Facing Africa: Describing Noma in Ethiopia.

Noma affects the most marginalized communities in the world, beginning as oral ulceration and rapidly progressing to orofacial gangrene. With a mortality rate estimated to be as high as 90% and with very few able to access treatment in its active phase, very little is understood about the disease. This retrospective review of patients treated by Facing Africa for deformity and functional impairment secondary to noma between May 2015 and 2019 highlights some of the difficulties encountered by those afflicted. Eighty new patients with historical noma defects were identified and were seen over the course of nine surgical missions, with notes providing valuable geographical, socioeconomic, and psychosocial information. The mean self-reported age of onset was 5 years and 8 months, with a median time of 18 years from onset to accessing treatment. Before intervention, 65% covered their face in public, 59% reported difficulty eating, 81% were unhappy with their appearance, and 71% experienced bullying. We aimed at emphasizing the significant burden, both psychologically and physically of noma, demonstrating the disparity between recent decades of progress in the well-being of Ethiopians in general and the access to health care and mental health support for some of those most in need.

Noma (cancrum oris) in the South African context.

Noma (cancrum oris) is a destructive necrotising disease affecting orofacial tissues predominantly of malnourished young children. It is characterised by a rapid acute onset which usually starts in the mouth, spreads intra-orally destroying soft tissue and bone and progresses to perforate the facial skin, causing disfigurement. Polybacterial anaerobic infection is critical too, but is not alone sufficient for the initiation of noma. Cofactors, first and foremost malnutrition, but also systemic viral and bacterial infections are crucial to the development of noma. A patient with necrotising stomatitis or noma must be admitted to hospital for antibiotic treatment, fluid and electrolytes as well as nutritional supplementation and general supportive treatment. The epidemiology of noma in the South African population is unknown, and the clinicopathological features are poorly characterised. Although worldwide there is no evidence that HIV infection is a strong risk factor for noma, HIV infection may play a substantial role in the pathogenesis of noma in South Africa.

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.

Noma: an "infectious" disease of unknown aetiology.

Noma (cancrum oris) is a devastating gangrenous disease that leads to severe tissue destruction in the face and is associated with high morbidity and mortality. It is seen almost exclusively in young children living in remote areas of less developed countries, particularly in Africa. The exact prevalence of the disease is unknown, but a conservative estimate is that 770000 people are currently affected by noma sequelae. The cause remains unknown, but a combination of several elements of a plausible aetiology has been identified: malnutrition, a compromised immune system, poor oral hygiene and a lesion of the gingival mucosal barrier, and an unidentified bacterial factor acting as a trigger for the disease. This review discusses the epidemiology, clinical features, current understanding of the pathophysiology, and treatment of the acute phase and sequelae requiring reconstructive surgery. Noma may be preventable if recognised at an early stage. Further research is needed to identify more exactly the causative agents.

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.

Zigomicosis subcutanea cronica complicada con noma de Madagascar / Chronic subcutaneous zygomycosis with noma of Madagascar

Describimos el caso de un nino de seis anos de edad remitido con diagnostico de actinomicosis y mucormicosis, por presentar masas lenosas, no dolorosas, en tercio inferior de la cara. Se practico biopsia de la lesion y de ganglio linfatico adyacente en cuyo reporte histopatologico se destacaba la presencia de hifas anchas y aseptadas en un area de necrosis con caseificacion. Con esta apreciacion y las caracteristicas clinicas del paciente se hizo el diagnostico de zigomicosis por cuyo motivo se inicio tratamiento con itraconazol. Posteriormente regreso con destruccion, por necrosis, del tercio inferior de la cara, exposicion del maxilar inferior y compromiso del globo ocular izquierdo. Esta observacion nos llevo a pensar en un noma, considerada como complicacion secundaria de enfermedad sistemica, poco frecuente en nuestro medio y producida por la invasion de ciertos tipos de bacterias

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.

Cancrum oris.

Cancrum oris is a gangrenous infection of the oral cavity. Debilitating diseases predispose to the condition. The exact bacteriology is uncertain although Vincent's Spirochaete and the fusiform bacillus in symbiosis have been considered to be the actual cause of the condition. The presentation of the disease is variable, for the condition may affect the soft tissues of the face or the bones of the facial skeleton or both concurrently. This disease has a high mortality rate. If recovery from toxaemia ensues, subsequent healing becomes a lengthy affair because of the destructive nature of the condition. Since the introduction of antibiotics as a form of therapy, a higher survival rate has been achieved. Because of the nature of the condition the morbidity rate is exceptionally high with functional disturbances and disfigurement being a legacy of the disease. Reconstructive procedures are generally required at some subsequent stage.