Immune Markers Are Associated With Asymptomatic Intracranial Large Artery Stenosis and Future Vascular Events in NOMAS.

BACKGROUND: Inflammation contributes to atherosclerosis but is incompletely characterized in intracranial large artery stenosis (ICAS). We hypothesized that immune markers would be associated with ICAS and modify the risk ICAS confers on future vascular events. METHODS: This study included a subsample of stroke-free participants in the prospective NOMAS (Northern Manhattan Study), who had blood samples analyzed with a 60-plex immunoassay (collected from 1993 to 2001) and ICAS assessment with time-of-flight magnetic resonance angiography (obtained from 2003 to 2008). We dichotomized ICAS as either ≥50% stenosis or not (including no ICAS). We ascertained post-magnetic resonance imaging vascular events. We used least absolute shrinkage and selection operator procedures to select immune markers independently associated with ICAS. Then, we grouped selected immune markers into a derived composite Z score. Using proportional odds regression, we quantified the association of the composite immune marker Z score, ICAS, and risk of vascular events. RESULTS: Among 1211 participants (mean age, 71±9 years; 59% women; 65% Hispanic participants), 8% had ≥50% ICAS. Using least absolute shrinkage and selection operator regression, we identified CXCL9 (C-X-C motif chemokine ligand 9), HGF (hepatocyte growth factor), resistin, SCF (stem cell factor), and VEGF-A(vascular endothelial growth factor A) to have the strongest positive relationships with ≥50% ICAS in fully adjusted models. Selected markers were used to derive a composite immune marker Z score. Over an average follow-up of 12 years, we found that each unit increase in immune marker Z scores was associated with an 8% (95% CI, 1.05-1.11), 11% (95% CI, 1.06-1.16), and 5% (95% CI, 1.01-1.09) increased hazard of death, vascular death, and any vascular event, respectively, in adjusted models. We did not find a significant interaction between immune marker Z scores and ICAS in their relationship with any longitudinal outcome. CONCLUSIONS: Among a diverse stroke-free population, selected serum immune markers were associated with ICAS and future vascular events. Further study is needed to better understand their role in the pathogenesis of ICAS and as a potential therapeutic target in stroke prevention.

Herpes simplex virus 2 serology is associated with thinner whole-brain cortex in community-dwelling older adults.

Prior work in the Northern Manhattan Study (NOMAS) identified impaired cognition in cross-sectional analyses and more rapid memory decline in individuals with evidence of prior common infectious disease exposures. In this study, we sought to determine the cross-sectional relationship between prior exposure to cytomegalovirus, herpes simplex viruses 1 and 2, Chlamydia pneumoniae, and Helicobacter pylori and three magnetic resonance imaging (MRI) signatures (whole-brain cortical thickness, a previously validated AD signature, and hippocampal volume) in 455 NOMAS participants. We performed confounder-adjusted linear regression analyses between neuroimaging scores and both continuous serologies and categorical seropositivity of each pathogen, as well as a combined infectious burden index (IBI). We identified that increased serologic titers of herpes simplex virus 2 were associated with reduced whole-brain cortical thickness, and a combined score of HSV-2 and C. pneumoniae displayed an additive effect on reduced cortical thickness. Our findings suggest herpes simplex virus 2 seropositivity may contribute to accelerated brain aging, possibly resulting in an increased vulnerability to cognitive impairment and neurodegenerative disease in aging populations.

The severity of psychosocial and functional morbidity among facially disfigured untreated noma cases in Ethiopia.

