Buruli Ulcer also known as Mycobacterium ulcers is a chronic debilitating skin disease and soft tissue infection that often results in permanent disability and disfigurement. The skin disease is caused by an environmental bacterium - Burkholderia cepacian.
Background of the Etiologic Agent
Burkholderia cepacian is an aerobic gram –negative bacillus that comprises of catalase and lactose producing bacteria and additional 18 different species. Burkholderia cepacia n is an opportunistic organism that causes other diseases such as pneumonia and other underlying lung infections. B.cepacia is commonly found in water and soil and typically survives in moist and aquatic environments (Amissah et al., 2014). It has a relatively low virulence and rarely affects healthy hosts. However, in some situations, person to person has been documented especially in individuals with weak immune systems. Infected people are therefore isolated from the uninfected patients to reduce the limit of spread. Burkholderia cepacian belongs to the family of bacteria that causes tuberculosis and leprosy.
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Background of the Disease
Buruli is a county in Uganda where there was there was a high prevalence of Mycobacterium ulceran were reported in the 1960s. The World health organization used the discovery points as the official name of the disease hence became commonly referred to as’Buruli ulcer’. Mycobacterium Ulcerans according to the statistics done by the World Health Organization (WHO) is the third most prevalent and shared mycobacterial infection in the world after Tuberculosis and Leprosy (Chany et al., 2013). Due to the nature of the causative organism to survive in moist conditions, the disease affects individuals in tropical and humid regions. Research shows that Africa has the greatest frequency of the diseases especially in tropical countries such as Ghana, Cote d’ Ivore which has about 40 percent prevalence(O’Brien et al.,2014). Other countries in the world include Mexico, South America and Australia where transmissions over the recent years have been observed mainly in moderate nontropical climates.
In Africa, especially the west countries studies conducted reveals the peak age group for the infections to happen is 5 to 15 years. However, Buruli ulcer can affect any age group depending on the susceptibility of the individual to illnesses. In countries such as Japan, the effect group is 40 to 60 years (O’Brien et al., 2014). In Japan, the disease has a low mortality rate as compared to West African countries. However, its disabling nature may have an enormous impact on both socio-economic and physical effect on individuals.
In many countries, Mycobacterium ulcerans infections only occur after significant environmental disturbances. In Australia, for example, the first infection happened after there were terrible floods in most of the districts. The outbreaks were therefore postulated to have occurred due to the unprecedented floods. A series epidemiological studies show that seasonal variation especially in tropical areas augments the appearance and the occurrence of Buruli ulcers. This is because the conditions become favorable for the development of the Buruli ulcers due to the concentration of possible vectors in the areas.
The mode of transmission of Mycobacterium ulcerans has not been fully known. However, research shows that contaminated water is the leading cause of the infections. The contaminated water is commonly found in stagnant and slow moving water where the bacteria multiply significantly. Additionally, the transmission is also via skin trauma. In this case, water insects play a crucial role in all the foci transmission. In Australia, salt marsh mosquitos are known for the transmission of Mycobacterium viruses as well as their potential role as possible vectors.
Symptoms
Mycobacterium ulcer infection at first presents itself as a painless swelling (nodule). The swelling occurs mostly at the upper and lower limbs. Other parts of the body may also be affected. The painless swellings may also diffuse regarding plague to the arms or face causing a swelling known as (edema). The module progresses to the skin around and eventually breaks down to reveal an ulcer that has a deep center of necrotic tissue (O’Brien et al., 2014). Due to the local immunosuppressive nature of the infection, the disease progresses without pain or any fever. Urgent treatment within four weeks causes the nodules or the swelling to undermined borders in the body such as the bones. Occasionally, when the bones are affected gross deformities occurs.
Diagnosis
Diagnosis is often made by a trained health professional in areas that are prone to the infections. Conditions included in the determination include the patient's geographical location, the location of the nodule/lesions, and severity of the pain and most importantly the age of the patient. Conditions excluded in the prognosis are lower leg ulcers, tropical phagedenic and diabetic ulcers as they are mostly caused by other bacterium infections such as Haemophilus ducreyi.
Early nodular lesion is examined to determine their rate of mutation and spread across the surrounding areas using a microscope as they may be confused with boils or subcutaneous infections such as fungal infection. It is, therefore, important for health practitioners to be knowledgeable of the clinical presentation of the diseases.
Treatment
The treatment of the disease combines antibiotics and other complementary therapies. Antibiotics are one of the most preferred where combinations of various antibiotics are given for approximately 8weeks to treat ulcers. The combination of antibiotics such as rifampicin, streptomycin and clarithromycin are used as they have been considered to be effective through randomized trials.
Surgery is also an alternative method of treatment if the body declines and contradicts the antibiotics. However, there may be risks of relapse depending on the patient characteristics and especially if the surgery is performed without adjuvant antibiotics. Surgery helps in repairing large defects such as bone deformities or hastening the closure of the wound. Physical interventions such as wound management are critical in the healing process as well as treatment. Skin grafting is used in the healing of wounds thereby helping in rehabilitating and preventing the disability as well speeding up the process of healing the wounds.
Prognosis
Research conducted shows that polymerase chain reactions in future can increase the speed of diagnosis of Mycobacterium ulcerans which are some relatively expensive as compared to the microscopy which has proved to give false results especially in the detection of nodules(Stinear et al.,2004). According to Stinear et al. (2004), Polymerase chain reaction should be highly recommended as it shown to be quicker and accurate method of diagnosis.
Initials analysis from patient samples indicates that oral based vaccinations during epidemics and one year of follow ups can play an essential role in preventing the infections. The findings have conducted the Foundation for Innovative New Diagnostics (FIND) and the World Health Organization (WHO) hence lowering the prevalence. In endemic areas, there has been evidence especially of mosquitos transmitting the infections to an individual. To reduce the incidence of the disease, enhanced mosquito-control strategies should be put in place to decrease the risk of exposure.
References
Amissah, N. A., Gryseels, S., Tobias, N. J., Ravadgar, B., Suzuki, M., Vandelannoote, K., ... & Ablordey, A. (2014). Investigating the role of Free-living Amoebae as a Reservoir for Mycobacterium ulcers. PLoS Negl Trop Dis , 8 (9), e3148.
Chany, A. C., Tresse, C., Casarotto, V., & Blanchard, N. (2013). History, biology and chemistry of Mycobacterium ulcers infections (Buruli ulcer disease). Natural product reports , 30 (12), 1527-1567.
O’Brien, D. P., Jenkin, G., Buntine, J., Steffen, C. M., McDonald, A., Horne, S., ... & Johnson, P. D. (2014). Treatment and prevention of Mycobacterium ulcers infection (Buruli ulcer) in Australia: guideline update. Med J Aust , 200 (5), 267-270.
Stinear, T., B. C. Ross, J. K. Davies, L. Marino, R. M. Robins-Brown, F. Oppedisano, A. Sievers, and P. D. R. Johnson (2004). "Identification and characterization of IS2404 and IS2606: two distinct repeated sequences for detection of Mycobacterium ulcers by PCR" . J Clin Microbiol. 37 (4): 1018–23. PMC 88643 PMID 10074520 .
