Noma: An Elegy to Innocence and Youth

presented by

Angelino R G Hernandez MD (1) and Brian Maurer (2)

(1) Cienfuegos, Cuba

(2) Tariffville, Connecticut, USA

on May 16, 2004

(1) Cuban missionery physician in Zimbabawe 2002-2004, now practising in Cuba

(2) Physician Assistant, Enfield Pediatrics, Enfield, CT, USA

2 1/2 years old Zimbabwe girl
2 days
Lower face

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.


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



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.
  1. 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.
  2. Berthold P., Noma: a forgotten disease. Dent Clin North Am. 2003 Jul;47(3):559-74.
  3. Marck KW. A history of noma, the "Face of Poverty". Plast Reconstr Surg. 2003 Apr 15;111(5):1702-7.
  4. 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.