Laboratory confirmation of Buruli ulcer cases in Ghana, 2008-2016.

BACKGROUND: Buruli ulcer (BU), a necrotizing skin infection caused by Mycobacterium ulcerans is the third most important mycobacterial disease globally after tuberculosis and leprosy in immune competent individuals. This study reports on the retrospective analyses of microbiologically confirmed Buruli ulcer (BU) cases in seventy-five health facilities in Ghana. METHOD/PRINCIPAL FINDINGS: Pathological samples were collected from BU lesions and transported either through courier services or by car directly to the laboratory. Samples were processed and analysed by IS2404 PCR, culture and Ziehl-Neelsen staining for detection of acid-fast bacilli. From 2008 to 2016, we analysed by PCR, 2,287 samples of 2,203 cases from seventy-five health facilities in seven regions of Ghana (Ashanti, Brong Ahafo, Central, Eastern, Greater Accra, Northern and Volta). The mean annual positivity rate was 46.2% and ranged between 14.6% and 76.2%. The yearly positivity rates from 2008 to 2016 were 52.3%, 76.2%, 56.7%, 53.8%, 41.2%, 41.5%, 22.9%, 28.5% and 14.6% respectively. Of the 1,020 confirmed cases, the ratio of female to male was 518 and 502 respectively. Patients who were 15 years of age and below accounted for 39.8% of all cases. The median age was 20 years (IQR = 10-43). Ulcerative lesions were 69.2%, nodule (9.6%), plaque (2.9%), oedema (2.5%), osteomyelitis (1.1%), ulcer/oedema (9.5%) and ulcer/plaque (5.2%). Lesions frequently occurred on the lower limbs (57%) followed by the upper limbs (38%), the neck and head (3%) and the least found on the abdomen (2%). CONCLUSIONS/SIGNIFICANCE: Our findings show a decline in microbiological confirmed rates over the years and therefore call for intensive education on case recognition to prevent over-diagnosis as BU cases decline.

Abordagem domiciliar de situações clínicas comuns em adultos

Curso da atenção domiciliar que apresenta as principais situações clínicas comuns em adultos, descrevendo o manejo dos pacientes na atenção domiciliar e reforçando o papel do cuidador como parte fundamental da equipe de cuidado. São apresentadas as seguintes situações clínicas: asma, doença pulmonar obstrutiva crônica, pneumonia, coronariopatia, doença vascular periférica, insuficiência cardíaca, hanseníase, SIDA, malária, tuberculose, infecção do trato urinário, osteomielite, pós-operatório em ortopedia, transtornos psiquiátricos, abordagem ao usuário de álcool e outras drogas, esclerose múltipla e esclerose lateral amiotrófica. Em cada uma das situações são tratados os aspectos conceituais, o diagnóstico, o manejo na atenção domiciliar, as orientações que devem ser fornecidas ao cuidador, o plano de alta na atenção domiciliar e quando referenciar para outros serviços.

The potential role of magnetic resonance imaging in patients with Hansen's neuropathy of the feet: a preliminary communication.

A magnetic resonance imaging (MRI) protocol was performed in leprosy patients with a neuropathic foot and superficial ulcers and/or localized cellulitis but no clinical suspicion of osteomyelitis. The aim of the study was to determine if unsuspected osteomyelitis was present in this defined group of leprosy patients. A total of 15 neuropathic feet from 9 patients were included. Clinically and on MRI, the forefoot was predominantly affected. MRI findings of osteomyelitis were found in 4 feet. In feet with osteomyelitis, 3 had a superficial ulcer and 3 had clinical signs of localized cellulitis. A clinical diagnosis of cellulitis was confirmed on MRI in 2 feet.A striking discrepancy between clinical and MRI findings was found.This study shows that, compared with clinical evaluation, MRI is a sensitive method for the detection of unsuspected osteomyelitis in neuropathic feet with superficial ulcers and/or cellulitis. MRI findings in this group of patients may influence clinical decision making and may prevent further complications, because osteomyelitis requires more aggressive medical treatment. This preliminary communication should pave the wave for designed controlled studies so that patients with Hansen's neuropathy may get the best medical care.

