Drugs for treating Buruli ulcer (Mycobacterium ulcerans disease).

BACKGROUND: Buruli ulcer is a necrotizing cutaneous infection caused by infection with Mycobacterium ulcerans bacteria that occurs mainly in tropical and subtropical regions. The infection progresses from nodules under the skin to deep ulcers, often on the upper and lower limbs or on the face. If left undiagnosed and untreated, it can lead to lifelong disfigurement and disabilities. It is often treated with drugs and surgery. OBJECTIVES: To summarize the evidence of drug treatments for treating Buruli ulcer. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE (PubMed); Embase (Ovid); and LILACS (Latin American and Caribbean Health Sciences Literature; BIREME). We also searched the US National Institutes of Health Ongoing Trials Register (clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en/). All searches were run up to 19 December 2017. We also checked the reference lists of articles identified by the literature search, and contacted leading researchers in this topic area to identify any unpublished data. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared antibiotic therapy to placebo or alternative therapy such as surgery, or that compared different antibiotic regimens. We also included prospective observational studies that evaluated different antibiotic regimens with or without surgery. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria, extracted the data, and assessed methodological quality. We calculated the risk ratio (RR) for dichotomous data with 95% confidence intervals (CI). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included a total of 18 studies: five RCTs involving a total of 319 participants, ranging from 12 participants to 151 participants, and 13 prospective observational studies, with 1665 participants. Studies evaluated various drugs usually in addition to surgery, and were carried out across eight countries in areas with high Buruli ulcer endemicity in West Africa and Australia. Only one RCT reported adequate methods to minimize bias. Regarding monotherapy, one RCT and one observational study evaluated clofazimine, and one RCT evaluated sulfamethoxazole/trimethoprim. All three studies had small sample sizes, and no treatment effect was demonstrated. The remaining studies examined combination therapy.Rifampicin combined with streptomycinWe found one RCT and six observational studies which evaluated rifampicin combined with streptomycin for different lengths of treatment (2, 4, 8, or 12 weeks) (941 participants). The RCT did not demonstrate a difference between the drugs added to surgery compared with surgery alone for recurrence at 12 months, but was underpowered (RR 0.12, 95% CI 0.01 to 2.51; 21 participants; very low-certainty evidence).An additional five single-arm observational studies with 828 participants using this regimen for eight weeks with surgery (given to either all participants or to a select group) reported healing rates ranging from 84.5% to 100%, assessed between six weeks and one year. Four observational studies reported healing rates for participants who received the regimen alone without surgery, reporting healing rates ranging from 48% to 95% assessed between eight weeks and one year.Rifampicin combined with clarithromycinTwo observational studies administered combined rifampicin and clarithromycin. One study evaluated the regimen alone (no surgery) for eight weeks and reported a healing rate of 50% at 12 months (30 participants). Another study evaluated the regimen administered for various durations (as determined by the clinicians, durations unspecified) with surgery and reported a healing rate of 100% at 12 months (21 participants).Rifampicin with streptomycin initially, changing to rifampicin with clarithromycin in consolidation phaseOne RCT evaluated this regimen (four weeks in each phase) against continuing with rifampicin and streptomycin in the consolidation phase (total eight weeks). All included participants had small lesions, and healing rates were above 90% in both groups without surgery (healing rate at 12 months RR 0.94, 95% CI 0.87 to 1.03; 151 participants; low-certainty evidence). One single-arm observational study evaluating the substitution of streptomycin with clarithromycin in the consolidation phase (6 weeks, total 8 weeks) without surgery given to a select group showed a healing rate of 98% at 12 months (41 participants).Novel combination therapyTwo large prospective studies in Australia evaluated some novel regimens. One study evaluating rifampicin combined with either ciprofloxacin, clarithromycin, or moxifloxacin without surgery reported a healing rate of 76.5% at 12 months (132 participants). Another study evaluating combinations of two to three drugs from rifampicin, ciprofloxacin, clarithromycin, ethambutol, moxifloxacin, or amikacin with surgery reported a healing rate of 100% (90 participants).Adverse effects were reported in only three RCTs (158 participants) and eight prospective observational studies (878 participants), and were consistent with what is already known about the adverse effect profile of these drugs. Paradoxical reactions (clinical deterioration after treatment caused by enhanced immune response to M ulcerans) were evaluated in six prospective observational studies (822 participants), and the incidence of paradoxical reactions ranged from 1.9% to 26%. AUTHORS' CONCLUSIONS: While the antibiotic combination treatments evaluated appear to be effective, we found insufficient evidence showing that any particular drug is more effective than another. How different sizes, lesions, and stages of the disease may contribute to healing and which kind of lesions are in need of surgery are unclear based on the included studies. Guideline development needs to consider these factors in designing practical treatment regimens. Forthcoming trials using clarithromycin with rifampicin and other trials of new regimens that also address these factors will help to identify the best regimens.

