Noma is an opportunistic infection promoted by extreme poverty. It evolves rapidly from a gingival inammation to Lancet 2006; 367: pgpg
grotesque orofacial gangrene. It occurs worldwide, but is most common in sub-Saharan Africa. The peak incidence of Department of Biomedical
acute noma is at ages 14 years, coinciding with the period of linear growth retardation in deprived children. Noma is Sciences, School of Dentistry
(Prof C O Enwonwu ScD,
a scourge in communities with poor environmental sanitation. It results from complex interactions between W A Falkler Jr PhD,
malnutrition, infections, and compromised immunity. Diseases that commonly precede noma include measles, R S Phillips PhD), and
malaria, severe diarrhoea, and necrotising ulcerative gingivitis. The acute stage responds readily to antibiotic Department of Biochemistry
treatment. The sequelae after healing include variable functional and aesthetic impairments, which require and Molecular Biology, School
of Medicine
reconstructive surgery. Noma can be prevented through promotion of national awareness of the disease, poverty (Prof C O Enwonwu), University
reduction, improved nutrition, promotion of exclusive breastfeeding in the rst 36 months of life, optimum prenatal of Maryland, Baltimore, MD,
care, and timely immunisations against the common childhood diseases. USA [A: we give only one
degree per author; are those
selected OK? Are any of the
The WHO International Statistical Classication of infectious processes of the face, which mostly expand other authors full prfoessors?]
Diseases, code A69.0 lists necrotising ulcerative stomatitis, along cellular spaces of the head and neck, the noma Correspondence to:
which includes noma, cancrum oris, and fusospirochaetal lesion spreads through anatomical barriers such as Prof Cyril O Enwonwu,
gangrene. Noma is derived from the Greek vo, which muscles.5 Names for the disease include cam-tan-ma Department of Biomedical
means to graze or to devour.1,2 Orofacial noma is an (oral inammation like a galloping horse) in Vietnam2 Sciences, University of Maryland,
666 West Baltimore Street,
infectious disease that starts as gingival ulceration and and ciwon iska (the wind disease), which metaphorically Baltimore, MD 21201, USA
spreads rapidly through the orofacial tissues, establishing underscores its rapid development, among the Hausa cenwonwu@umaryland.edu
itself with a well-demarcated perimeter surrounding a tribe in Nigeria. In 1848, Tourdes6 described orofacial
blackened necrotic centre (gure 1).1,3,4 The gangrene can noma as a gangrenous aection of the mouth, especially
involve not only the mandible and maxilla but also the attacking children in whom the constitution is altered by
nose and infraorbital margins (gure 2). Unlike other bad hygiene and serious illness, especially from the
eruptive fevers, beginning as an ulcer of the mucous
membrane with oedema of the face, extending from
within out, rapidly destroying the soft parts and the
bone, and almost always quickly fatal. This description
is still accurate, except for the reduction in mortality rate
with prompt treatment.1,79
Acute [A: OK?] noma is seen predominantly in children
aged 14 years, although late stages can occur in
adolescents and adults.1,2,10,11 The WHO designates noma
a health priority.12 There have been several recent reviews
on noma,2,1316 and some2,14 provide detailed information
on the history of the disease dating back to classical and
medieval civilisations in Europe. Surgical repair
procedures for the sequelae of noma have also been
reviewed lately.2,14,17 This Seminar therefore focuses
primarily on acute noma.
represent the tip of the iceberg, because no more than Neighbourhood village Noma group p
10% of aected children seek medical care during the children (n=55) (n=58)
acute stage.7,16 Mean (SD) age, years 240 (128) 258 (102)
Over the years, acute noma was known as a disease of Height for age Z score
deprived children [A: since we explain in the next Mean (SD) 143 (222) 382 (216) <0001
sentence that the disease has now appeared in HIV- Number (%) 20 SD or more 20 (37%) 53 (91%) <0001
positive children, we think the part of the sentence about Number (%) 30 SD or more 7 (13%) 41 (70%) <0001
non-immunocompromised was superuous and Number (%) 40 SD or more 4 (8%) 25 (43%) <0001
potentially confusing.].1,3,11,24 More recently, there have Weight for age Z score
been sporadic reports of acute noma-like disease Mean (SD) 187 (167) 365 (182) <0001
occurring in HIV-positive individuals.8,9,28,29 Between 1989 Number (%) 20 SD or more 26 (47%) 51 (88%) <0001
and 1993, the HIV status of 26 of the 45 children younger Number (%) 30 SD or more 12 (21%) 47 (81%) <0005
than 3 years admitted to the University of Zambia Number (%) 40 SD or more 5 (10%) 27 (47%) <005
Hospital for treatment of noma was ascertained; nine
Adapted from Enwonwu and colleagues with permission. The neighbourhood village children without noma include siblings of
11
Microbiology
The earliest bacteriological studies of noma were reported by Sawyer and colleagues.64 The presence of
described by Weaver and Tunnicli in 1907.57 An important similar organisms in malnourished children with or
major microscopic observation is the presence of large without necrotising ulcerative gingivitis also suggested
numbers of fusiform bacilli and spirochaetes.1,16,57 Hicken that some other organisms or factors might lead to the
and Eldredge58 suggested that a symbiotic association of development of noma from this putative precursor
fusiform bacilli with a non-haemolytic streptococcus and lesion.
