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Chavda VP, Haritopoulou-Sinanidou M, Bezbaruah R, Apostolopoulos V. Vaccination efforts for Buruli Ulcer. Expert Rev Vaccines 2022; 21:1419-1428. [PMID: 35962475 DOI: 10.1080/14760584.2022.2113514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Buruli ulcer is one of the most common mycobacterial diseases usually affecting poorer populations in tropical and subtropical environments. This disease, caused by M. ulcerans infection, has devastating effects for patients, with significant health and economic burden. Antibiotics are often used to treat affected individuals, but in most cases, surgery is necessary. AREA COVERED We present progress on Buruli ulcer vaccines and identify knowledge gaps in this neglected tropical disease. EXPERT OPINION The lack of appropriate infrastructure in endemic areas, as well as the severity of symptoms and lack of non-invasive treatment options, highlights the need for an effective vaccine to combat this disease. In terms of humoral immunity, it is vital to consider its significance and the magnitude to which it inhibits or slowdowns the progression of the disease. Only by answering these key questions will it be possible to tailor more appropriate vaccination and preventative provisions.
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Affiliation(s)
- Vivek P Chavda
- Department of Pharmaceutics and Pharmaceutical Technology, L M College of Pharmacy, Ahmedabad, India
| | | | - Rajashri Bezbaruah
- Department of Pharmaceutical Sciences, Faculty of Science and Engineering, Dibrugarh University, Dibrugarh, Assam, India
| | - Vasso Apostolopoulos
- Institute for Health and Sport, Immunology and Translational Research Group, Victoria University, Melbourne VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Immunology Program, Melbourne VIC, Australia
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2
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Johnson RC, Sáez-López E, Anagonou ES, Kpoton GG, Ayelo AG, Gnimavo RS, Mignanwande FZ, Houezo JG, Sopoh GE, Addo J, Orford L, Vlasakakis G, Biswas N, Calderon F, Della Pasqua O, Gine-March A, Herrador Z, Mendoza-Losana A, Díez G, Cruz I, Ramón-García S. Comparison of 8 weeks standard treatment (rifampicin plus clarithromycin) vs. 4 weeks standard plus amoxicillin/clavulanate treatment [RC8 vs. RCA4] to shorten Buruli ulcer disease therapy (the BLMs4BU trial): study protocol for a randomized controlled multi-centre trial in Benin. Trials 2022; 23:559. [PMID: 35804454 PMCID: PMC9270751 DOI: 10.1186/s13063-022-06473-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/09/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Buruli ulcer (BU) is a neglected tropical disease caused by Mycobacterium ulcerans that affects skin, soft tissues, and bones, causing long-term morbidity, stigma, and disability. The recommended treatment for BU requires 8 weeks of daily rifampicin and clarithromycin together with wound care, physiotherapy, and sometimes tissue grafting and surgery. Recovery can take up to 1 year, and it may pose an unbearable financial burden to the household. Recent in vitro studies demonstrated that beta-lactams combined with rifampicin and clarithromycin are synergistic against M. ulcerans. Consequently, inclusion of amoxicillin/clavulanate in a triple oral therapy may potentially improve and shorten the healing process. The BLMs4BU trial aims to assess whether co-administration of amoxicillin/clavulanate with rifampicin and clarithromycin could reduce BU treatment from 8 to 4 weeks. METHODS We propose a randomized, controlled, open-label, parallel-group, non-inferiority phase II, multi-centre trial in Benin with participants stratified according to BU category lesions and randomized to two oral regimens: (i) Standard: rifampicin plus clarithromycin therapy for 8 weeks; and (ii) Investigational: standard plus amoxicillin/clavulanate for 4 weeks. The primary efficacy outcome will be lesion healing without recurrence and without excision surgery 12 months after start of treatment (i.e. cure rate). Seventy clinically diagnosed BU patients will be recruited per arm. Patients will be followed up over 12 months and managed according to standard clinical care procedures. Decision for excision surgery will be delayed to 14 weeks after start of treatment. Two sub-studies will also be performed: a pharmacokinetic and a microbiology study. DISCUSSION If successful, this study will create a new paradigm for BU treatment, which could inform World Health Organization policy and practice. A shortened, highly effective, all-oral regimen will improve care of BU patients and will lead to a decrease in hospitalization-related expenses and indirect and social costs and improve treatment adherence. This trial may also provide information on treatment shortening strategies for other mycobacterial infections (tuberculosis, leprosy, or non-tuberculous mycobacteria infections). TRIAL REGISTRATION ClinicalTrials.gov NCT05169554 . Registered on 27 December 2021.
