**9. Vincent angina and noma (cancrum oris, gangrenous stomatitis)**

Vincent angina, named after the French physician Jean H. Vincent (1862–1950), represents acute necrotizing ulcerative gingivitis caused by fusiform bacteria and spirochetes [84, 85]. It is also called as trench mouth or fusospirochetosis. The patients complain of progressive painful swelling and hemorrhagic ulceration of the gum. The punched-out ulcer, 2–4 mm in size, is seen in the interdental papilla, and is covered with white pseudomembranes. Bad breath is associated. The infection can effectively be treated with penicillin. Infrequently, Vincent angina may spread to involve the mouth and throat to be diagnosed as acute necrotizing periodontitis.

Noma is a rapidly progressive and necrotizing infection of the soft and hard tissues around the oral cavity, as an advanced clinical form of Vincent angina [86, 87]. It is also called as fusospirochetal gangrene. It represents gangrenous stomatitis or necrotizing fasciitis of the oral cavity. The preferred age of the patients is below 10 years, and the disease mostly occurs in malnourished children of African poverty. The prognosis is poor. In developed countries, severely immunosuppressed patients (including acquired immunodeficiency syndrome) with poor oral hygiene may suffer from this critical condition. It begins in the form of Vincent angina, and is rapidly followed by painless and extensive necrosis of the oral cavity. Eventually, the extensive involvement of the cheek, nose, palate, and maxillary bones results in serious facial destruction. Hence, the name of "cancrum oris" (meaning oral cancer). Gas formation may be associated. In noma neonatorum, the disease manifests massive orofacial (mucocutaneous) gangrene in the neonate [88]. A similar disorder may be encountered in the genitalia and is called as noma pudendi.

The polymicrobial etiology is known in both conditions. Gram stain smeared from the ulcer easily identifies both fusiform bacteria and long spiral-shaped spirochetes (**Figure 31**). The key players are anaerobic, Gram-negative fusiform pathogens, *Fusobacterium nucleatum* (older term: *Bacillus fusiformis*) and *Prevotella intermedia*. The spiral microbes are identified as *Borrelia vincentii*. Many other bacteria have been co-isolated, including *Porphyromonas gingivalis* (an anaerobic, Gram-negative, porphyrin-producing bacillary pathogen of periodontitis),*Tannerella forsynthesis*, *Treponema denticola*, *Staphylococcus aureus*, and nonhemolytic streptococci.

#### **Figure 31.**

*Vincent angina (Gram). Gram-stained smear prepared from a painful gingival ulcer demonstrates mixed bacterial infection, including Gram-negative fusiform bacilli and filamentous spiral microbes. Gram-positive cocci and long rods are also intermingled.*

pathogen for endogenous endophthalmitis. Hyperalimentation may lead to

*Traumatic ophthalmitis caused by* Fusarium *infection in a Cambodian teenager (gross and H&E). The corneal fungal infection extended to the lens, palpebra and orbital connective tissue. Chained or beaded (several-celled) appearance of hyphae is characteristic of* Fusarium *spp. (the courtesy of Dr. Chhut Vanthana, a pathologist at*

*Endophthalmitis in a leprosy patient (gross, H&E and immunostain). The eyeball is totally collapsed and deteriorated. Traumatic infection resulted in ophthalmophthisis. Gram-positive cocci inside the eyeball are immunoreactive for streptococcal antigens. Black melanin pigment in the iris is shown in the right bottom corner.*

Gangrenous/emphysematous inflammation may occur in the stomach [33, 66] (see **Figures 16** and **17**), esophagus [67], colorectum [68] (see **Figures 15** and **18**), urinary bladder [69, 70], ureter [71], urethra [72], penis [73], epididymis/testis [74, 75], endometrium [76], vagina [77], breast [78], bone [79], striated muscle [80], aorta [81], mediastinum [82], and endocardium [83]. Most cases are categorized in the nonclostridial etiology. Clostridial infection is seen in the gastrointestinal tract and pancreas, including emphysematous pancreatitis [28], as described in the Section 6.2.