A clinical and radiological follow-up study in leprosy patients with asymptomatic neuropathic feet.

OBJECTIVES: An MRI study done in 2000 on 10 leprosy patients with neuropathic feet, without clinical complications such as ulcerations, osteomyelitis or Charcot deformities revealed abnormalities in nine patients, with degradation, interruption of subcutaneous fat and effusion/synovitis, all located in the first metatarsophalangeal (MTP) region. Since these MRI abnormalities may precede clinical complications of the foot, a follow-up study was performed. DESIGN: A new evaluation was based on a clinical examination and an MRI of the same patients who participated in the initial study. RESULTS: Four patients were lost to follow-up. Average follow-up period was 4-6 years. MRI abnormalities in the MTP 1 region in the first study were no longer visible in three patients, but were still present in two patients. In six patients new MRI findings were found, without clinical evidence of ulceration, osteomyelitis or Charcot deformity. No relationship was found between MRI findings in the MTP 1 region at the start of the study and the development of foot ulcers, callus or skin fissures in the MTP 1 region during follow-up. CONCLUSION: MRI findings of interruption and infiltration of the subcutaneous fat in leprosy patients with uncomplicated neuropathic feet do not necessarily have any clinical implication for the development of future foot problems.

[Contribution of paleopathology to defining the pathocoenosis of infectious diseases (Part one)]. / Apporti della paleopatologia alla definizione della patocenosi delle malattie infettive (prima parte).

Studying the remains of mummies obtained by archaeological research may provide key information concerning historical pathocoenosis. Paleopathology makes it possible to recognise, characterise and connect different features involved in human pathocoenosis, such as epidemiology, in a historical perspective, and cultural development, via the introduction of new livestock farming techniques and agriculture in general. Several distinct pathologies may produce direct and indirect changes in the skeleton of affected individuals. Therefore bone remains represent very important sources of information to study such diseases. Changes related to trauma and nutrition deficiency as well as secondary signs, induced by tuberculosis, brucellosis, leprosy, syphilis, malaria, periostitis and aspecific osteomyelitis, persist in bones. In addition, other diseases may cause indirect alterations and subsequent secondary bone in the skeleton via different mechanisms. A secondary bone dimorphism may be induced by poliomyelitis. Aspecific lesions may arise in a skeletal bone and then cause secondary alterations in near-bone segments. Reviewing studies of paleopathologic research found in the literature, we emphasize the relationship between the appearance of major infectious diseases and the development of human activities; whereas it is clear that the introduction of livestock farming had a key role in the pathocoenosis of distinct infections such as tuberculosis, brucellosis and leprosy, some doubts and uncertainty remain in relation to the origin of others with epidemiologically important pathologies, such as syphilis.

Alteraciones óseas en pacientes con Lepra / No disponible

Con el fin de estudiar el tipo de lesiones óseas en pacientes con lepra de alta terapéutica y su evolución, se ha estudiado a un grupo de 16 pacientes con antecedentes de lepra, mediante las radiografías realizadas a lo largo de su evolución. Las lesiones que se observaron con mayor frecuencia en los pies fueron las reabsorciones óseas en falanges (50% de los pacientes), osteoartritis infecciosa (43%), y pérdida o amputaciones de dedos, incluso en algunos casos con pérdida completa del antepié (5 pacientes). En las manos la lesión más frecuente en nuestra muestra fue del adelgazamiento de falanges con pérdida parcial de uno o más dedos. A lo largo de la evolución radiográfica se puede apreciar el empeoramiento progresivo de las reabsorciones óseas, con mayor adelgazamiento de falanges y metatarsianos a lo largo de los años hasta llegar a producir amputaciones (AU)

A study of 16 leprosy patients and their radiological files was carried out to evaluate the bone lesions in leprosy. The most frequent lesions were bone resorption in phalanges (50%) of patients), infectious osteoarthritis (43%), and finger lose or amputation, even complete lose of phalanges and metatarsals (5 patients). The most frequent lesion in hands was the phalanx narrowing, with partial amputation of one or more. We can appreciate the progressive worsening of the lesions following the radiographic evolution: year-by-year the bone resorption became increasingly severe, and finally amputation appears (AU)

Aggressive multifocal Buruli ulcer with associated osteomyelitis in an HIV-positive patient.