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Affiliation(s)
- Roch Christian Johnson
- Centre Interfacultaire de Formation et de Recherche en Environnement pour le Développement Durable (CIFRED), Université d'Abomey-Calavi, Abomey-Calavi, Benin
- Fondation Raoul Follereau, Paris, France
| | - Emma Sáez-López
- Department of Microbiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Esaï Sèdjro Anagonou
- Centre Interfacultaire de Formation et de Recherche en Environnement pour le Développement Durable (CIFRED), Université d'Abomey-Calavi, Abomey-Calavi, Benin
| | - Godwin Gérard Kpoton
- Centre Interfacultaire de Formation et de Recherche en Environnement pour le Développement Durable (CIFRED), Université d'Abomey-Calavi, Abomey-Calavi, Benin
| | - Adjimon Gilbert Ayelo
- Centre Interfacultaire de Formation et de Recherche en Environnement pour le Développement Durable (CIFRED), Université d'Abomey-Calavi, Abomey-Calavi, Benin
| | - Ronald Sètondji Gnimavo
- Centre Interfacultaire de Formation et de Recherche en Environnement pour le Développement Durable (CIFRED), Université d'Abomey-Calavi, Abomey-Calavi, Benin
| | - Franck Zinsou Mignanwande
- Centre Interfacultaire de Formation et de Recherche en Environnement pour le Développement Durable (CIFRED), Université d'Abomey-Calavi, Abomey-Calavi, Benin
| | - Jean-Gabin Houezo
- Programme National de Lutte Contre l'Ulcère de Buruli, Cotonou, Bénin
| | | | - Juliet Addo
- Global Health Catalyst, GlaxoSmithKline, Brentford, London, UK
| | - Lindsay Orford
- Global Health Catalyst, GlaxoSmithKline, Brentford, London, UK
| | | | - Nandita Biswas
- Global Health Catalyst, GlaxoSmithKline, Brentford, London, UK
| | - Felix Calderon
- Global Health Catalyst, GlaxoSmithKline, Brentford, London, UK
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK
- Consiglio Nazionale Delle Ricerche, Istituto Per Le Applicazioni del Calcolo, Rome, Italy
| | | | - Zaida Herrador
- National Centre for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Alfonso Mendoza-Losana
- Global Health Catalyst, GlaxoSmithKline, Brentford, London, UK
- Department of Bioengineering and Aeroespace Engineering, Carlos III University of Madrid, Madrid, Spain
| | | | - Israel Cruz
- National School of Public Health, Instituto de Salud Carlos III, Madrid, Spain
- CIBER Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Santiago Ramón-García
- Department of Microbiology, Faculty of Medicine, University of Zaragoza, Zaragoza, Spain.
- CIBER Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
- Research & Development Agency of Aragon (ARAID) Foundation, Zaragoza, Spain.
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3
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Robbe-Saule M, Foulon M, Poncin I, Esnault L, Varet H, Legendre R, Besnard A, Grzegorzewicz AE, Jackson M, Canaan S, Marsollier L, Marion E. Transcriptional adaptation of Mycobacterium ulcerans in an original mouse model: New insights into the regulation of mycolactone. Virulence 2021; 12:1438-1451. [PMID: 34107844 PMCID: PMC8204960 DOI: 10.1080/21505594.2021.1929749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mycobacterium ulcerans is the causal agent of Buruli ulcer, a chronic infectious disease and the third most common mycobacterial disease worldwide. Without early treatment, M. ulcerans provokes massive skin ulcers, caused by the mycolactone toxin, its main virulence factor. However, spontaneous healing may occur in Buruli ulcer patients several months or years after the disease onset. We have shown, in an original mouse model, that bacterial load remains high and viable in spontaneously healed tissues, with a switch of M. ulcerans to low levels of mycolactone production, adapting its strategy to survive in such a hostile environment. This original model offers the possibility to investigate the regulation of mycolactone production, by using an RNA-seq strategy to study bacterial adaptation during mouse infection. Pathway analysis and characterization of the tissue environment showed that the bacillus adapted to its new environment by modifying its metabolic activity and switching nutrient sources. Thus, M. ulcerans ensures its survival in healing tissues by reducing its secondary metabolism, leading to an inhibition of mycolactone synthesis. These findings shed new light on mycolactone regulation and pave the way for new therapeutic strategies.