OBJECTIVES: Noma is a facially disfiguring disease that affects the oral cavity and midface structures. If left untreated, the disease is fatal. Noma causes severe cosmetic and functional defects in survivors, leading to psychiatric and social problems. However, there are limited data on psychosocial and functional sequelae associated with this disease. This cross-sectional study aimed to investigate psychosocial and functional morbidity among facially disfigured untreated Noma cases. Study participants were volunteer patients diagnosed with noma and awaiting surgery at two noma treatment centers in Ethiopia. A questionnaire derived from the APA's DSM-5, the DAS59, and the Appearance Anxiety Inventory protocol was used to measure the psychosocial and functional morbidity of the cases between September 16 and October 10, 2022. RESULTS: A total of 32 noma cases (19 women and 13 men) awaiting the next surgical campaigns were involved in the study. Study participants reported severe social (Likert score = 2.8) and psychological (Likert score = 3.0) morbidity. Functional limitation was moderate (Likert score = 2.9). This study has shown that psychosocial and functional morbidity in untreated noma cases in Ethiopia is substantial. Therefore, policymakers, clinicians, and researchers need to pay sufficient attention to providing adequate health care and preventing the occurrence of the disease in the long term.

Noma disease (cancrum oris, orofacial gangrene) in an acute myeloid leukemia patient: a case report.

BACKGROUND: Noma is a rare disease that occurs mainly in malnourished patients in developing countries. Noma starts as facial swelling and gingival necrosis that eventually necrotizes underlying tissues including the jaw bone, leaving severe disfigurement. It is reported extremely rarely in patients with severe immunosuppression or blood dyscrasia. CASE PRESENTATION: The gingivitis that occurred in a 12-year-old Asian female patient with acute myeloid leukemia was getting increasingly worse. Although the proper treatment was done, the patient's condition did not improve, and eventually, a large full-thickness defect was left in the maxillofacial part. CONCLUSIONS: Early diagnosis and management is the only way to prevent the progression, which leads to facial disfigurement. We present a case of noma in a pediatric acute myeloid leukemia patient, in which oral function was restored through surgical intervention.

Intracranial Large Artery Stenosis and Past Infectious Exposures: Results From the NOMAS Cohort.

BACKGROUND: Intracranial large artery stenosis (ILAS) is an important contributor to ischemic stroke in the United States and worldwide. There is evidence to suggest that chronic exposure to certain infectious agents may also be associated with ILAS. We aimed to study this association further in an ethnically diverse, prospective, population-based sample of Northern Manhattan. METHODS: We enrolled a random sample of stroke-free participants from an urban, racially, and ethnically diverse community in 1993. Participants have been followed prospectively and a subset underwent brain magnetic resonance angiograms from 2003 to 2008. Intracranial stenoses of the circle of Willis and vertebrobasilar arteries were scored as 0=no stenosis, 1≤50% (or luminal irregularities), 2=50% to 69%, 3≥70% stenosis, and 4=flow gap. We summed the individual score of each artery to produce a global ILAS score (possible range, 0-44). Past infectious exposure to Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, and herpes simplex virus 1 and 2 was determined using serum antibody titers. RESULTS: Among 572 NOMAS (Northern Manhattan Study) participants (mean age 71.0±8.0 years, 60% women, 68% Hispanic) with available magnetic resonance angiogram and serological data, herpes simplex virus 2 (beta=0.051, P<0.001) and cytomegalovirus (beta=0.071, P<0.05) were associated with ILAS score after adjusting for demographics and vascular risk factors. Stratifying by anterior and posterior circulations, herpes simplex virus 2 remained associated with the anterior circulation (beta=0.055 P<0.01) but not with posterior circulation ILAS score. CONCLUSIONS: Chronic infectious exposures, specifically herpes simplex virus 2 and cytomegalovirus were associated with asymptomatic ILAS as seen on magnetic resonance angiogram imaging. This may represent an additional target of intervention in the ongoing effort to stem the substantial global burden of strokes related to ILAS.

Case Report: Malignant Transformation of Noma: Repair by Forearm Flap.

Noma is a progressive infectious disease manifested by a necrotic ulcer of the mouth and face. It usually occurs in poor, malnourished children, with about 30,000-140,000 cases each year and a low survival rate. The exact cause of noma remains unclear, but bacterial infection has been postulated to be a major cause of this disease. Antibiotics and improved nutrition could help inhibit the progression of noma, but most patients still require oral surgery because of the bacterial infection-induced tissue damage. In this study, we report an unusual case of a noma patient whose facial lesion developed a malignancy. The necrotic tissue and infectious area were surgically resected, and a forearm flap was used to repair the patient's facial defect. This case aimed at increasing people's awareness of tropical diseases such as noma.