Mycobacterium ulcerans infection causes a skin disease known as Buruli ulcer (BU), a disorder manifested usually as a solitary and painless nodule or papule that progresses to massive necrotizing destruction and cutaneous ulceration. When healing occurs, it often results in disabling deformities. Buruli ulcer is considered the third most common mycobacterial disease in immunocompetent people, after tuberculosis and leprosy. Although the emergence of Buruli ulcer in Western African countries over the past decade has been dramatic, it has been scarcely reported in industrialized countries. We report a patient from Equatorial Guinea who was human immunodeficiency virus-positive, presenting aggressive and multifocal BU associated with an underlying destructive osteomyelitis, in which only an aggressive surgical approach yielded to a resolution of the disease. In a global world, with increasing migratory population fluxes, an increased awareness of dermatologists regarding the clinical, histopathological and microbiological features of BU is important in order to avoid significant delays in diagnosis and treatment.

Leprous osteitis presenting as bone cyst and erosions.

A 30-year-old man presented to the Hansen outpatient department with swelling and ulceration of toes for 2 months and swelling of the right fifth and fourth fingers and the left second finger for 1 month. In addition to skin lesions of lepromatous leprosy (subpolar type), there was nontender, non-fluctuant swelling of the right fifth and fourth fingers and left second finger. Skin over the right fifth finger showed sinus-like openings with associated purulent discharge. He also had swelling and ulceration of second left toe. Slit-skin smear (SSS) showed a bacterial index of 6+ from the ear lobes and cutaneous nodules, 4+ from the patch, and 3+ from normal skin. Modified Ziehl-Neelsen staining of the discharge extruding from the sinuses on the right fifth finger also showed abundant acid-fast bacilli. Radiography of the hands and feet showed lytic lesions in the distal epimetaphyseal region o proximal phalanx of the right fifth finger and left second finger and erosion of distal end of proximal phalanges of both second toes. Histopathological examination of biopsy specimen from the patch (back) showed features of lepromatous leprosy, and Fite-Faraco stain for tissue acid-fast bacteria (AFB) was strongly positive. Fine-needle-aspiration cytology (FNAC) from the lytic lesion in the bone also showed predominantly foamy macrophages with strongly positive staining for AFB with a few interspersed lymphocytes, epithelioid cells and Langhans giant cells. On the basis of these features, a clinical diagnosis of subpolar lepromatous leprosy with leprous osteitis was made. In today's clinical era of improved case detection and prompt treatment with effective multidrug regimens, advanced bone changes are rarely encountered. We describe this case of lepromatous leprosy that developed cavitating lesions of the phalanges of the hand, seen on x-ray as well-defined bone cyst and erosions.

Metaplasia ósea en enfermos de lepra lepromatosa

En el presente artículo, los autores intentan recoger su experiencia referente a la presencia de calcificaciones en partes blandas localizadas en las úlceras tróficas de miembros inferiores de diez pacientes de lepra lepromatosa. Los pacientes fueron residentes en el Sanatorio San Francisco de Borja, llevaban muchos años de evolución de su enfermedad y en el momento del estudio se encontraban clínica y bacteriológicamente inactivos (AU)

MR imaging of neuropathic feet in leprosy patients with suspected osteomyelitis.