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Affiliation(s)
| | | | | | | | - Hugo Varet
- Plate-forme Transcriptome Et Epigenome, Biomics, Centre De Ressources Et Recherches Technologiques (C2RT), Institut Pasteur, Paris, France.,Hub De Bioinformatique Et Biostatistique - Département Biologie Computationnelle, Institut Pasteur, Paris, France
| | - Rachel Legendre
- Plate-forme Transcriptome Et Epigenome, Biomics, Centre De Ressources Et Recherches Technologiques (C2RT), Institut Pasteur, Paris, France.,Hub De Bioinformatique Et Biostatistique - Département Biologie Computationnelle, Institut Pasteur, Paris, France
| | | | - Anna E Grzegorzewicz
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, United States
| | - Mary Jackson
- Mycobacteria Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado, United States
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Foulon M, Robbe-Saule M, Esnault L, Malloci M, Mery A, Saint-André JP, Kempf M, Homedan C, Marion E, Marsollier L. Ketogenic diet impairs Mycobacterium ulcerans growth and toxin production, enhancing hosts' response to the infection in an experimental mouse model. J Infect Dis 2021; 224:1973-1983. [PMID: 33944942 DOI: 10.1093/infdis/jiab236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Ketogenic diets have been used to treat diverse conditions, and there is growing evidence of their benefits for tissue repair and in inflammatory disease treatment. However, their role in infectious diseases has been little studied. Buruli ulcer (Mycobacterium ulcerans infection) is a chronic infectious disease characterized by large skin ulcerations caused by mycolactone, the major virulence factor of the bacillus. Here, we investigated the impact of ketogenic diet on this cutaneous disease in an experimental mouse model. This diet prevented ulceration, by modulating bacterial growth and host inflammatory response. β-hydroxybutyrate, the major ketone body produced during ketogenic diet and diffusing in tissues, impeded M. ulcerans growth and mycolactone production in vitro underlying its potential key role in infection. These results pave the way for the development of new patient management strategies involving shorter courses of treatment and improving wound healing, in line with the major objectives of the World Health Organization.
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Affiliation(s)
- Mélanie Foulon
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d'Angers, Angers, France
| | - Marie Robbe-Saule
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d'Angers, Angers, France
| | - Lucille Esnault
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d'Angers, Angers, France
| | - Marine Malloci
- MicroPICell Imaging Core Facility, SFR Santé F. Bonamy UMS016, INSERM, CNRS, Université de Nantes, Nantes, France
| | - Anthony Mery
- Département de biochimie et génétique, CHU Angers, France
| | | | - Marie Kempf
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d'Angers, Angers, France.,Laboratoire de bactériologie, CHU, Angers, France
| | - Chadi Homedan
- Département de biochimie et génétique, CHU Angers, France
| | - Estelle Marion
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d'Angers, Angers, France
| | - Laurent Marsollier
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d'Angers, Angers, France
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5
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Fevereiro J, Fraga AG, Pedrosa J. Genetics in the Host-Mycobacterium ulcerans interaction. Immunol Rev 2021; 301:222-241. [PMID: 33682158 DOI: 10.1111/imr.12958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/30/2022]
Abstract
Buruli ulcer is an emerging infectious disease associated with high morbidity and unpredictable outbreaks. It is caused by Mycobacterium ulcerans, a slow-growing pathogen evolutionarily shaped by the acquisition of a plasmid involved in the production of a potent macrolide-like cytotoxin and by genome rearrangements and downsizing. These events culminated in an uncommon infection pattern, whereby M. ulcerans is both able to induce the initiation of the inflammatory cascade and the cell death of its proponents, as well as to survive within the phagosome and in the extracellular milieu. In such extreme conditions, the host is sentenced to rely on a highly orchestrated genetic landscape to be able to control the infection. We here revisit the dynamics of M. ulcerans infection, drawing parallels from other mycobacterioses and integrating the most recent knowledge on its evolution and pathogenicity in its interaction with the host immune response.
