Mycobacterium ulcerans infection in North Queensland: the 'Daintree ulcer'.

BACKGROUND: As the third most common mycobacterial infection in the world after tuberculosis and leprosy, Mycobacterium ulcerans is a major health and development problem that has become the focus of a World Health Organisation (WHO) initiative seeking to reduce the burden of this disease. The Daintree River catchment in north Queensland is an endemic focus for Mycobacterium ulcerans infection, known locally as the 'Daintree Ulcer'. The aim of this study is to analyse the changing pattern of the disease over the last 44 years in the region. METHODS: The study is a descriptive review of all human cases where infection had been acquired in an endemic region of far north Queensland. Demographic information, lesion characteristics, management and outcomes were recorded in a database. RESULTS: Over the period there were 92 cases of M. ulcerans infection. The average age was 41.7 years and 56.7% were male. There was distinct clustering of cases in several defined locations in the area. Most cases (90%) presented with ulcers, and all but three patients were treated surgically. Excision and skin grafting was more commonly used in the period between 1964-1988. Excision alone was the most common treatment used thereafter. Earlier recognition and smaller lesion size is thought to have contributed to the change in surgical practice. CONCLUSIONS: Ulcers caused by M. ulcerans infection are a distinct clinical entity in tropical North Queensland. Early recognition, diagnosis and prompt surgical intervention has minimised morbidity associated with this disease.

Clinic-epidemiological evaluation of ulcers in patients with leprosy sequelae and the effect of low level laser therapy on wound healing: a randomized clinical trial.

BACKGROUND: Mycobacterium leprae is the only pathogenic bacteria able to infect peripheral nerves. Neural impairment results in a set of sensitive, motor and autonomic disturbances, with ulcers originating primarily on the hands and feet. The study objectives were to analyze the clinic-epidemiological characteristics of patients attended at one specialized dressing service from a leprosy-endemic region of the Brazilian Amazon and to evaluate the effect of low level laser therapy (LLLT) on wound healing of these patients. METHODS: Clinic-epidemiological evaluation of patients with leprosy sequelae was performed at the reference unit in sanitary dermatology of the state of Pará in Brazil. We conducted anamnesis, identification of the regions affected by the lesions and measurement of ulcer depth and surface area. After that, we performed a randomized clinical trial. Fifty-one patients with ulcers related to leprosy were evaluated, twenty-five of them were randomly assigned to a low level laser therapy group or a control group. Patients were treated 3 times per week for 12 weeks. Outcome measures were ulcer surface area, ulcer depth and the pressure ulcer scale for healing score (PUSH). RESULTS: Ninety-seven ulcers were identified, with a mean (SD) duration of 97.6 (111.7) months, surface area of 7.3 (11.5) cm2, and depth of 6.0 (6.2) mm. Statistical analysis of the data determined that there were no significant differences in the variables analyzed before and after treatment with low level laser therapy. CONCLUSIONS: Ulcers in patients with leprosy remain a major source of economic and social losses, even many years after they have been cured of M. leprae infection. Our results indicate that it is necessary to develop new and more effective therapeutic tools, as low level laser therapy did not demonstrate any additional benefits to ulcer healing with the parameters used in this study. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov as NCT00860717.

[Epidemiologicl aspects of Buruli ulcer in Côte d'Ivoire: results of a national survey]. / Aspects épidémiologiques de l'ulcère de Buruli en Côte d'Ivoire: résultats d'une enquête nationale.

Ulcer caused by Mycobacterium ulcerans and called Buruli ulcer is characterised by large cutaneous ulceration which often leads to debilitating sequelae. The disease occurs in swampy and stagnant water areas in intertropical regions of Asia, the Indian Ocean, Latin America and Africa. West Africa has been affected for two decades with a significant increase in the last ten years. In Côte d'Ivoire, from 1991 to 1994, 2,246 cases have been detected. In 1995, the cumulative number was 5000 cases distributed throughout the forested and marshy areas of the southern part of the country. In order to assess the magnitude and severity of the disease in Côte d'Ivoire and to collect data necessary for developing a control plan, the National Programme of Buruli Ulcer Control (PNUM) conducted an extensive cross-sectional nation-wide survey. The results provide a total cumulative number of 10,382 cases distributed throughout almost all regions. The number of active cases was 4,642 which was equivalent to a prevalence of 0.32 per 1000. Buruli ulcer is the second most prevalent mycobacteriose in Côte d'Ivoire after tuberculosis and before leprosy. From 1996, the average annual incidence exceeded 2,000 cases. Moreover, the main identified risk factor was the presence of a watering point used by people nearby. Children were affected at a rate of 57%, with male predominance, while in adult cases, the female rate was higher. Children and women enjoyed higher recovery rates. Ulcerated cases represented 89.5% of active ones against 6.5% for oedematous forms and 4% in nodule cases. Definitive sequelae were more frequently observed in children with no difference of sex. We conclude that Buruli ulcer has been endemic in Côte d'Ivoire and is characterised by the severity of the lesions.