This study was undertaken to analyze MRI findings in leprosy patients with neuropathic feet, which are suspected of having osteomyelitis. As far as we know, there is no literature concerning osteomyelitis and MRI in neuropathic leprosy feet at present. Therefore, we have included MRI examination of 18 events of suspected osteomyelitis in 12 leprosy patients. All patients with long-standing neuropathic foot problems were clinically suspected of having osteomyelitis. All patients underwent the MRI protocol with the inclusion of Two Point Dixon Chemical Shift Imaging as a fat-suppression sequence. For the MRI evaluation, we used signs that are described in literature for detecting osteomyelitis in diabetic feet. The primary MRI signs were positive in 17 of 18 patients. The secondary MRI signs were positive in 100% of the patients. Our results show that MRI with the use of Two Point Dixon Chemical Shift Imaging is a promising diagnostic modality to detect osteomyelitis in the presence of neurosteoarthropathic changes in patients with leprosy. Whenever available, MRI could play an important role in detecting osteomyelitis in leprosy patients with long-standing neuropathic feet.

MR imaging of neuropathic feet in leprosy patients with suspected osteomyelitis

This study was undertaken to analyze MRI findings in leprosy patients with neuropathic feet, which are suspected of having osteomyelitis. As far as we know, there is no literature concerning osteomyelitis and MRI in neuropathic leprosy feet at present. Therefore, we have included MRI examination of 18 events of suspected osteomyelitis in 12 leprosy patients. All patients with long-standing neuropathic foot problems were clinically suspected of having osteomyelitis. All patients underwent the MRI protocol with the inclusion of Two Point Dixon Chemical Shift Imaging as a fat-suppression sequence. For the MRI evaluation, we used signs that are described in literature for detecting osteomyelitis in diabetic feet. The primary MRI signs were positive in 17 of 18 patients. The secondary MRI signs were positive in 100% of the patients. Our results show that MRI with the use of Two Point Dixon Chemical Shift Imaging is a promising diagnostic modality to detect osteomyelitis in the presence of neurosteoarthropathic changes in patients with leprosy. Whenever available, MRI could play an important role in detecting osteomyelitis in leprosy patients with long-standing neuropathic feet.

A case of paracoccidioidomycosis: experience with long-term therapy.

We describe long-term therapy for paracoccidioidomycosis occurring in a 61-year-old house-painter from Venezuela. The diagnostic examinations made in South America had shown pulmonary granulomatous lesions and an osteolytic pattern of the left knee that had been considered suspect of malignant disease with an indication for limb amputation. With the aid of fine needle aspiration biopsy (FNAB) and culture examination we diagnosed an osteomyelitis by Paracoccidioides brasiliensis and initiated therapy with itraconazole, 400 mg per day, reduced to 200 mg per day after 2 months. At the end of 2 years of drug therapy, we observed complete regression of the pulmonary lesions and of the osteolytic area of the left knee. Moreover, we have periodically observed our patient to verify his clinical development and he is still in good health. We suggest that this pathology be considered in differential diagnosis of leprosy, tuberculosis, leishmaniasis, and systemic mycoses, even in non-endemic areas.

Vertebral osteomyelitis presenting with bilateral pleural effusions in a leprous patient.

We present a highly rare case of vertebral osteomyelitis due to Salmonella newport that was associated with pleural effusion in a leprous woman. The salmonella infection was considered to be precipitated by her hemolytic anemia resulting from dapsone. The direct spread of infection from the vertebrae led to the pleurisy.

Shrinkage of the below-knee stump in leprosy.

The long-term progress of below-knee stumps was studied in 65 leprotic amputees. Thirty-seven patients underwent amputation with a long posterior flap (LP) and 28 patients with an equal anterior and posterior flap (EF) technique. Mean follow-up was for 6 and 7 years respectively. Shrinkage of the soft tissue and retraction of the posterior calf muscles caused the posterior skin flap of the stump to rotate posteriorly in all cases, with a mean 26 degrees of rotation in LP stumps and 42 degrees of rotation in EF stumps. The LP stumps remained thicker, with soft tissue padding at the bony ends, and had fewer stump complications than the EF stumps.