[Leprosy awareness-raising summer seminar: results of participant survey during 2012 and 2015].

In order to assess the effectiveness of this leprosy awareness-raising program, we surveyed 123 participants between 2012 and 2015. They were asked about their satisfaction with the program and what impact it had on them. In the past four years 80% to 100% have reported being "very satisfied" with the seminar. Many participants were grateful for the opportunity to be able to learn about leprosy from multiple perspectives and interact with people affected by leprosy. Interaction and sharing of opinions between participants were also regarded as important. These findings elucidated the importance of this seminar to provide opportunities for knowing the right information about leprosy, interacting with people affected by leprosy, coming to know of their experience and thoughts, and gaining exposure to other participants' opinions.

Deep learning for AI-based diagnosis of skin-related neglected tropical diseases: A pilot study.

BACKGROUND: Deep learning, which is a part of a broader concept of artificial intelligence (AI) and/or machine learning has achieved remarkable success in vision tasks. While there is growing interest in the use of this technology in diagnostic support for skin-related neglected tropical diseases (skin NTDs), there have been limited studies in this area and fewer focused on dark skin. In this study, we aimed to develop deep learning based AI models with clinical images we collected for five skin NTDs, namely, Buruli ulcer, leprosy, mycetoma, scabies, and yaws, to understand how diagnostic accuracy can or cannot be improved using different models and training patterns. METHODOLOGY: This study used photographs collected prospectively in Côte d'Ivoire and Ghana through our ongoing studies with use of digital health tools for clinical data documentation and for teledermatology. Our dataset included a total of 1,709 images from 506 patients. Two convolutional neural networks, ResNet-50 and VGG-16 models were adopted to examine the performance of different deep learning architectures and validate their feasibility in diagnosis of the targeted skin NTDs. PRINCIPAL FINDINGS: The two models were able to correctly predict over 70% of the diagnoses, and there was a consistent performance improvement with more training samples. The ResNet-50 model performed better than the VGG-16 model. A model trained with PCR confirmed cases of Buruli ulcer yielded 1-3% increase in prediction accuracy across all diseases, except, for mycetoma, over a model which training sets included unconfirmed cases. CONCLUSIONS: Our approach was to have the deep learning model distinguish between multiple pathologies simultaneously-which is close to real-world practice. The more images used for training, the more accurate the diagnosis became. The percentages of correct diagnosis increased with PCR-positive cases of Buruli ulcer. This demonstrated that it may be better to input images from the more accurately diagnosed cases in the training models also for achieving better accuracy in the generated AI models. However, the increase was marginal which may be an indication that the accuracy of clinical diagnosis alone is reliable to an extent for Buruli ulcer. Diagnostic tests also have their flaws, and they are not always reliable. One hope for AI is that it will objectively resolve this gap between diagnostic tests and clinical diagnoses with the addition of another tool. While there are still challenges to be overcome, there is a potential for AI to address the unmet needs where access to medical care is limited, like for those affected by skin NTDs.

An mHealth App (eSkinHealth) for Detecting and Managing Skin Diseases in Resource-Limited Settings: Mixed Methods Pilot Study.

