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

Abstract

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.

Isolation of Fusobacterium necrophorum from cancrum oris (noma).

“…This disease occurs almost exclusively among poor malnourished children in developing countries. [1][2][3] Although cancrum oris has been described by ancient medical writers such as Hippocrates and Galen and studied as a disease entity for more than 150 years, the etiologic agents of this disease have never been convincingly documented. 4 As a result of the microscopic observations of smears from infected tissues, as well as the logical progression of acute necrotizing gingivitis (ANG) to noma, the disease has been associated with the presence of large numbers of fusiform bacilli and spirochetal organisms.…”

Pathogenesis of cancrum oris (noma): confounding interactions of malnutrition with infection.

“…2,19 The etiology of ANG is poorly defined and the reported risk factors include stress, poor oral hygiene, and immune suppression resulting from malnutrition as well as from bacterial and viral infections. 2,11,20,21 Our recent studies suggest that infections by the human herpesviruses, particularly the human cytomegalovirus (HCMV), contribute to the onset and progression of ANG in impoverished Nigerian children. 22 Nonetheless, only a relatively small percentage of ANG cases appear to evolve into noma.…”

“…3,4 Although noma is observed in adults, 9 the disease typically affects mostly children between three and 12 years of age. 1,10,11 Poverty is the most important cause of noma in Africa, 3 and chronic malnutrition is a major predisposing factor. 1,2,12,13 A background of poor oral and general hygiene characterizes children at risk for this disease, and most cases of noma present with a distinct history of recent prior debilitating infections, with measles being the most frequent, 1,2,14 affecting 30 (43%) of 69 Nigerian children who subsequently developed noma.…”

Noma management in a child with systemic lupus erythematosus

“…5 This disease occurs almost exclusively among poor malnutrition children in developing countries. 6,7 The exact cause of the disease is still not known. 1 It is postulated that the disease is triggered by a consortium of micro organisms of which F�s��acteri�� necr����r�� is a key component.…”