We did a comprehensive search of scientific publications including databases OLD MEDLINE via OVID (1951–65), MEDLINE via PubMed (1950–2005), and ISI web of science. The search terms used were “noma”, “cancrum oris”, “oral gangrene”, “orofacial necrosis”, “necrotiz[s]ing ulcerative gingivitis”, and “noma, malnutrition AND oral health”, “noma AND measles”, “noma AND viral infections”, and “noma AND HIV/AIDS”. Many published reports on noma were also identified through searches of COE's
SeminarNoma (cancrum oris)
Section snippets
Global burden of noma
Noma was not always restricted to tropical or African countries.2, 10 It was common in Europe until the end of the 19th century.1, 2 Noma disappeared from more developed countries in the 20th century, except for cases reported in the concentration camps of Bergen-Belsen and Auschwitz18, 19 and, more recently, in association with intense immunosuppressive therapy,20 in patients with HIV infection or AIDS,8, 9 as well as in native American children with severe combined immunodeficiency syndrome.21
Clinical presentation, progression, and sequelae
Many patients with acute noma present with a range of features reflecting pre-existing, debilitating health conditions. They include fever (temperature 38·3–40·5°C), tachycardia, high respiratory rate, and anorexia. The medical history generally shows recurrent fevers, diarrhoea, and infections with parasites (eg, malaria) and viruses (eg, measles, herpes) in the recent past.1, 2, 3, 5 Severe anaemia, with haemoglobin concentrations as low as 50–60 g/L, white-blood-cell counts of 20–30×109 per
Orofacial features
The orofacial lesion can occur unilaterally or bilaterally, but it is unilateral in many cases. Descriptions of the initial stages are inconsistent because the disease is generally well established before the victim seeks medical help.1, 2, 16 The early features include soreness of the mouth, pronounced halitosis, foetid taste, tenderness of the lip or cheek, cervical lymphadenopathy, a foul-smelling purulent oral discharge, and a blue-black discolouration of the skin in the affected area.1, 3,
Differential diagnosis of noma
The disorder known as noma neonatorum affects newborn and preterm infants and clinically resembles noma in children.47, 48, 49 The necrotic lesion, generally in the oronasal region, develops during the first month of life; in most cases, there is evidence of infection with Pseudomonas aeruginosa, Escherichia coli, klebsiella, or staphylococci.47, 48 Except for one case in a preterm baby in the USA,50 virtually all the reported cases have been in infants born in India, China, Lebanon, or Israel.
Microbiology
The earliest bacteriological studies of noma were described by Weaver and Tunnicliff in 1907.57 An important major microscopic observation is the presence of large numbers of fusiform bacilli and spirochaetes.1, 16, 57 Hicken and Eldredge58 suggested that a symbiotic association of fusiform bacilli with a non-haemolytic streptococcus and Staphylococcus aureus was needed to produce noma. Emslie40 observed that these organisms were predominant in smears from patients with acute noma but also
Risk factors for noma
Noma has not been reported in healthy, privileged African children.13, 22 Poverty is the key risk factor in Africa2, 3, 22 and elsewhere.43, 44 A retrospective study of 173 cases at a hospital in Nigeria showed that 98% were from very poor homes with a mean of seven children per family.76 The global dimensions of poverty and its health implications, particularly malnutrition, are well documented.77 Chronic malnutrition is a major predisposing factor in all countries reporting noma.2, 3, 13, 16
Treatment of acute noma
The key points of management during the acute phase of noma (panel 1) are prompt admission to hospital, correction of dehydration and electrolyte imbalance, nutritional rehabilitation to correct energy deficit and deficiencies of proteins and micronutrients, treatment with antibiotics, daily dressing of the lesion with gauze soaked in oral antiseptic, and treatment of associated systemic diseases.2, 16, 86 Some researchers16 recommend the use of a broad-spectrum antibiotic, whereas others86
Prevention and early detection of noma
Noma is encountered mainly in underprivileged, illiterate, remote communities. It becomes established very rapidly, leaving patients little time to seek medical assistance. Parents, and even many health personnel, know little about the disease. Information campaigns are therefore needed at national, regional, and village levels. All health personnel, including physicians and dentists, should routinely screen at-risk children for early signs of noma (panel 2), and suspected cases should be
Proposed pathogenesis of noma
There is a three-way relation between malnutrition, immune dysfunctions in the host, and increased susceptibility to infections.91, 92, 93, 94, 95 As shown in figure 8 under the broad umbrella of poverty, this relation tends to be synergistic91, 94 and results in impaired oral mucosal immunity. In African communities at risk of noma, the adverse consequences of IUGR, which include impaired development of immune function, especially cell-mediated immunity,96, 97 become apparent in early
Search strategy and selection criteria
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Noma, Actinomycosis, and Nocardia
2023, Manson's Tropical Diseases, Fourth EditionPrevalence, incidence, and reported global distribution of noma: a systematic literature review
2022, The Lancet Infectious DiseasesCitation Excerpt :A related disease with a similar clinical picture is noma neonatorum. This disease mainly affects preterm or low-birthweight infants, in most cases with Pseudomonas aeruginosa, Escherichia coli, Klebsiella spp, or Staphylococcus spp infections.3,19 Almost all patients who have noma neonatorum succumb to the disease following sepsis.5
Infections Caused by Anaerobic Microorganisms
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