BACKGROUND: In sub-Saharan Africa, the disease burden from skin diseases, including skin-related neglected tropical diseases (skin NTDs), is extremely high. These diseases often are overlooked due to limited access to health care stemming from, for example, remote geographical locations and a lack of experts. To address these gaps, we developed a mobile health app, eSkinHealth, which is a field-adapted platform to serve as a portable electronic patient chart and for teledermatology. OBJECTIVE: The purpose of the study is to evaluate the usability and effectiveness of the app in rural Côte d'Ivoire for diagnosing and managing skin NTDs and other skin diseases. METHODS: A 2-arm trial with local health care providers and patients with skin diseases was implemented over a 3-month period. The providers were assigned to an intervention receiving the eSkinHealth app or control with usual care. Four nurses and 8 community health care workers participated in each arm. The training was provided on the use of the app to the intervention arm only, while both arms were trained on skin diseases. For the usability study, we evaluated our approach with the System Usability Scale (SUS) and in-depth interviews. For the effectiveness study, our primary outcome was to evaluate the detection and management of 5 skin NTDs as our targeted diseases, namely, Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws, using the eSkinHealth app. Procedures of our methods were reviewed and approved by the institutional review board of the Ministry of Health and by Tulane University. RESULTS: The mean age of our participants (providers) was 40.5 and 42.5 years for the intervention and control arms, respectively, and all were male (n=24). The average SUS scores taken from the intervention arm at baseline, the midpoint (6 weeks), and the end of study (12 weeks) were 72.3 (SD 11.5), 72.3 (SD 12.4), and 86.3 (SD 10.8), respectively. All participants interviewed, including 4 dermatologists and program managers, were satisfied with the app. Especially community health care workers felt empowered by being equipped with the tool. A total of 79 cases of skin NTDs were reported in the intervention arm as compared to 17 cases in the control arm (P=.002). Besides the skin NTDs, more skin diseases and conditions were reported from the control than from the intervention arm (P<.001). However, 100 cases (66%) were not given any particular diagnosis in the control arm and were documented only as a "dermatosis." In the intervention arm, 151 cases (72.9%) were diagnosed within the eSkinHealth platform, and the remaining were diagnosed on-site by dermatologists. CONCLUSIONS: The study provided evidence for the usability and effectiveness of the eSkinHealth app embedded into our surveillance approach to improve the detection and management of skin NTDs and other skin diseases in Côte d'Ivoire and, furthermore, is expected to contribute to knowledge on mobile health approaches in the control of skin diseases in resource-limited settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05300399; https://clinicaltrials.gov/ct2/show/NCT05300399.

A global call for action to tackle skin-related neglected tropical diseases (skin NTDs) through integration: An ambitious step change.

On 8 June 2022, the World Health Organization (WHO) released pivotal guidance, "Ending the neglect to attain the Sustainable Development Goals: A strategic framework for integrated control and management of skin-related neglected tropical diseases." Skin-related neglected tropical diseases, or skin NTDs, comprise a group of NTDs that produce signs and symptoms on the skin and include at least 9 diseases or disease groups. Moving away from disease-specific approaches, it is anticipated that synergies will be identified and integrated building on this shared feature, where possible, to achieve a greater health impact. This paper intends to draw attention to the prospects created by this scheme. The framework is a key basis for a proposal produced by WHO dedicated to skin NTD integration and describes the practical opportunities for this evolving strategy. It underlines the wider health benefits that will follow, thus working towards Universal Health Coverage and skin health for all.

Support for children identified with acute flaccid paralysis under the global polio eradication programme in Uttar Pradesh, India: a qualitative study.

BACKGROUND: Cases of polio in India declined after the implementation of the polio eradication programme especially in these recent years. The programme includes surveillance of acute flaccid paralysis (AFP) to detect and diagnose cases of polio at early stage. Under this surveillance, over 40,000 cases of AFP are reported annually since 2007 regardless of the number of actual polio cases. Yet, not much is known about these children. We conducted a qualitative research to explore care and support for children with AFP after their diagnosis. METHODS: The research was conducted in a district of western Uttar Pradesh classified as high-risk area for polio. In-depth interviews with parents of children with polio (17), with non-polio AFP (9), healthcare providers (40), and key informants from community including international and government officers, religious leaders, community leaders, journalists, and academics (21) were performed. RESULTS: Minimal medicine and attention were provided at government hospitals. Therefore, most parents preferred private-practice doctors for their children with AFP. Many were visited at homes to have stool samples collected by authorities. Some were visited repetitively following the sample collection, but had difficulty in understanding the reasons for these visits that pertained no treatment. Financial burden was a common concern among all families. Many parents expressed resentment for their children's disease, notably have been affected despite receiving multiple doses of polio vaccine. Both parents and healthcare providers lacked information and knowledge, furthermore poverty minimised the access to available healthcare services. Medicines, education, and transportation means were identified as foremost needs for children with AFP and residual paralysis. CONCLUSIONS: Despite the high number of children diagnosed with AFP as part of the global polio eradication programme, we found they were not provided with sufficient medical support following their diagnosis. Improvement in the quality and sufficiency of the healthcare system together with integration of AFP surveillance with other services in these underprivileged areas may serve as a key solution.