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Affiliation(s)
- João Fevereiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Alexandra G Fraga
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Jorge Pedrosa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal
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6
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Chauffour A, Robert J, Veziris N, Aubry A, Pethe K, Jarlier V. Telacebec (Q203)-containing intermittent oral regimens sterilized mice infected with Mycobacterium ulcerans after only 16 doses. PLoS Negl Trop Dis 2020; 14:e0007857. [PMID: 32866170 PMCID: PMC7494103 DOI: 10.1371/journal.pntd.0007857] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 09/16/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022] Open
Abstract
Buruli ulcer (BU), caused by Mycobacterium ulcerans, is currently treated with a daily combination of rifampin and either injectable streptomycin or oral clarithromycin. An intermittent oral regimen would facilitate treatment supervision. We first evaluated the bactericidal activity of newer antimicrobials against M. ulcerans using a BU animal model. The imidazopyridine amine telacebec (Q203) exhibited high bactericidal activity whereas tedizolid (an oxazolidinone closely related to linezolid), selamectin and ivermectin (two avermectine compounds) and the benzothiazinone PBTZ169 were not active. Consequently, telacebec was evaluated for its bactericidal and sterilizing activities in combined intermittent regimens. Telacebec given twice a week in combination with a long-half-life compound, either rifapentine or bedaquiline, sterilized mouse footpads in 8 weeks, i.e. after a total of only 16 doses, and prevented relapse during a period of 20 weeks after the end of treatment. These results are very promising for future intermittent oral regimens which would greatly simplify BU treatment in the field. The current treatment for Buruli ulcer (BU), an infection caused by Mycobacterium ulcerans, is based on a daily antibiotic combination of rifampin associated with streptomycin or clarithromycin. A shorter or intermittent treatment without an injectable drug would clearly simplify the management in the field. We evaluated the bactericidal activity of several new antimicrobial drugs in a mouse model of BU and found that telacebec (Q203) exhibited the greatest bactericidal effect. We subsequently identified new antibiotic combinations containing telacebec with high sterilizing activity when administered twice a week for 8 weeks, i.e. at a total of only 16 doses.
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Affiliation(s)
- Aurélie Chauffour
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
- * E-mail:
| | - Jérôme Robert
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
- Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Laboratoire de Bactériologie-Hygiène, Groupe hospitalier APHP, Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Nicolas Veziris
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
- Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Laboratoire de Bactériologie-Hygiène, Groupe hospitalier APHP, Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Département de Bactériologie, Groupe hospitalier APHP, Sorbonne Université, Site Saint-Antoine, Paris, France
| | - Alexandra Aubry
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
- Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Laboratoire de Bactériologie-Hygiène, Groupe hospitalier APHP, Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Kevin Pethe
- Lee Kong Chian School of Medicine, Nanyang Technological University, Experimental Medicine Building, Singapore, Singapore
- School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Vincent Jarlier
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie et des Maladies Infectieuses (CIMI-Paris), Paris, France
- Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Laboratoire de Bactériologie-Hygiène, Groupe hospitalier APHP, Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
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7
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Takahashi T, Kabuto M, Nakanishi G, Tanaka T, Fujimoto N. Histological and quantitative polymerase chain reaction-based analysis of Buruli ulcer using mapping biopsy method. PLoS Negl Trop Dis 2020; 14:e0008051. [PMID: 32569298 PMCID: PMC7332088 DOI: 10.1371/journal.pntd.0008051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 07/02/2020] [Accepted: 01/13/2020] [Indexed: 11/18/2022] Open
Abstract