Staphylococcus aureus was needed to produce noma. Table 2 summarises the microorganisms recovered
Emslie40 observed that these organisms were predominant from the active sites of noma lesions in Nigerian children;
in smears from patients with acute noma but also Fusobacterium necrophorum was the most commonly
reported presence of other organisms. Macdonald59 isolated.65 [A: no need to repeat data from table; the
studied cultures from patients with noma in Nigeria and percentages arent really necessary with a denominator
reported that Bacteroides melaninogenicus might be an of 8.] Actinomyces, veillonella, and -streptococci are
important associated microorganism in mixed infections normal oral ora. Most of the other microorganisms
of mucous membranes. (staphylococci, pseudomonas) isolated from one or a few
Early studies of necrotising ulcerative gingivitis, a cases have previously been associated with noma
putative precursor of noma,3,40,41 incriminated spirochaetes, lesions.40 Prevotella intermedia is involved in periodontal
fusiform bacteria and Prevotella intermedia as potential diseases66,67 and has also been identied as a putative
causative agents.60,61 Some reports have associated pathogen in necrotising ulcerative gingivitis in young
necrotising ulcerative gingivitis, noma, or both with adults.61 This microorganism promotes tissue destruction
human cytomegalovirus,62 measles virus,3,40 herpes through its ability to degrade lipids66 and the production
simplex virus,40,46 and other unspecied viruses. PCR of proteolytic enzymes.68
studies of herpesviruses in 22 Nigerian children with The association of F necrophorum with necrobacilliosis
necrotising ulcerative gingivitis showed that 15 (68%) in wallabies,22,69 and the similarity of this disease to noma
had viral infection and eight (36%) had viral coinfection in people resulted in the proposal that the organism is
[A: please check calculations of absolute numbers.].45 involved in the aetiology of human noma.22 F necrophorum
Human cytomegalovirus infection (59%) was the most did not seem to be part of the normal ora in
common. The ndings suggested that this virus and malnourished Nigerian children without noma living in
possibly other herpesviruses contribute to the onset or agricultural and herding villages.70 In that study,70
progression of necrotising ulcerative gingivitis in F nucleatum was recovered from all 30 children sampled
malnourished Nigerian children. Microbiological and F necrophorum from only one child. These ndings
samples from the same children were cultured in children at risk of noma suggest that F necrophorum is
anaerobically on selective media.63 The predominant a trigger organism for the disease and that it gains a
bacteria isolated were Prevotella intermedia, foothold only when certain staging conditions, such as
Fusobacterium nucleatum, Peptostreptococcus micros, lowered host resistance or oral lesions, are present.65,70
campylobacter, streptococci, and enteric gram-negative Although a predominantly animal pathogen,
rods; these ndings did not dier from those in the F necrophorum has been isolated from people with
healthy sites of malnourished children without Lemierres syndrome71 and other infectious diseases.72
necrotising ulcerative gingivitis. More anaerobes, The infections in animals associated with F necrophorum
particularly Prevotella intermedia, were present in the include liver abscesses and diphtheria in cattle, foot rot
mouths of the malnourished than of the healthy children. in domestic animals, and necrotic lesions in the oral
These ndings suggested that malnourished children cavity.73 These diseases are typied by necrosis of the
have a dierent ora from healthy children, as previously tissues involved, abscess formation, and a characteristic
putrid odour. The organism is a commensal in the gut of proximity to neglected livestock, nomadic lifestyle, and a
herbivores, and infection arises from faecal contamination high prevalence of diseases such as measles, malaria,
of damaged mucous membranes or skin.74 Virulence and diarrhoea.11,13,80 The rate of low birthweight in these
factors of F necrophorum have been summarised communities is as high as 20%,81 and it is attributable
elsewhere;13,65 they include various toxins and a growth- mainly to IUGR rather than to prematurity.82 Exclusive
stimulating factor for Prevotella intermedia. More studies breastfeeding in the rst 3 months of life is rare in
are needed to identify the role of this microorganism in communities at risk of noma;83 the reported rate of
the causation of noma. exclusive breastfeeding in Nigerian villages, for example,
In an attempt to explore the bacterial diversity in noma varies from less than 2%84 to about 12%.85 Foods given to
lesions by culture-independent molecular methods, 16S infants are of poor quality and are prepared under