Methods and Approaches for Buruli Ulcer Surveillance in Africa: Lessons Learnt and Future Directions.

Over 95% of the global burden of Buruli ulcer disease (BU) caused by Mycobacterium ulcerans occurs in equatorial Africa. National and sub-national programs have implemented various approaches to improve detection and reporting of incident cases over recent decades. Regional incidence rates are currently in decline; however, surveillance targets outlined in 2012 by WHO have been missed and detection bias may contribute to these trends. In light of the new 2030 NTD roadmap and disease-specific targets, BU programs are required to strengthen case detection and begin a transition towards integration with other skin-NTDs. This transition comes with new opportunities to enhance existing BU surveillance systems and develop novel approaches for implementation and evaluation.In this review, we present a breakdown and assessment of the methods and approaches that have been the pillars of BU surveillance systems in Africa: (1) Passive case detection, (2) Data systems, (3) Clinical training, (4) Active case finding, (5) Burden estimation, and (6) Laboratory confirmation pathways. We discuss successes, challenges, and relevant case studies before highlighting opportunities for future development and evaluation including novel data collection tools, risk-based surveillance, and integrated skin-NTD surveillance. We draw on both experience and available literature to critically evaluate methods of BU surveillance in Africa and highlight new approaches to help achieve 2030 roadmap targets.

Nutritional status and wound healing in patients with Mycobacterium ulcerans disease (Buruli ulcer): a pilot study from rural Côte d'Ivoire

Background: Buruli ulcer (BU) is a neglected tropical disease caused by Mycobacterium ulcerans which manifests as deep ulceration of the skin. Wounds from any cause heal slowly if individuals are malnourished. Objectives: To assess the impact of nutritional status on wound healing, we carried out a nutritional assessment of 11 patients diagnosed with BU in rural Côte d'Ivoire, and followed them longitudinally through the wound healing process. Materials & Methods: We conducted patient interviews to collect data on their socioeconomic characteristics, food intake and perception of nutrition. We then prospectively carried out clinical observations to assess their wound healing until complete healing or the end of the study period (median follow-up period: 19 weeks). Results: The age of the patients ranged from 6 to 66 years (median: 24; interquartile range: 20.5-52). Nine patients had normal nutritional status, one had mild malnutrition and one had moderate malnutrition as assessed by their body mass index and/or mid-upper arm circumference. Three (60%) of the five patients with adequate caloric intake, but only 1/6 (17%) of the patients with an inadequate caloric intake achieved complete healing during follow-up. Low food intake from appetite loss primarily due to wound pain and odour was reported by seven patients after developing wounds. Conclusion: Our study is the first of its kind, and the findings highlight the importance of integrating nutritional interventions into wound management protocols, and properly assessing and controlling wound pain in patients with BU.

Hansen's disease (leprosy) in Japan, 1947-2020: an epidemiologic study during the declining phase to elimination.