Distraction Therapy to Correct Trismus Following Noma.

Trismus is a frequent complication of healed Noma infection and is caused by soft tissue and muscle contraction. Free-flap surgery is recommended to replace the missing oral mucosa and soft tissue. However, significant complications can occur if this surgery is performed in places like Africa, where conditions are usually less than optimal. In 2007, the authors started to treat patients with trismus in Niamey, Niger by distracting the soft tissue and muscle constriction between the jaws with a bone distractor continuously for 1 month with the aim of achieving a mouth opening of 3 cm. The distraction was limited to 1 mm/d. performed under local anesthesia with some sedation. Minor complications such as infection in the pin holes were easily managed. In 2009, 2 patients with trismus after Noma with a follow-up of 2 years were reported. Till date, the authors have successfully performed trismus release in more than 69 patients in Niamey and Guinea Bissau. The present study analyses the results of distraction therapy in 40 patients with follow-ups until 60 months. At the end of distraction, the mean interincisal distance was 2.7 ±â€Š0.5 cm. Mouth opening 6 months after distraction had not reverted. However, 3 to 5 years after treatment, some signs of relapse were detected, with an average mouth opening of 1.5 ±â€Š1.9 cm. Physiotherapy was unfortunately not feasible. The presented results strongly support the efficacy of distraction therapy to correct trismus in Noma patients.

Noma in a boy with septic shock: a case report.

BACKGROUND: Noma is a rare disease, which is characterized by rapid progression and a high rate of mortality; however, relatively few cases of noma infection accompanied by septic shock in children have been described. Further, most health care professionals have no knowledge of this disease or of its clinical significance. CASE PRESENTATION: Herein, we present a case report of a six-year-old male patient who was diagnosed with noma infection at a Chinese pediatric medical intensive care unit (PMICU), at which time, it was discovered that he had septic shock. Following treatment by continuous renal replacement therapy (CRRT) for septic shock arising from noma, the patient was in generally good condition, and the local wound was seen to be essentially healed five weeks post-admission. CONCLUSION: Noma is an opportunistic infectious disease condition. Treatment of the acute phase of noma predominantly focuses on controlling the infection and improving systemic conditions. In addition, CRRT could be considered as a treatment option for cases that present with noma accompanied by septic shock.

The surgical management of extra-articular ankylosis in noma patients.

Extraarticular ankylosis occurs frequently in children suffering from noma sequelae. Over 20years of operating on these patients, we observed high recurrence of mouth opening limitation. We therefore progressively changed our surgical strategy. This retrospective study compares the impact of different parameters (types of surgery, noma type, physiotherapy compliance, age and sex) on immediate and long-term mouth opening. It includes a series of 121 patients with extraarticular ankylosis operated on between 1990 and 2015. Soft tissue reconstruction evolved from local and pedicled flaps to large free flaps. Mouth opening was performed by bone-bridge excision, sometimes associated to contralateral coronoidectomy. Mouth opening technique including bilateral coronoidectomy with free flap reconstruction was the only independent factor for significantly better immediate mouth opening with a mean increase of 8.7mm [95% confidence interval (CI) 4.3-13.1, P<0.001) and this effect was maintained in the 3years of follow-up. Another positive factor related to long-term results was excellent physiotherapy, while noma type 4 was a negative factor. Recurrence remains problematic in the management of noma sequelae. If physiotherapy and long-term follow-up cannot be offered, patients should not be operated on, because if limitation of mouth opening recurs, oral feeding may become impossible when a facial defect has been reconstructed.

Nomalike Necrotizing Stomatitis in a Child with Crohn's Disease.

Noma is an opportunistic infection characterized by devastating gangrenous stomatitis leading to severe tissue destruction that predominantly affects malnourished children in sub-Saharan Africa. Only a few cases have been reported in immunocompromised patients from developed countries. We present an unusual case of nomalike necrotizing stomatitis in a previously healthy child with Crohn's disease in Korea.

