Mycobacterium ulcerans infection (Buruli ulcer) on the face: a comparative analysis of 13 clinically suspected cases from the Democratic Republic of Congo.

We report our experience in managing 13 consecutive clinically suspected cases of Buruli ulcer on the face treated at the hospital of the Institut Médical Evangélique at Kimpese, Democratic Republic of Congo diagnosed during 2003-2007. During specific antibiotherapy, facial edema diminished, thus minimizing the subsequent extent of surgery and severe disfigurations. The following complications were observed: 1) lagophthalmos from scarring in four patients and associated ectropion in three of them; 2) blindness in one eye in one patient; 3) disfiguring exposure of teeth and gums resulting from excision of the left labial commissure that affected speech, drinking, and eating in one patient; and 4) dissemination of Mycobacterium ulcerans infection in three patients. Our study highlights the importance of this clinical presentation of Buruli ulcer, and the need for health workers in disease-endemic areas to be aware of the special challenges management of Buruli ulcer on the face presents.

Effect of a control project on clinical profiles and outcomes in buruli ulcer: a before/after study in Bas-Congo, Democratic Republic of Congo.

BACKGROUND: Buruli ulcer (BU) is a necrotizing bacterial infection of skin, subcutaneous tissue and bone caused by Mycobacterium ulcerans. Although the functional impairment caused by BU results in severe suffering and in socio-economic problems, the disease remains largely neglected in Africa. The province of Bas-Congo in Democratic Republic of Congo contains one of the most important BU foci of the country, i.e. the Songololo Territory in the District of Cataractes. This study aims to assess the impact of a BU control project launched in 2004 in the Songololo Territory. METHODS: We used a comparative non-randomized study design, comparing clinical profiles and outcomes of the group of patients admitted at the General Reference Hospital (GRH) of the "Institut Médical Evangélique" (IME) of Kimpese 3 years before the start of the project (2002-2004) with those admitted during the 3 years after the start of the project (2005-2007). RESULTS: The BU control project was associated with a strong increase in the number of admitted BU cases at the GRH of IME/Kimpese and a fundamental change in the profile of those patients; more female patients presented with BU, the proportion of relapse cases amongst all admissions reduced, the proportion of early lesions and simple ulcerative forms increased, more patients healed without complications and the case fatality rate decreased substantially. The median duration since the onset of first symptoms however remained high, as well as the proportion of patients with osteomyelitis or limitations of joint movement, suggesting that the diagnostic delay remains substantial. CONCLUSION: Implementing a specialized program for BU may be effective in improving clinical profiles and outcomes in BU. Despite these encouraging results, our study highlights the need of considering new strategies to better improve BU control in a low resources setting.

Role of dermatologists in leprosy elimination and post-elimination era.

Would it not have been better to have left out the word 'elimination' altogether in the question and do what WHO has done in its new strategic plan for 2006-2010, 'Global Strategy for further reducing the Leprosy Burden and Sustaining Leprosy Control Activities'? Why not use a title such as 'The Role of Dermatologists in reducing the Leprosy Burden and Sustainig Leprosy Control Activities'? Some elements of the 'foundation' of the elimination policy have been (and are still) very controversial, its definition and the unsubstantiated (up till now) claim that when reaching a prevalence rate of less than 1 per 10,000, the transmission of the infection would be interrupted and the incidence would therefore decline.

Impairments and Hansen's disease control in Rondônia state, Amazon region of Brazil.

This retrospective study of impairments in a decentralized and integrated, routine Hansen's disease (HD) programme was done on a cohort of all new patients detected in Rondônia state from 1996 to 1999. It shows that the dynamics of impairments during treatment in Rondônia are similar to what has been published in other recent studies from Africa and Asia. Data about impairments at detection and at release from treatment (cure), the prescription of steroids, and epidemiological information are provided. Of the original 5350 new patients, 4230 patients (80%) completed multidrug therapy (MDT) and had complete data about their impairment status. At the start of treatment, 9% of the paucibacillary (PB) and 26% of the multibacillary (MB) patients had WHO grade 1 impairment. Three percent of the PB and 11% of the MB patients had visible deformities (WHO grade 2 impairment). Of the patients without impairments (grade 0) at the start of treatment, 5% of the PB and 20% of the MB patients developed impairments during treatment. Of the PB patients with a WHO impairment grade 1 at start of treatment, 34% improved and 6% got worse. Of the MB patients 34% improved and 12% became worse. In a separate study of patients from the 1997 intake, 17% of the PB and 58% of the MB patients were treated at least once with a course of steroids or thalidomide during MDT treatment. It is noted in the literature that the percentage of persons with recent nerve function impairment (NFI), nerve pain or tenderness and/or reaction reactions differs between projects. This may reflect real differences or may be caused by differences in routine monitoring and/or criteria and methods of treatment. The use of the WHO maximum score, particularly for the patients with grade 2, is not as sensitive to change as utilizing the summary of Eye, Hand and Foot (EHF) scores. If overall impairment figures are given, the proportions of MB patients may define the differences between projects, therefore it is important to analysis and present the results of PB and MB patients separately. The most simple (outcome) indicator to estimate the effectiveness of patient management would be the proportions of patients with impairment grade 0 at start of treatment who develop either grade 1 or 2 impairments during treatment. An additional (outcome) indicator could be the proportion of patients with impairment grade 1 at start of treatment who develop grade 2 impairments during treatment. Currently, no operational targets or acceptable level of performance for patient management have been set. This would be important to enable programme managers to determine if adequate patient education, treatment and follow up have been provided after the disease detection to prevent and/or minimize problems associated with the disease. The available evidence strongly suggests that reactions and impairments related to HD will continue to occur in large numbers, requiring the development of adequate infrastructures and sustainable services to detect and to manage problems associated with HD during and after MDT treatment.