Patient |
2 1/2 years old Zimbabwe girl |
Duration |
2 days |
Distribution |
Lower face |
| History |
We admitted a severely malnourished two and one half year
old girl to the paediatric ward of the Gewande Provincial
Hospital, Zimbabwe with a necrotic area on the lower jaw for
a few days duration. The child was anorexic, very weak, unable
to walk and had productive cough. She is the only child of
a single mother who is employed at a construction company.
Poverty and hyper-inflation in Zimbabwe have made access to
food very limited.
|
Physical Examination |
Examination revealed a wasted female child weighing 5.0 kg,
and measuring 70 cm in length. She was pale with sparse scalp
hair. The oral mucosa showed a cheesy discharge consistent
with thrush and there was no edema edema or anasarca. Temperature
35 deg C (axillary) There was a black escar over the area
of the lower lip. Over a few days this entire area became
necrotic and sloughed off. She continued to feed in spite
of the oral problems. She was transferred to the National
Hospital on the sixth hospital day.
During her hospital course in Gewande she was feeding well,
but losing weight and had a persistent hypothermia of 35 deg
C. Because of progressive necrosis of the oral mucosae, the
patient was transferred on day five to the National Hospital
where she died shortly thereafter.
|
| Images |
|
| Laboratory Data |
Hg: 3 gm%
WBC: 5, 000
Chest Xray: : Opacity of the entire left lung
Culture (from necrotic oral area): A moderate growth of Klebsiella
sp. Sensitive to Tetracycline, Ciprofloxacine, and Nalidixic
Acid.
HIV test: positive
|
| Histopathology |
|
| Diagnosis |
Noma (necrotizing ulcerative stomatitis or cancrum oris) |
Reasons Presented |
The purpose of this presentation is to
honor the passing of a child of poverty and political upheaval
in a country once known for the health of its people. Amrita
Sen writes:
There is, of course, plenty of poverty in the world in
which we live. But more awful is the fact that so many people
including children from disadvantaged backgrounds are forced
to lead miserable and precarious lives and to die prematurely.
That predicament relates in general to low incomes, but not
just to that. It also reflects inadequate public health provisions
and nutritional support, deficiency of social security arrangements,
and the absence of social responsibility and of caring governance
|
| Questions |
We welcome your comments on Noma and on the realities of health
care in countries such as Zimbabwe. Please tell us of similar
cases you may have encountered.
|
| References |
- Chidzonga MM HIV/AIDS orofacial lesions in 156 Zimbabwean
patients at referral oral and maxillofacial surgical clinics.
Oral Dis. 2003 Nov;9(6):317-22.
- Berthold P., Noma: a forgotten disease. Dent Clin North
Am. 2003 Jul;47(3):559-74.
- Marck KW. A history of noma, the "Face of Poverty".
Plast Reconstr Surg. 2003 Apr 15;111(5):1702-7.
- Naidoo S, Chikte UM. Noma (cancrum oris): case report in
a 4-year-old HIV-positive South African child. SADJ. 2000
Dec;55(12):683-6.
|
| Comments from Faculty and Members |
Sunil Dogra MD, Dept. of Dermatology, Postgraduate
Institute of Medical Education and Research, Chandigarh, India
on March 17, 2004
This is a destructive condition, still seen in the developing
nations where poverty and poor hygiene are still prevalent.
I remember seeing a child with this condition about 2 years
back at our hospital, which was managed successfully with parenteral
antibiotics and supportive management. Though it left a scar
over face and lip area.
Anatoli Freiman MD, Montreal, Canada on March
18, 2004
Thank you for sharing this sad case. NOMA a devastating disease
(90% mortality without timely treatment) and is mostly related
to poverty, malnutrition and poor dental hygiene. The saddest
part is that it's largely preventable.
Editor's note
A formal case presentation and editorial about this patient
appeared in the International Journal of Dermatology
in 2005. |
