A necrotic orofacial lesion presenting in an immunocompromised patient in the UK: case review with features of noma

Noma is a gangrenous and destructive orofacial disease. It comes from the Greek word nomein, meaning ‘to devour’. Caused by a rapidly spreading opportunistic infection, noma has a strong affiliation to extreme poverty and is infamously known as the ‘face of poverty’. It is predominantly endemic to children between the ages of two and six who are malnourished, and is incited by disease. However, there is rare precedent of this disease emerging in adulthood in more economically developed countries, with noma-like lesions in the UK doubling since 2015. We report on a 90-year-old patient who initially presented to their general medical practitioner for a necrotic lip ulcer, which was originally thought to be a cold sore. The patient was later admitted to hospital due to reduced mobility and severe anaemia, with underlying features of sepsis, malnutrition, immunosuppression, oral necrosis and progressive ulceration over three weeks. Immediate treatment began following admission, including intravenous antibiotics, oral care and nutritional supplementation, before a definitive clinical diagnosis of noma was made after a biopsy, which ruled out malignancy. The rapid treatment response, albeit before a diagnosis was confirmed, allowed for the disease process to halt. This atypical presentation in a UK hospital highlights the need for periodic review of such lesions, so that current knowledge of their presentation and management is maintained.