Background In Japan, Buruli ulcer cases are often advanced, requiring surgical treatment. However, extensive debridement is often difficult because of cosmetic and functional sequelae. Moreover, the lesions are complicated and composed of edematous erythema, necrotic ulcer, and erythematous skin lesions caused by a paradoxical reaction, which also make it difficult to perform adequate debridement. Methodology/Principal findings We performed quantitative polymerase chain reaction (PCR) analysis for IS2404 using 29 samples taken from mapping biopsy. We evaluated the relationship among mycobacterial burden, histopathological findings, and clinical outcomes using 83 tissue samples taken from mapping biopsy and debrided Buruli ulcer. On quantitative PCR, the Cp values of IS2404 amplification were substantially different in each site. The major histological findings could be divided into massive subcutaneous necrosis with scant inflammatory cell infiltration and dense inflammatory cell infiltration. Of the 84 sites, 34 were subjected to repeated histological evaluations. In these sites, histological necrosis did not disappear over time despite standard antibiotic treatment. In contrast, the ulcers were cured and no recurrences were observed without resecting the 11 biopsied sites that lacked histological necrosis. Although quantitative PCR revealed that a lower Cp value of IS2404 was associated with histological massive necrosis, sites that showed lower Cp values clinically did not always need debridement. Conclusion/Significance Our descriptive study revealed that the histological findings and amounts of mycobacterial DNA differed according to the sites despite being found in one lesion. Our results showed that the need for surgical debridement in each site was correlated with histological necrosis without inflammatory cell infiltration, as the inflammation is supposed to represent an active host immune response rather than mycobacterial burden. We suggest that the debridement of lesions with histological necrosis in mapping biopsy may be useful for Japanese cases with unsuccessful standard antibiotic treatment to achieve sufficient clinical improvement. We have proposed a preoperative mapping biopsy procedure to perform optimal debridement for Buruli ulcer presenting complicated skin lesions. Briefly, multiple punch biopsies are performed from various sites around the Buruli ulcer lesions and the range of resection is decided according to the histological findings of the biopsies. Herein, we performed histological examination and quantitative PCR analysis using 83 tissue samples taken from mapping biopsy and debrided Buruli ulcer to validate our method. Our results suggested that the sites with histological necrosis need to be resected during surgical debridement and that the sites without histological necrosis can be preserved. These results in combination with those of previous studies are supportive of the mapping biopsy procedure that we have proposed. However, a randomized controlled study questioned the need for adjunct surgical treatment in Buruli ulcer. Further studies are needed to establish the Japanese evidence for surgical treatment in Japanese cases of Buruli ulcer.
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Affiliation(s)
- Toshifumi Takahashi
- Department of Dermatology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga, Japan
- * E-mail:
| | - Miho Kabuto
- Department of Dermatology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga, Japan
| | - Gen Nakanishi
- Department of Dermatology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga, Japan
| | - Toshihiro Tanaka
- Department of Dermatology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga, Japan
| | - Noriki Fujimoto
- Department of Dermatology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga, Japan
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8
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Van Der Werf TS, Barogui YT, Converse PJ, Phillips RO, Stienstra Y. Pharmacologic management of Mycobacterium ulcerans infection. Expert Rev Clin Pharmacol 2020; 13:391-401. [PMID: 32310683 DOI: 10.1080/17512433.2020.1752663] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Pharmacological treatment of Buruli ulcer (Mycobacterium ulcerans infection; BU) is highly effective, as shown in two randomized trials in Africa. AREAS COVERED We review BU drug treatment - in vitro, in vivo and clinical trials (PubMed: '(Buruli OR (Mycobacterium AND ulcerans)) AND (treatment OR therapy).' We also highlight the pathogenesis of M. ulcerans infection that is dominated by mycolactone, a secreted exotoxin, that causes skin and soft tissue necrosis, and impaired immune response and tissue repair. Healing is slow, due to the delayed wash-out of mycolactone. An array of repurposed tuberculosis and leprosy drugs appears effective in vitro and in animal models. In clinical trials and observational studies, only rifamycins (notably, rifampicin), macrolides (notably, clarithromycin), aminoglycosides (notably, streptomycin) and fluoroquinolones (notably, moxifloxacin, and ciprofloxacin) have been tested. EXPERT OPINION A combination of rifampicin and clarithromycin is highly effective but lesions still take a long time to heal. Novel drugs like telacebec have the potential to reduce treatment duration but this drug may remain unaffordable in low-resourced settings. Research should address ulcer treatment in general; essays to measure mycolactone over time hold promise to use as a readout for studies to compare drug treatment schedules for larger lesions of Buruli ulcer.