[Child care management in maxillofacial humanitarian mission]. / Prise en charge de l'enfant en mission humanitaire maxillofaciale.

Our practice in a humanitarian (or crisis) context differs from what we experience in daily practice. There are several reasons for this. First, the diseases encountered are sometimes unfamiliar, such as sequelae of noma, or the presentation of familiar diseases may be unusual, such as facial malformations seen at a late stage. Secondly, these missions take place in developing countries, and consequently, evaluation and anticipation of possible malnutrition should be considered, especially because facial diseases themselves may be responsible for nutritional problems. Lastly, conditions are often difficult, occurring in an unusual environment, and we sometimes have to face communication and equipment problems. The goal of our work, based on a 15-year experience (in Bamako and Mopti with the Association "Santé et Développement", and in Ouagadougou with the organization "Les enfants du noma") and the analysis of literature, is to point out these features and maybe to be helpful to others.

Aplicación de terapia de presión negativa en un caso de pioderma gangrenoso / Vacuum assisted negative pressure therapy in a clinical case of pyoderma gangrenosum

El pioderma gangrenoso es una enfermedad cutánea de etiología desconocida. Las lesiones comienzan típicamente como pústulas o nódulos de rápida evolución hacia úlceras profundas, mal determinadas y violáceas. El fenómeno de patergia está presente en un 20-50% de los casos, por lo que el desbridamiento de las lesiones conduce a un recrudecimiento del cuadro. Presentamos el caso de una paciente diagnosticada de pioderma gangrenoso en la cual, debido a la lenta evolución con inmunosupresores sistémicos y al importante dolor sufrido durante las curas, se decide la aplicación de terapia de presión negativa sobre las lesiones, obteniendo resultados favorables a corto-medio plazo (AU)

Pyoderma gangrenosum is a rare cutaneous disease of uncertain cause. Lesions usually start like pustulae or nodules that rapidly progress into shallow or deep ulcers, undermined. Pathergy occurs in 20% to 50% of the cases, that is why debriding lesions may only worsen them. We present a case of a woman with pioderma gangrenosum whose lesions evolution were slow despite systemic inmunosupression and whose dressing changes were very painful, so we decide to use vacuum assisted negative pressure therapy, obtaining favorable results in short to medium term (AU)

[Noma and Burkitt disease; a particular association about three observations seen in the Teaching Hospital Center Yalgado Ouedraogo (Burkina Faso)]. / Noma et maladie de Burkitt, une association exceptionnelle à propos de trois observations vues au centre hospitalier universitaire Yalgado Ouedraogo (Burkina Faso).

Cancrum oris is a gangrenous stomatitis arising from a periodontal infection and leading to severe soft tissue and bone destruction. The pathology involves numerous factors including local thrombosis, vascularitis, necrotizing gingivitis, immunodeficiency, Gram negative and anaerobic infection. It is usually a disease of infants and malnourished children in tropical areas often occurring after a debilitating disease like measles [3]. Burkitt lymphoma is a highly aggressive non-Hodgkin lymphoma first described by Burkitt in 1958 in African children from areas holoendemic for malaria. It is the first cancer of African child [6]. The association between Burkitt lymphoma and cancrum oris is non common. We report in the present study three cases of this association at the Academic Hospital Yalgado Ouedraogo of Ouagadougou. This association poses a problem of late diagnosis with difficulties in therapeutic management.

Noma and cervicofacial necrotizing fasciitis: clinicopathological differentiation and an illustrative case report of noma.

Noma predominantly affects malnourished young children. The pathogenesis of noma is complex and multifactorial, involving interaction between local polybacterial infection on the one hand, and malnutrition, immunosuppression, or systemic bacterial or viral infections on the other hand. Noma is considered to be an opportunistic disease, but the immediate cause is uncertain. Immunosuppression associated with a high HIV load may be an important risk factor in South Africa. Cervicofacial necrotizing fasciitis, on the other hand, occurs mainly in adults. It is frequently a consequence of an odontogenic infection and is characterized by an irregular pattern of rapidly spreading necrosis of fascia, muscle, and skin. We present an unusual case of noma in a 32-year-old malnourished HIV-seropositive female with AIDS in whom, within a period of 3 days, the initial intraoral necrotizing process spread rapidly and caused circular full thickness perforating destruction of the lower lip. Prompt diagnosis and treatment brought about control of the active disease and limited the extension of the established noma and of progression of the disease at other affected oral sites.