OBJECTIVES: Leprosy, or Hansen's disease was a major public health problem in Japan in the early 20th century. Today, the number of new cases has decreased significantly. We aimed to investigate the trends of leprosy in Japan over the past 73 years and the challenges faced in recent years. METHODS: We assessed the data on newly registered cases of leprosy from 1947 to 2020. RESULTS: A total of 10,796 newly registered cases of leprosy were reported during the study period, of which 7573 were registered in mainland Japan, 2962 in Okinawa, and 250 were of foreign origin. Most autochthonous cases were born before 1950 in mainland Japan and before 1975 in Okinawa. The number of nonautochthonous cases surpassed that of autochthonous cases in 1992. Nonautochthonous cases originated from 26 countries, particularly Brazil and the Philippines. Three cases of antimicrobial resistance have been detected among nonautochthonous cases since 2004. CONCLUSION: Our data suggest that ongoing transmission of leprosy likely ceased in the 1940s in mainland Japan and in the 1970s in Okinawa. With the recent rise of nonautochthonous cases with globalization, continuous surveillance and efforts to maintain leprosy services within the country are necessary even after reaching the state of elimination.

The Early Detection and Case Management of Skin Diseases With an mHealth App (eSkinHealth): Protocol for a Mixed Methods Pilot Study in Côte d'Ivoire.

BACKGROUND: There is a high prevalence of skin diseases sub-Saharan Africa, including skin neglected tropical diseases (NTDs) that could lead to lifelong disabilities and deformities if not diagnosed and treated early. To achieve early detection and early treatment of these skin diseases, we developed a mobile health app, eSkinHealth. OBJECTIVE: This paper outlines a protocol for evaluating the effect of our eSkinHealth app in the early detection and effective management of skin diseases in Côte d'Ivoire. METHODS: A mixed methods pilot trial will be conducted in Côte d'Ivoire and will consist of 3 phases: (1) the development and improvement of the eSkinHealth app, (2) a pilot trial to evaluate the usability of the eSkinHealth app for local medical staff in Côte d'Ivoire, and (3) a pilot trial to evaluate the effectiveness of early detection and case management of targeted skin NTDs (Buruli ulcer, leprosy, yaws, and lymphatic filariasis) with the eSkinHealth app in Côte d'Ivoire. The pilot study will be implemented as a 2-arm trial with local health care providers and patients with skin NTDs over a 3-month follow-up period. The local health care providers will be assigned to an intervention group receiving the eSkinHealth app to be used in their daily practices or a control group. Training will be provided on the use and implementation of the app and the diagnostic pipeline to the intervention group only, while both groups will receive training on skin diseases. Our primary outcome is to evaluate the early detection and effective management of skin diseases using the eSkinHealth app in Côte d'Ivoire by the number of cases diagnosed and managed. Additionally, we will evaluate the eSkinHealth app with validated questionnaires and in-depth interviews. Procedures of our methods have been reviewed and approved by the Institutional Review Board of the Ministry of Health, Côte d'Ivoire and by Tulane University in 2021. RESULTS: This study was funded in 2021. We started the enrollment of patients in February 2022, and data collection is currently underway. We expect the first results to be submitted for publication in 2023. CONCLUSIONS: Our eSkinHealth app is a field-adapted platform that could provide both direct diagnostic and management assistance to health workers in remote settings. The study will provide evidence for the usability and the effectiveness of the eSkinHealth app to improve the early detection and case management of skin NTDs in Côte d'Ivoire and, furthermore, is expected to contribute to knowledge on mobile health approaches in the control of skin NTDs. TRIAL REGISTRATION: ClinicalTrials.gov NCT05300399; https://clinicaltrials.gov/ct2/show/study/NCT05300399. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39867.

Integrated Management of Skin NTDs-Lessons Learned from Existing Practice and Field Research.

Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. Because a number of these diseases share not only the geographical distribution, but also a common feature which is skin involvement, bringing together a sub-group of 'skin NTDs' is one way forward to promote further integration among NTDs. With these diseases, which include leprosy, Buruli ulcer, yaws, mycetoma, lymphatic filariasis, and leishmaniasis, patients may be left with life-long deformities and disabilities when diagnosis and treatment are delayed. Stigma is another serious consequence of skin NTDs as it places a large barrier on the economic activities and social life of a patient. As a result, this creates a vicious cycle and obstructs a key goal of society, the elimination of poverty. Enhancement in surveillance systems as well as the further development of diagnostic methods, improvement in treatment and management, and identification of preventative measures for skin NTDs are therefore urgently needed. This article summarizes the existing practices and field research on skin NTDs and identifies potential synergies that could be achieved by adopting this integrated approach.

Buruli Ulcer: a Review of the Current Knowledge.