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Affiliation(s)
- Tjip S Van Der Werf
- Departments of Internal Medicine/Infectious Diseases, University Medical Centre Groningen, University of Groningen , Groningen, Netherlands.,Pulmonary Diseases & Tuberculosis, University Medical Centre Groningen, University of Groningen , Groningen, Netherlands
| | - Yves T Barogui
- Ministère De La Sante ́, Programme National Lutte Contre La Lèpre Et l'Ulcère De Buruli , Cotonou, Benin
| | - Paul J Converse
- Department of Medicine, Johns Hopkins University Center for Tuberculosis Research , Baltimore, Maryland, USA
| | - Richard O Phillips
- Kumasi, Ghana And Kwame Nkrumah University of Science and Technology, Komfo Anokye Teaching Hospital , Kumasi, Ghana
| | - Ymkje Stienstra
- Departments of Internal Medicine/Infectious Diseases, University Medical Centre Groningen, University of Groningen , Groningen, Netherlands
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9
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Affiliation(s)
- Paul D R Johnson
- Infectious Diseases Department, Austin Health, and University of Melbourne, Heidelberg, VIC 3084, Australia.
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10
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Phillips RO, Robert J, Abass KM, Thompson W, Sarfo FS, Wilson T, Sarpong G, Gateau T, Chauty A, Omollo R, Ochieng Otieno M, Egondi TW, Ampadu EO, Agossadou D, Marion E, Ganlonon L, Wansbrough-Jones M, Grosset J, Macdonald JM, Treadwell T, Saunderson P, Paintsil A, Lehman L, Frimpong M, Sarpong NF, Saizonou R, Tiendrebeogo A, Ohene SA, Stienstra Y, Asiedu KB, van der Werf TS. Rifampicin and clarithromycin (extended release) versus rifampicin and streptomycin for limited Buruli ulcer lesions: a randomised, open-label, non-inferiority phase 3 trial. Lancet 2020; 395:1259-1267. [PMID: 32171422 PMCID: PMC7181188 DOI: 10.1016/s0140-6736(20)30047-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/23/2019] [Accepted: 01/07/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Buruli ulcer is a neglected tropical disease caused by Mycobacterium ulcerans infection that damages the skin and subcutis. It is most prevalent in western and central Africa and Australia. Standard antimicrobial treatment with oral rifampicin 10 mg/kg plus intramuscular streptomycin 15 mg/kg once daily for 8 weeks (RS8) is highly effective, but streptomycin injections are painful and potentially harmful. We aimed to compare the efficacy and tolerability of fully oral rifampicin 10 mg/kg plus clarithromycin 15 mg/kg extended release once daily for 8 weeks (RC8) with that of RS8 for treatment of early Buruli ulcer lesions. METHODS We did an open-label, non-inferiority, randomised (1:1 with blocks of six), multicentre, phase 3 clinical trial comparing fully oral RC8 with RS8 in patients with early, limited Buruli ulcer lesions. There were four trial sites in hospitals in Ghana (Agogo, Tepa, Nkawie, Dunkwa) and one in Benin (Pobè). Participants were included if they were aged 5 years or older and had typical Buruli ulcer with no more than one lesion (caterories I and II) no larger than 10 cm in diameter. The trial was open label, and neither the investigators who took measurements of the lesions nor the attending doctors were masked to treatment assignment. The primary clinical endpoint was lesion healing (ie, full epithelialisation or stable scar) without recurrence at 52 weeks after start of antimicrobial therapy. The primary endpoint and safety were assessed in the intention-to-treat population. A sample size of 332 participants was calculated to detect inferiority of RC8 by a margin of 12%. This study was registered with ClinicalTrials.gov, NCT01659437. FINDINGS Between Jan 1, 2013, and Dec 31, 2017, participants were recruited to the trial. We stopped recruitment after 310 participants. Median age of participants was 14 years (IQR 10-29) and 153 (52%) were female. 297 patients had PCR-confirmed Buruli ulcer; 151 (51%) were assigned to RS8 treatment, and 146 (49%) received oral RC8 treatment. In the RS8 group, lesions healed in 144 (95%, 95% CI 91 to 98) of 151 patients, whereas lesions healed in 140 (96%, 91 to 99) of 146 patients in the RC8 group. The difference in proportion, -0·5% (-5·2 to 4·2), was not significantly greater than zero (p=0·59), showing that RC8 treatment is non-inferior to RS8 treatment for lesion healing at 52 weeks. Treatment-related adverse events were recorded in 20 (13%) patients receiving RS8 and in nine (7%) patients receiving RC8. Most adverse events were grade 1-2, but one (1%) patient receiving RS8 developed serious ototoxicity and ended treatment after 6 weeks. No patients needed surgical resection. Four patients (two in each study group) had skin grafts. INTERPRETATION Fully oral RC8 regimen was non-inferior to RS8 for treatment of early, limited Buruli ulcer and was associated with fewer adverse events. Therefore, we propose that fully oral RC8 should be the preferred therapy for early, limited lesions of Buruli ulcer. FUNDING WHO with additional support from MAP International, American Leprosy Missions, Fondation Raoul Follereau France, Buruli ulcer Groningen Foundation, Sanofi-Pasteur, and BuruliVac.
