[Cutaneous and soft skin infections due to non-tuberculous mycobacteria]. / Infecciones cutáneas y de partes blandas por micobacterias no tuberculosas.

The frequency of isolation as well as the number of species of non-tuberculous mycobacteria (NTM) has increased in the last years. Nearly every pathogenic species of NTM may cause skin and soft tissue infections, but rapidly growing mycobacteria (Mycobacterium fortuitum, Mycobacterium chelonae and Mycobacterium abscessus), Mycobacterium marinum and Mycobacterium ulcerans are the most commonly involved. Many of these cutaneous mycobacteriosis, such as rapidly growing mycobacteria, M. marinum, Mycobacterium avium complex, Mycobacterium kansasii or Mycobacterium xenopi are world-wide distributed. In contrast, some others have a specific geographical distribution. This is the case of M. ulcerans, which causes a cutaneous diseases endemic of Central and West Africa (Buruli ulcer) and Australia (Bairnsdale ulcer), being the third mycobacterial infection after tuberculosis and leprosy. Cutaneous mycobacteriosis usually appear either after contact of traumatic or surgical wounds with water or other contaminated products, or, secondarily, as a consequence of a disseminated mycobacterial disease, especially among immunosuppressed patients. For an early diagnosis, it is necessary to maintain a high degree of suspicion in patients with chronic cutaneous diseases and a history of trauma, risk exposure and negative results of conventional microbiological studies. In general, individualized susceptibility testing is not recommended for most NTM infections, except for some species, and in case of therapeutic failure. Treatment includes a combination of different antimicrobial agents, but it must be taken into account that NTM are resistant to conventional antituberculous drugs. Severe cases or those with deep tissues involvement could also be tributary of surgical resection.

Buruli ulcer disease: prospects for a vaccine.

Buruli ulcer disease (BUD), caused by Mycobacterium ulcerans, is a neglected bacterial infection of the poor in remote rural areas, mostly affecting children. BUD is a mutilating disease leading to severe disability; it is the third most common mycobacterial infection in immunocompetent people after tuberculosis and leprosy. It is most endemic in West Africa, but cases have been reported from more than 30 countries. Treatment with antibiotics is possible, long-lasting and requires injections; there are cases of treatment failures, and the disease is prone to resistance. A vaccine against M. ulcerans would protect persons at risk in highly endemic areas, and could be used as a therapeutic vaccine to shorten the duration of treatment and prevent relapses. There is considerable evidence supporting the notion that generation of a vaccine is feasible. This article reviews the present state of the art with special emphasis on the immunology of the infection and the prospects for development of a vaccine.

[Buruli ulcer--Africa's latest mycobacterial scourge]. / Burulisåret--Afrikas senaste mykobakteriella gissel.

Buruliulcer is an extensive ulceration usually on the extremities. The ulcer can spread to subcutaneous fat, muscle and even bone causing osteomyelitis and death. It is the the third most common mycobacterial disease in humans after tuberculosis and leprosy. The bacterium grows in still standing water and infects children through small ulcerations in their skin. Mycobacterium ulcerans may also be transmitted by the bite of aquatic bugs (Naucordiae), which harbor the bacterium in their salivary glands. The disease affects poor people in rural, tropical areas where deforestation has led to flooding rivers, stagnant bodies of water and marsh. Benin, Cote d'Ivoire and Ghana in West Africa are seriously hit. Skin transplantation is the treatment of choice. Treatment with antibiotics has been disappointing.

Mycobacterium ulcerans infection.

After tuberculosis and leprosy, Buruli-ulcer disease (caused by infection with Mycobacterium ulcerans) is the third most common mycobacterial disease in immunocompetent people. Countries in which the disease is endemic have been identified, predominantly in areas of tropical rain forest; the emergence of Buruli-ulcer disease in West African countries over the past decade has been dramatic. Current evidence suggests that the infection is transmitted through abraded skin or mild traumatic injuries after contact with contaminated water, soil, or vegetation; there is one unconfirmed preliminary report on possible transmission by insects. The clinical picture ranges from a painless nodule to large, undermined ulcerative lesions that heal spontaneously but slowly. Most patients are children. The disease is accompanied by remarkably few systemic symptoms, but occasionally secondary infections resulting in sepsis or tetanus cause severe systemic disease and death. Extensive scarring can lead to contractures of the limbs, blindness, and other adverse sequelae, which impose a substantial health and economic burden. Treatment is still primarily surgical, and includes excision, skin grafting, or both. Although BCG has a mild but significant protective effect, new vaccine developments directed at the toxins produced by M. ulcerans are warranted. In West Africa, affected populations are underprivileged, and the economic burden imposed by Buruli-ulcer disease is daunting. Combined efforts to improve treatment, prevention, control, and research strategies (overseen by the WHO and funded by international relief agencies) are urgently needed.

