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Buruli Ulcer

Disease Listing | General Information | Technical Information | Additional Information

Clinical Features World Health Organization (WHO) clinical case definition for Buruli ulcer divides the disease into two stages: active and inactive. The active form is characterized by non-ulcerative (papules, nodules, plaques, and edema) and ulcerative disease. The distinctive features of a Buruli ulcer include undermining edges, cotton wool like appearance, and thickening and darkening of the skin surrounding the lesion. The inactive form is characterized by evidence of previous infection with a depressed stellate scar with or without sequelae.
Etiologic Agent Mycobacterium ulcerans
Incidence The incidence of Buruli ulcer disease is not precisely defined primarily because of inadequate surveillance data and difficulty of laboratory confirmation. No cases of Buruli ulcer disease have been reported in the United States. Buruli ulcer disease has been reported in many countries: Angola, Australia, Benin, Bolivia, Burkina Faso, Cameroon, China, Congo, Cote D'Ivoire, Democratic Republic of the Congo, French Guyana, Gabon, Ghana, Guinea, India, Indonesia, Japan, Liberia, Malaysia, Mexico, Nigeria, Papua New Guinea, Peru, Sierra Leone, Sudan, Suriname, Togo, and Uganda.
Sequelae Although mortality is low, morbidity is high. The healing process of ulcers, whether induced by surgery or self-healing, often results in severe contracture scaring and deformity.
Diagnosis and Confirmation Buruli ulcer disease is diagnosed based on the WHO clinical case definition. Confirmation of disease is achieved through the use of two or more of the following laboratory tests: acid-fast bacilli (AFB), polymerase chain reaction (PCR), histopathology, and culture. With the exception of AFB, these tests are not suited for use in the remote rural areas where Buruli ulcer disease occurs most frequently and confirmation, if achieved at all, is well after treatment has begun.
Treatment The options for treatment are limited. Currently, surgery is the recommended treatment for all stages of disease; including excision of nodules and debridement and skin grafting of ulcers. It is believed that surgical intervention at the preulcerative stage eliminates or reduces the risk of ulceration; however no follow-up studies have been conducted to evaluate this statement. Antibiotic trials using combinations of anti-mycobacterial drugs are underway.
Transmission Route of transmission remains unclear. One hypothesis is that M. ulcerans enters through a break in the skin, via insect bite, cut or wound.
Risk Groups The disease has been associated with slow-moving, stagnant water and environmental changes including mining, deforestation, and irrigation. In West Africa, many cases are found in poor, rural farming communities. Socioeconomic status, gender, and race do not appear to be risk factors for disease. Children under the age of 15 are disproportionately affected. However, adults are also susceptible. HIV is not a known risk factor, although there are reports of HIV-infected individuals with Buruli ulcer.
Surveillance BUD is not a reportable disease in most affected countries. WHO encourages all endemic countries to perform surveillance.
Trends There are reports of increasing incidence in several African countries.
Challenges The lack of knowledge surrounding the reservoir and route of transmission of M. ulcerans, diagnostic tests that can easily be performed in rural areas, and treatment options are major challenges to the prevention and control of BUD.
Opportunities Opportunities include reduction of BUD infection utilizing anti-mycobacterial drug therapy, reduction in incidence of BUD as a result of knowledge of reservoir and route of transmission of M. ulcerans, increased surveillance for BUD as integrated disease surveillance, and decrease in morbidity as a result in early diagnosis and treatment due the development of diagnostic tests.


Date: October 6, 2005
Content source: National Center for Immunization and Respiratory Diseases: Division of Bacterial Diseases
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