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Affiliation(s)
- Richard O Phillips
- Kwame Nkrumah University of Science and Technology, Kumasi Centre for Collaborative Research in Tropical Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Jérôme Robert
- Centre d'immunologie et des maladies infectieuses, Inserm, Sorbonne Université, Bactériologie site Pitié, AP-HP Sorbonne Université, Centre National de Référence des Mycobactéries, Paris, France
| | | | | | - Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi Centre for Collaborative Research in Tropical Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Thierry Gateau
- Centre de diagnostic et de traitement de la lèpre et de l'Ulcère de Buruli Madeleine et Raoul Follereau, Ouémé-Plateau, Pobè, Bénin
| | - Annick Chauty
- Centre de diagnostic et de traitement de la lèpre et de l'Ulcère de Buruli Madeleine et Raoul Follereau, Ouémé-Plateau, Pobè, Bénin
| | - Raymond Omollo
- Drugs for Neglected Diseases initiative, Africa Regional Office, Nairobi, Kenya
| | | | - Thaddaeus W Egondi
- Drugs for Neglected Diseases initiative, Africa Regional Office, Nairobi, Kenya
| | - Edwin O Ampadu
- National Buruli ulcer Control Programme, Ghana Health Service, Accra, Ghana
| | - Didier Agossadou
- Programme National de Lutte contre la lèpre et l'Ulcère de Buruli, Cotonou, Benin
| | - Estelle Marion
- Centre de recherche en cancérologie et immunologie Nantes-Angers, French National Institute of Health and Medical Research, Université d'Angers, Angers, France
| | - Line Ganlonon
- Centre de diagnostic et de traitement de la lèpre et de l'Ulcère de Buruli Madeleine et Raoul Follereau, Ouémé-Plateau, Pobè, Bénin
| | | | - Jacques Grosset
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John M Macdonald
- Department of Dermatology & Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA; Hospital Bernard Meys Project Medishare, Port-au-Prince, Haiti
| | | | | | - Albert Paintsil
- Reconstructive and Plastic Surgery Unit, Korle-BU Teaching Hospital, Accra, Ghana
| | | | - Michael Frimpong
- Kwame Nkrumah University of Science and Technology, Kumasi Centre for Collaborative Research in Tropical Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Nanaa Francisca Sarpong
- Kwame Nkrumah University of Science and Technology, Kumasi Centre for Collaborative Research in Tropical Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | | | - Ymkje Stienstra
- Department of Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Tjip S van der Werf
- Department of Medicine/Infectious Diseases, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands.
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11
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Omansen TF, Marcsisin RA, Chua BY, Zeng W, Jackson DC, Porter JL, Stienstra Y, van der Werf TS, Stinear TP. In Vivo Imaging of Bioluminescent Mycobacterium ulcerans: A Tool to Refine the Murine Buruli Ulcer Tail Model. Am J Trop Med Hyg 2020; 101:1312-1321. [PMID: 31595865 DOI: 10.4269/ajtmh.18-0959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Buruli ulcer (BU) is a neglected tropical disease caused by infection with Mycobacterium ulcerans. Unclear transmission, no available vaccine, and suboptimal treatment regimens hamper the control of this disease. Carefully designed preclinical research is needed to address these shortcomings. In vivo imaging (IVIS®, Perkin Elmer, Waltham, MA) of infection is an emerging tool that permits monitoring of disease progression and reduces the need to using large numbers of mice at different time-points during the experiment, as individual mice can be imaged at multiple time-points. We aimed to further describe the use of in vivo imaging (IVIS) in BU. We studied the detection of M. ulcerans in experimentally infected BALB/c mouse tails and the subsequent histopathology and immune response in this pilot study. IVIS-monitoring was performed weekly in ten infected BALB/c mice to measure light emitted as a proxy for bacterial load. Nine of 10 (90%) BALB/c mice infected subcutaneously with 3.3 × 105 M. ulcerans JKD8049 (containing pMV306 hsp16+luxG13) exhibited light emission from the site of infection, indicating M. ulcerans growth in vivo, whereas only five of 10 (50%) animals developed clinical signs of the disease. Specific antibody titers were detected within 2 weeks of the infection. Interferon (IFN)-γ and interleukin (IL)-10 were elevated in animals with pathology. Histopathology revealed clusters of acid-fast bacilli in the subcutaneous tissue, with macrophage infiltration and granuloma formation resembling human BU. Our study successfully showed the utility of M. ulcerans IVIS monitoring and lays a foundation for further research.