Aetiology and presentation of ankylosis of the temporomandibular joint: report of 23 cases from Abuja, Nigeria.

Several studies have reviewed the management of ankylosis of the temporomandibular joint (TMJ), but only a few focused on the aetiology and clinical features. We retrospectively studied the aetiology and clinical features of patients with ankylosis of the TMJ who presented to the Maxillofacial Unit, National Hospital, Abuja, Nigeria, between 2004 and 2009. There were 13 male and 10 female patients, M:F ratio 1.3:1, age range 6-62, mean (SD) 20 (13) years. The aetiological factors were trauma (n=11) that comprised falls (n=6), untreated fractures of the zygomatic arch (n=4) and myositis ossificans (n=1); infection (n=9), that comprised cancrum oris (n=3) and ear infection (n=6); congenital or unknown (n=2), and coronoid hyperplasia (n=1). The maximum interincisal distance at presentation ranged from 0 to 25 mm (mean (SD) 6.7 (7.2) mm). Seventeen had facial deformities. The diagnoses recorded were as follows: left extracapsular ankylosis, (n=8); right intracapsular bony ankylosis, (n=6); left intracapsular bony ankylosis, (n=4); bilateral intracapsular bony ankylosis, (n=4), and bilateral intracapsular fibrous ankylosis (n=1). Extreme poverty was the main predisposing factor. There is a need for a concerted effort among healthcare providers, policy makers, and the world in general to eradicate poverty and improve healthcare to limit the incidence of ankylosis of the TMJ.

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.

One-stage operation for noma-induced bilateral ankylosis accompanied with mouth verrucous carcinoma - a case report and review of literature.

A rare case of a male patient who suffered from noma with sequelae of ankylosis in bilateral temporomandibular joints for 52 years and a neoplasm in the right commissure of the lips for 1 year, was operated on to resolve the ankylosis, remove the neoplasm and reconstruct the soft tissue defect with a forearm flap through a one-stage operation. The neoplasm pathology was verrucous carcinoma.

Long-term results of trismus release in noma patients.

Noma, also known as cancrum oris, is an infectious disease that results in a loss of orofacial tissue, due to gangrene of soft and bony tissue. It is especially seen in young children in the sub-Saharan region. Among the sequelae of patients who survive noma, trismus is one of the most disabling. This retrospective research studied the long-term results of trismus release in noma patients. Thirty-six patients could be traced in the villages and were included in the study. The mean mouth opening in this group was 10.3mm (95% CI: 7.0; 13.6mm) and the mean period after discharge from hospital was 43 months. Better mouth opening was observed in patients who continued physiotherapy after discharge, were older, and those with a 'soft' (vs. 'hard') inner and outer cheek on palpation. The result of trismus release in noma patients in the long term was extremely poor in this study.

Early outcome of noma surgery.

INTRODUCTION: Reconstructive noma surgery is performed on many short-term medical missions. The treatment outcome, however, has rarely been studied. MATERIALS AND METHODS: We studied complications and clinical outcome of reconstructive noma surgery performed during four short-term medical missions. Logistic regression analysis was used to determine which factors influenced treatment outcome. RESULTS: A total of 74 treatments were performed on 63 patients. We found a complication rate of 64% (n=47) and a success percentage of 59% (n=44). Complexity of treatment procedure and occurrence of complete trismus were independent significant factors negatively influencing the outcome. Only 14 of the 36 complex procedures had a good outcome. CONCLUSIONS: Our study is one of the first to evaluate the early clinical outcome of reconstructive noma surgery in short-term medical missions. It shows that the outcome is not always favourable, particularly in complex reconstructions and in the subgroup of patients with complete trismus.