Ulceraciones en la lepra. Tratamiento / Ulcerations in lepra. Management

Se estudian las úlceras en la lepra, su etiología, frecuencia y localización, la mayoría de carácter neurotrófico. Se describen diferentes tratamientos tópicos y quirúrgicos, resaltando las dificultades terapéuticas y la cronicidad (AU)

Predisposing factors for recurrent skin ulcers in leprosy.

This study was designed to determine the factors associated with recurrence of leprosy ulcers. Between April and August 1992, 55 consecutive leprosy patients admitted with skin ulcers were studied. Factors predisposing to recurrence, e.g. patient's age, disease duration, ulcer site, ulcer depth and physical deformity (taking into account neuromuscular and skeletal damage) were evaluated. Ulcer recurrence occurred in 40/55 (75%) patients. Recurrent ulceration was associated with location in the lower extremity (P = 0.02), where recurrences were more common in the midfoot and heel (P = 0.01). Recurrence was also associated with severity of physical deformity (P = 0.01), which increased the odds of recurrent ulceration by 4.2 times (95% confidence interval, 1.01-18.3). The severity of physical deformity itself was associated with the age of the patient (P = 0.04) and the disease duration (P = 0.02). In conclusion, there is a need to focus on identification of risk factors for recurrent leprosy ulceration. Targeted prevention strategies would be required if morbidity associated with recurrent skin ulceration is to be avoided.

A clinico-epidemiological profile of non-healing wounds in an Indian hospital.

One hundred patients with non-healing wounds of more than six weeks' duration were studied for clinico-epidemiological factors and their correlation with healing time. The majority of subjects were aged 30-59 years; those aged 50 and over had significantly delayed healing. Most of the subjects were farmers and physical labourers. Leprosy was the most common cause of non-healing wounds, followed by diabetes, trauma and venous ulcers; the lower limbs were the most common site of involvement. Diabetic wounds were more common in those aged 40 years and above. Diabetic wounds were slower to heal than others. The time to healing was calculated from the day subjects received treatment advice at the wound clinic. Seventy-five of the study group were included for calculation of healing time. The others were lost to follow-up or excluded for other reasons.

[Present status of Buruli ulcer in Ghana, West Africa].

Recently, Buruli ulcer is emerging from the West and Central African countries. The disease come up with necrotizing and immno-suppressive type ulcer in the skin, subcutaneous tissue and bone, infected by Mycobacterium ulcerans, and shows indolent chronic course as mycobacterial infection, like tuberculosis and Hansen's disease. After the transmission to human, the lesion is usually single and begin as firm, painless, subcutaneous nodule and on any area of human body skin, though most frequently on lower limbs. In countries of West Africa, it is suspected that the disease should be spreading most widely in Ghana. During April and June 1999, Ghana Health Service pick up the new patients by nation-wide examination. The author visited Ghana twice at March and September 1999 and made on-the-spot inspections not only at a community and Ga district Health Service Center in Accra region but also at St. Martin's hospital in Agroyesum, Amanse west district, Ashanti region. At the time, the author did see the present state of Buruli ulcer, i.e. health and medical enlightenment. This report, includes the results due to undergoing nation-wide examination on Buruli ulcer at 2 District in Ghana (List 1 and 2), the present states of the patients and the enlightenment provided by the staffs of Ga district Health Service Center (Photografs 1-14). Staffs working for WHO and Ghana Health Service are tackling to Buruli ulcer problems, but conditions of the patients are very hard because these patients must live in tropical wetlands, poor health, poor medical and poor economic conditions.