PURPOSE OF THE REVIEW: Buruli ulcer (BU) is a necrotizing and disabling cutaneous disease caused by Mycobacterium ulcerans, one of the skin-related neglected tropical diseases (skin NTDs). This article aims to review the current knowledge of this disease and challenges ahead. RECENT FINDINGS: Around 60,000 cases of BU have been reported from over 33 countries between 2002 and 2017. Encouraging findings for development of point-of-care tests for BU are being made, and its treatment is currently in the transition period from rifampicin plus streptomycin (injection) to all-oral regimen. A major recent advance in our understanding of its pathogenesis has been agreement on the mechanism of action of the major virulence toxin mycolactone in host cells, targeting the Sec61 translocon during a major step in protein biogenesis. SUMMARY: BU is distributed mainly in West Africa, but cases are also found in other parts of the world. We may be underestimating its true disease burden, due to the limited awareness of this disease. More awareness and more understanding of BU will surely contribute in enhancing our fight against this skin NTD.

Case series of patients with chronic foot ulcers treated with autologous platelet-rich plasma.

Treatment for patients with chronic wounds is entering a new era, and autologous platelet-rich plasma (PRP) is among the most promising treatments. PRP contains a concentration of platelets obtained by centrifuging the patient's blood. Because it contains fibrin and high concentrations of growth factors, PRP is known to promote wound healing. In this study, we present five patients with chronic foot ulcers successfully treated with PRP in our institution. The patients had various underlying diseases: diabetes (n = 2), peripheral arterial disease (n = 1), both diabetes and peripheral arterial disease (n = 1), and cutaneous polyarteritis nodosa (n = 1). Also, we provide a description of PRP's mechanisms, advantages, and limitations.

Revisiting Buruli ulcer.

Buruli ulcer (BU), or Mycobacterium ulcerans infection, is a new emerging infectious disease which has been reported in over 33 countries worldwide. It has been noted not only in tropical areas, such as West Africa where it is most endemic, but also in moderate non-tropical climate areas, including Australia and Japan. Clinical presentation starts with a papule, nodule, plaque or edematous form which eventually leads to extensive skin ulceration. It can affect all age groups, but especially children aged between 5 and 15 years in West Africa. Multiple-antibiotic treatment has proven effective, and with surgical intervention at times of severity, it is curable. However, if diagnosis and treatment is delayed, those affected may be left with life-long disabilities. The disease is not yet fully understood, including its route of transmission and pathogenesis. However, due to recent research, several important features of the disease are now being elucidated. Notably, there may be undiagnosed cases in other parts of the world where BU has not yet been reported. Japan exemplifies the finding that awareness among dermatologists plays a key role in BU case detection. So, what about in other countries where a case of BU has never been diagnosed and there is no awareness of the disease among the population or, more importantly, among health professionals? This article will revisit BU, reviewing clinical features as well as the most recent epidemiological and scientific findings of the disease, to raise awareness of BU among dermatologists worldwide.

Loiasis in a Japanese Traveler Returning from Central Africa.

We encountered a probable case of loiasis in a returned traveler from Central Africa. A 52-year-old Japanese woman presented to our hospital complaining of discomfort in her eyes and skin. She reported having frequently visited Central Africa over many years and having been extensively exposed to the rainforest climate and ecosystem. Although no microfilariae were found in her blood, there was an elevated level of IgG antibodies against the crude antigens of Brugia pahangi, which have cross-reactivity with Loa loa. She was treated with albendazole for 21 days, after which the antigen-specific IgG level decreased and no relapse occurred.

Laboratory procedures for the detection and identification of cutaneous non-tuberculous mycobacterial infections.

There is evidence that the incidence of cutaneous non-tuberculous mycobacterial (NTM) infection is increasing worldwide. Novel culture methods and new analytical procedures have led to significant advancements in understanding the origin and progression of NTM infections. Differential identification of NTM isolates is important because culture characteristics and/or sensitivity to anti-mycobacterium drugs vary between different mycobacterial species. In this manuscript, we describe the latest diagnostic techniques for cutaneous NTM infection and show how these methodologies can be used for the diagnosis of Buruli ulcer in Japan.