Noma neonatorum is characterized by a gangrenous phenomen affecting mucocutaneous junctions of mouth, nasal and anal area and occasionally, the eyelids and scrotum. Especially it is observed during the first few weeks of neonatal life [1-2] and is mainly linked to Pseudomonas aeruginosa (P. aeruginosa), prematurity, and low birth weight. No established treatment in the few reported cases, and mortality is nearly inevitable . In this report we have presented in a premature with noma neonatorum caused by Acinetobacter baumannii (A. baumannii).
We admitted a female twin delivered at 31weeks’ gestation in another hospital referred to our hospital. Apgar scores were 6-7-7 at 1-5-10mins, and the weight was 1260g. On examination, baby have mild respiratory distress, cardiac auscultation was normal, neonatal reflexes mildly depressed. Other systemic examinations were remarkable. The baby was stabilized with continuous positive airway pressure (CPAP) with PEEP 6 and was transferred to the neonatal intensive care unit (NICU). Compled blood cell (CBC), biochemistry analysis, C-reactive protein (CRP), procalsitonin, blood culture was taken, and the baby was treated empirically with ampicillin and gentamicin. Cranial ultrasound revealed grade 2 intraventricular hemorrhage. On day 6 she developed increasing respiratory distress and hypotension. A sepsis evaluation was performed including blood cultures, and a CBC had a hemoglobin of 16.1g/dl, platelets of 43,000mm3 and a white blood cell count of 33.860/l with 74.3% segmented neutrophils, 15.5% lymphocytes, 5.9% monocytes, 3.9% eosinophils. CRP elevated 205mg/L (normal range <5mg/L), and procalcitonin levels was 36.8ng/ml (normal range <0.05ng/ml). Treatment changed with vancomycin, meropenem, colisitine and liposomal amphotericin B. Pentoxifyline added her treatment. On day 8 a pustular rash appeared in the anal regions and the general condition of the patient has deteriorated. In addition, she developed severe hypotension necessitating pressor support with dopamine, dobutamine, epinephrine and norepinephrine. Blood culture result of multi drug resistant A. baumannii and antibiotic sensitivity test was performed which showed A. baumannii sensitive to only ciprofloxacin, tetracycline and
colisitine. Based on the culture and sensitivity test ciprofloxacin added the treatment. Supportive treatments were added fresh frozen plasma, thrombocytes and erythrocytes product packets. Swabs were taken from the pharynx, the rectum, and both eyes and were found as a negative. On day 9 the perianal and genital region was also erythematous and edematous around the necrotic center (Figure 1).
Baby develops acute renal failure with creatinine 4.6mg/dL, anuria. Other laboratory analysis was CBC had a hemoglobin of 9.6g/dl, platelets of 79 000mm3 and a white blood cell count of 65.079/l with 86.8% segmented neutrophils, prothrombin time 33.9sec with Internalization normalization ratio (INR) of 2.83. Hepatic markers were abnormal. During the ensuing two days anal and genital necrotic lesion was grew up. On day 11 patient with severe acidosis and refractory hypotension, whose general
condition was disrupted during follow-up, she was died although
all supportive treatment.
In the original series of 35 patients, the lesions were seen in
the majority of cases in the orofacial region (27 of 35 patients),
as well as in the anogenital region in 7 of 35 patients . In
2014, Raimondi et all were reported a case of a 28day-old female
infant was born with extremely low birth weight. She has diffuse
gingival noma, initially misdiagnosed as thrush. P.aeruginosa
was grown from all swabs but cultures were sterile. The strain
showed resistance to penicillins, carbapenems, aminoglycosides,
sulfamethoxazole-trimethoprim, and nitrofurantoin while being
sensitive to colistin. A regimen of intravenous and topical colistin
was followed for 3 weeks .
Nayak et all recently described a 25day-old Indian female
infant that referred with facial tissue destruction and fever. Swab
test showed Gram negative bacilli. P. aeruginosawas isolated. They
had treated her with netilmicin, amikacin, clindamycin and topical
clindamycin cream .
Freeman at all delivered a case 26 weeks’ gestation twin
and and the weight was 808g. On day 15 she received a noma
neonatorum diagnosis in perianal regions. She was treated with
intravenous meropenem and tobramycin based on antibiotic
susceptibility test results, and topical silver sulfadiazine was
applied to the skin lesions. She was discharged on day of Life 90.
They suggest that noma neonatorum represents a neonatal form
of ecthyma gangrenosum. The etiologic agent in almost all of the
cases is the same (P. aeruginosa) and the histopathology similar
A level III European NICU, extremely low birth weight, and
multi drug rezistance A. baumannii was grown from blood
culture. Yet, it is an environment where P.aeruginosacolonization
is a feared and not uncommon event, and neonatologists need to
have an appropriate index of suspicion for noma to prevent its
mortality or morbidity.
pediatricians and neonatologist’s necessity to be consider that
multidrug-resistant nosocomial bacteria such as P. aeruginosa
might observe with a destroyer mucosal lesions without any
systemic symptoms. Appropriate antibiotic, such as colisitine, may
be useful in that cases unfortunately we vanish our case causes
multiorgan failure and A. baumannii sepsis.