection preceding the development of noma in Nigerian children. Acquired immunodeficiency as well as the impaired endocrine balance of the chronically malnourished permits, for example, widespread infection with the measles virus. Anergy resulting from the combination of malnutrition and measles virus infection promotes selective overgrowth and invasion by an infective consortium consisting of anaerobic organisms and other species capable of elaborating necessary growth factors for the former. Because of the pre-existing depletion of adaptive physiologic resources in the malnourished child, the infection is not readily contained locally as necrotizing ulcerative gingivitis but instead spreads rapidly to the next naturally occurring anatomical barriers. This is then followed by continuing necrosis and possible sequestration as exemplified by noma.

An interesting case of adult facial gangrene (from Papua, New Guinea)

A case of a nomalike lesion occurring in an elderly woman is described. The patient was admitted to the hospital in a debilitated state and was undergoing supportive management when the facial condition developed. Because of the rapidly progressing nature of the lesion, apparently emanating from the alveolar soft tissues, a diagnosis of cancrum oris was made. Although progression of the lesion was halted following institution of an appropriate therapeutic regimen, the patient's general condition deteriorated and she finally died 12 days after admission. The exact nature of the underlying systemic condition was never diagnosed.

Histopathologic changes in macaques with an acquired immunodeficiency syndrome (AIDS)

The authors recently described the clinical course of an Acquired Immunodeficiency Syndrome (AIDS) in a colony of macaque monkeys. In the present study, they have reviewed the histopathology of tissues obtained from a cohort of 16 animals with this clinical syndrome at necropsy. They found evidence in these animals of several opportunistic infections, including cytomegalovirus (CMV), simian virus 40 (SV-40), and noma. Furthermore, a number of other unusual pathologic processes were noted. In 4 animals an array of lymphoproliferative disorders was observed, ranging from multiple nodules of lymphocytes in the kidney, liver, and bone marrow, to frank lymphoma. Evidence of retroperitoneal fibrosis was found in 3 of the animals. Finally, amyloidosis was observed in several animals; in two instances it was present only in the mucosa of the small intestine.

Noma. Report of two cases

Noma is an infectious process involving the oral cavity and occasionally other structures. It is characteristically a childhood affliction, and it never occurs in healthy persons. Conservative treatment in debriding facial lesions greatly enhances reconstructive efforts.

Cancrum oris: principles of management and reconstructive surgery

A survey of 140 cases of cancrum oris in Nigerian Africans is presented. The salient clinical features, the problems of management and the modern approaches to the reconstruction of facial deformities seen in this disease are described. Mainly affected were children under the age of 10 years and the commonest involvement was the full thickness of the cheek. A high incidence of ankylosis was noted and the methods of anaesthesia and surgical correction of ankylosis are examined. The number of patients presenting for reconstruction of facial defects due to cancrum oris appears to be increasing. Preventive measures that may reduce the incidence of the disease are suggested.

Noma in a nonhuman primate

A lesion in Macaca cyclopis which appears to conform to defined characteristics of noma in human beings has been reported. Clinical features in common include the gangrenous appearance of the lesion, the association with necrotizing ulcerative gingivitis, and the massive destruction of soft tissue and bone in the oronasofacial regions. Systemic features in common include debilitation of the host, leukocytosis, and depression of cellular immunologic responses. Microbiologic studies revealed the presence of organisms commonly found in necrotizing ulcerative gingivitis. The detection of true noma in nonhuman primates may now allow the opportunity for study of the etiology, pathophysiology, and therapy of this condition for human benefit.

An oral disease resembling noma in six rhesus monkeys (Macaca mulatta)

Over a 19-month period, five rhesus monkeys developed oral lesions of gingival erosion and bone denudation with sequestration. One other rhesus monkey developed facial necrosis which communicated with the oral cavity. These lesions were consistent with those seen in the disease called noma (cancrum oris) in humans.