ribosomal RNA genes of bacteria isolated from advanced conditions of poor hygiene. The infant mortality rate is as
noma lesions of four Nigerian children were PCR high as 114 per 1000 live births in some communities.11
amplied with universally conserved primers and Virtually all patients with noma report histories of
spirochaetal selective primers and cloned into previous recent debilitating infections, measles and
Escherichia coli.75 67 bacterial species or phylotypes were malaria being the most frequent.1,3,36,80 The potential
detected, of which 25 have not yet been grown in vitro.75 contribution of several viruses, especially in relation to
Since advanced noma lesions are infections open to the their role in the causation of necrotising ulcerative
environment, detection of species not commonly gingivitis, has been discussed.8,28,45 Studies in Nigeria
associated with the oral cavity (eg, from the soil) was not suggest an increasing frequency of necrotising ulcerative
surprising. gingivitis among poor rural children.24,45 During the past
two decades, there has also been an increase worldwide
Risk factors for noma in the prevalence of necrotising ulcerative gingivitis
Noma has not been reported in healthy, privileged African associated with HIV/AIDS.29,32 Nonetheless, in both HIV-
children.13,22 Poverty is the key risk factor in Africa2,3,22 and positive and HIV-negative children in Africa, only a small
elsewhere.43,44 A retrospective study of 173 cases at a proportion of cases of necrotising ulcerative gingivitis or
hospital in Nigeria showed that 98% were from very poor other oral ulcers evolve into noma.
homes with a mean of seven children per family.76 The
global dimensions of poverty and its health implications, Interventions
particularly malnutrition, are well documented.77 Chronic Treatment of acute noma
malnutrition is a major predisposing factor in all The key points of management during the acute phase of
countries reporting noma.2,3,13,16 The global distribution noma (panel 1) are prompt admission to hospital,
pattern of the disease10 reects the worldwide distribution correction of dehydration and electrolyte imbalance,
of malnutrition, particularly deciencies of vitamin A nutritional rehabilitation to correct energy decit and
and other micronutrients in children younger than deciencies of proteins and micronutrients, treatment
5 years.10,78 These associations, the occurrence of noma in with antibiotics, daily dressing of the lesion with gauze
the wartime concentration camps,18,19 and the absence of soaked in oral antiseptic, and treatment of associated
cases in well-nourished African children22 strongly systemic diseases.2,16,86 Some researchers16 recommend
support the role of malnutrition in its development. Most the use of a broad-spectrum antibiotic, whereas others86
of the reported cases of noma in African countries occur believe that metronidazole (20 mg/kg daily) is adequate
during the dry season, when food is scarce1,3,39 and the since noma is associated with predominantly anaerobic
incidence of severe measles is highest.1,79 microorganisms. Except for control of secondary
Noma is common in environments with unsafe haemorrhage and removal of any loose teeth, invasive
drinking water, scanty sanitation, poor oral health, intraoral procedures are contraindicated Oral hygiene
limited access to good health-care services, close measures are indicated when local conditions permit.16
Patients should rinse their mouths daily with a solution
of chlorhexidine digluconate (012020%).86 Marck2
Panel 1: Recommendations for the management of acute noma
emphasised that oral feeding, although the best option,
Correction of dehydration and electrolyte imbalance may not be possible owing to pain or incipient trismus,
Nutritional rehabilitation thus necessitating enteral nutrition with a tube. Parenteral
Treatment of predisposing diseaseseg, malaria, measles, tuberculosis nutrition is mandatory if the patient is very sick. A high-
Antibiotics (penicillin and metronidazole are generally eective) protein diet, enriched with energy source and essential
Local wound care (irrigation of the wound with appropriate antiseptic) micronutrients, is recommended. At the Noma Children
Physiotherapy to reduce brous scarring Hospital, Sokoto, Nigeria, a highly enriched nutrition
Removal of any remaining tissue slough and sequestra; generally, necrotectomy is not formula (Enfortal; ??????????, Netherlands [A: please give
done until acute stage is controlled name of manufacturer and the city where it is based]) has
Serological test for HIV infection and appropriate referral if positive given good results.2 The patients weight should be
monitored daily.
Ref number 05art3289_8 Special instructions (PLEASE MARK WITH RED SPOT IF URGENT)
Seminar
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