PIP: This paper focuses on Buruli-ulcer disease, the third most common mycobacterial disease among immunocompetent people. Buruli-ulcer disease is caused by an infection with Mycobacterium ulcerans, which belongs to the large group of environmental mycobacteria. It is endemic in many countries, usually in areas of tropical rain forest. Transmission of infection is through abraded skin or mild traumatic injuries after contact with contaminated water, soil, or vegetation. This disease mostly affects children which manifest from painless nodules to large, undermined ulcerative lesions that heals spontaneously but slowly. Buruli-ulcer disease is accompanied by few systemic symptoms, but occasionally secondary infections resulting in sepsis or tetanus cause severe systemic disease and death. However, extensive scarring can lead to contractures of the limbs, blindness, and other adverse complications. Management of the disease is still primarily surgical, and includes excision, skin grafting, or both. Although Bacillus Calmette-Guerin vaccine has mild but a significant protective effect, vaccine developments directed at the toxin produced by M. ulcerans are needed.

[Buruli ulcer (Mycobacterium ulcerans infection); report from the International Congress in Yamoussoukro, Ivory Coast]. / Buruli-ulcus (infectie met Mycobacterium ulcerans); verslag van een internationaal congres in Yamoussoukro, Ivoorkust.

Mycobacterium ulcerans infection (Buruli ulcer) is the third important mycobacterial disease world-wide in immunocompetent humans, after tuberculosis and leprosy. M. ulcerans is an environmental mycobacterium which has now been recovered from water and soil in swampy areas, and transmission to man occurs presumably through minor skin traumas. Endemic foci are known throughout the world, predominantly in tropical rain forest areas. The clinical presentation varies between a papule, a nodule or an ulceration with typically undermined edges. Surgery is the only effective treatment. BCG vaccination has a moderate protective effect. An association with HIV infection has not been demonstrated so far. Poor communities, with limited access to health care, and especially children are affected. The medical and socioeconomic burden imposed by the disease is tremendous. During the last decade the incidence of the disease has increased dramatically, particularly in West Africa. Possibly this is connected with changes in the natural ecosystem. The Yamoussoukro declaration on Buruli ulcer, adopted July 6, 1998, is the basis of improvement of awareness, health education, treatment, and research on M. ulcerans infection. Support by the international community is urgently needed.

[Antileprosy polychemotherapy in the member states of the OCCGE: a decade of implementation (1983-19930). The National Coordinators of the Leprosy Program of the 8 states of the OCCGE]. / La polychimiothérapie antilépreuse dans les Etats membres de l'OCCGE: une décennie de mise en oeuvre (1983-1993). Coordonnateurs Nationaux de Programme Lèpre des 8 Etats de l'OCCGE.

MDT for leprosy recommended by WHO in 1981 has been introduced and implemented in 8 Member States of OCCGE (an organization for leprosy control in francophone West Africa). This implementation from 1983 to 1993 can be divided in two phases: 1983-1987: introduction phase by pilot projects; 1988-1993: extension phase by national leprosy control programmes. During the ten years, MDT coverage rose to 68%, leprosy prevalence rate widely decreased (40.71 to 6.56 per 10,000), while annual detection rate weakly varied (1.89 to 1.26 per 10,000). Factors influencing this evolution of leprosy are brought out and recommendations are made about strategies to be developed for leprosy control up to year 2000.

[Intensification of the fight against leprosy using early and systematic polychemotherapy]. / Renforcement de la lutte contre la lèpre par une polychimiothérapie précoce et systématique.

The latest epidemiologic enquiries realized in West Africa and Central Africa have shown that real prevalence of leprosy is far greater, at least twice the number of patients than are actually listed in the medical records. This data proves that the fight against leprosy is highly inefficient and stresses the partial failure of the anti-hansenian strategy that has been adopted for over 10 years in this area, in spite of the use of rifampicin in multidrug therapy which would normally cure leprosy. Therefore we suggest that the fight against leprosy should be re-organised and reinforced in high endemic areas. The anti-hansenian programmes should be carried out by specific services composed of mobile and specialised teams whose task would be to aim for the early detection and continual testing for new cases. Only with this kind of organisation can chemotherapy be administered at the beginning, therefore arresting the disease before it reaches the multi-neuritis stage. This strategy offers great epidemiologic and economic advantages and would also give hope and dignity to the patients assured of a permanent cure. Leprosy would then be classed as a disease "just like any other".