**8.7 Gangrenous/emphysematous inflammation in other organs**

endophthalmitis caused by *Candida albicans*.

*Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia).*

**Figure 29.**

*Pathogenic Bacteria*

**Figure 30.**

**114**

Clinically, high fever, pain at the site of infection, and skin necrosis (gangrene) with hemorrhagic bulla formation are associated. Scarlatiniform rash may be noted.

Microscopically, pronounced myonecrosis with foci of infection of Grampositive cocci is observed. Gram-positive cocci grow within the lesion of advancing gangrenous necrosis of soft tissue. Cellular reactions are minimal, because of the ischemic (anaerobic) state with poor blood flow. In the cultured blood, short chains

The bacteria are commonly sensitive to penicillin and its derivatives, but the intravenous antibiotics administration is clinically ineffective, principally because of the absence of blood flow. The drug can hardly reach the site of infection.

Progressive gangrene of the extremities caused by infection of *Vibrio vulnificus* is characteristically seen in patients with liver cirrhosis or hemochromatosis [96–99]. High iron concentration in the serum is essential for the bacteria to grow in the body. The genus *Vibrio* is categorized in the "halophilic" bacteria preferring to a high salt concentration for growth on plates. In contrast to *V. cholerae* and *V. parahaemolyticus* growing at the salt concentration of sea water (3–3.5%), *V. vulnificus* prefers to a lower salt concentration of the brackish (estuarine) water at the mouse of the river. *V. vulnificus* resides in the sea fish and oyster, particularly during the summertime. The bacteria proliferate in the gut of the sea creature when the temperature is high. Two transmission pathways of the pathogen are known: transenteric infection and traumatic skin infection. The former septicemic condition is often fatal, initiating a painful skin lesion on the arm or leg resembling honeybee bite. Gangrenous changes of the extremity progress rapidly.

*Fulminant streptococcal infection (streptococcal myonecrosis) (Giemsa, H&E and Gram). Numerous chained cocci are demonstrated in the cultured blood. Vessels are thrombosed, and the striated muscle fibers show*

*coagulation necrosis. Colonies of Gram-positive cocci are scattered in the ischemic tissue.*

of Gram-positive cocci, morphologically typical of *Streptococcus*, are seen (**Figure 33**). Streptococcal septicemia provokes streptococcal toxic shock-like syndrome [94]. The bacterial exotoxins (superantigens) such as streptococcal pyrogenic exotoxins-A, B, C, F, and streptococcal superantigen provoke a severe cytokine storm. Hypercytokinemia activates hemophagocytosis by macrophages. Activation of NLRP3 inflammasome may be an essential event for the cytokine

Finally, massive gangrenous necrosis involves the extremity.

storm in streptococcal toxic shock-like syndrome [95].

**10.2** *Vibrio vulnificus* **infection**

*Pathology of Gangrene*

*DOI: http://dx.doi.org/10.5772/intechopen.93505*

**Figure 33.**

**117**

#### **Figure 32.**

*Noma-like condition in a diabetic male patient aged 80's (progressive ulcerative gingivitis) (H&E, Grocott and immunostain). A gas-forming, necrotizing lesion is observed in the biopsied maxillary bone. Grocott methenamine silver stain identifies colonies of filamentous bacteria in the lesion, probably representing* Actinomyces *colonization. The Gram-negative bacteria around the gas bubble are immunoreactive with a commercial antiserum against* Escherichia coli*, which shows wide cross-reactivity to Gram-negative bacteria (the courtesy by Dr. Tatsuru Ikeda, Pathology Center, Hakodate Goryoukaku Hospital, Hakodate, Japan).*

**Figure 32** demonstrates a diabetic male patient aged 80's, suffering from nomalike condition (progressive ulcerative gingivitis with massive maxillary necrosis). Numerous bacilli accompanying gas formation and immunoreactive with *E. coli* antiserum grew in the maxillary bone. Colonies of filamentous bacteria, representing anaerobic *Actinomyces* spp., were coinfected.