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Affiliation(s)
- Till F Omansen
- Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
| | - Renee A Marcsisin
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
| | - Brendon Y Chua
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
| | - Weiguang Zeng
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
| | - David C Jackson
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
| | - Jessica L Porter
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
| | - Ymkje Stienstra
- Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tjip S van der Werf
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Timothy P Stinear
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Parkville, Australia
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12
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Vaccine-Specific Immune Responses against Mycobacterium ulcerans Infection in a Low-Dose Murine Challenge Model. Infect Immun 2020; 88:IAI.00753-19. [PMID: 31818964 DOI: 10.1128/iai.00753-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/06/2019] [Indexed: 01/22/2023] Open
Abstract
The neglected tropical disease Buruli ulcer (BU) is an infection of subcutaneous tissue with Mycobacterium ulcerans There is no effective vaccine. Here, we assessed an experimental prime-boost vaccine in a low-dose murine tail infection model. We used the enoyl reductase (ER) domain of the M. ulcerans mycolactone polyketide synthases electrostatically coupled with a previously described Toll-like receptor 2 (TLR-2) agonist-based lipopeptide adjuvant, R4Pam2Cys. Mice were vaccinated and then challenged via tail inoculation with 14 to 20 CFU of a bioluminescent strain of M. ulcerans Mice receiving either the experimental ER vaccine or Mycobacterium bovis bacillus Calmette-Guérin (BCG) were equally protected, with both groups faring significantly better than nonvaccinated animals (P < 0.05). To explore potential correlates of protection, a suite of 29 immune parameters were assessed in the mice at the end of the experimental period. Multivariate statistical approaches were used to interrogate the immune response data to develop disease-prognostic models. High levels of interleukin 2 (IL-2) and low gamma interferon (IFN-γ) produced in the spleen best predicted control of infection across all vaccine groups. Univariate logistic regression revealed vaccine-specific profiles of protection. High titers of ER-specific IgG serum antibodies together with IL-2 and IL-4 in the draining lymph node (DLN) were associated with protection induced by the ER vaccine. In contrast, high titers of IL-6, tumor necrosis factor alpha (TNF-α), IFN-γ, and IL-10 in the DLN and low IFN-γ titers in the spleen were associated with protection following BCG vaccination. This study suggests that an effective BU vaccine must induce localized, tissue-specific immune profiles with controlled inflammatory responses at the site of infection.
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13
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Foulon M, Pouchin A, Manry J, Khater F, Robbe-Saule M, Durand A, Esnault L, Delneste Y, Jeannin P, Saint-André JP, Croué A, Altare F, Abel L, Alcaïs A, Marion E. Skin-specific antibodies neutralizing mycolactone toxin during the spontaneous healing of Mycobacterium ulcerans infection. SCIENCE ADVANCES 2020; 6:eaax7781. [PMID: 32133396 PMCID: PMC7043917 DOI: 10.1126/sciadv.aax7781] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/25/2019] [Indexed: 06/10/2023]
Abstract
Buruli ulcer, a neglected tropical infectious disease, is caused by Mycobacterium ulcerans. Without treatment, its lesions can progress to chronic skin ulcers, but spontaneous healing is observed in 5% of cases, suggesting the possible establishment of a host strategy counteracting the effects of M. ulcerans. We reveal here a skin-specific local humoral signature of the spontaneous healing process, associated with a rise in antibody-producing cells and specific recognition of mycolactone by the mouse IgG2a immunoglobulin subclass. We demonstrate the production of skin-specific antibodies neutralizing the immunomodulatory activity of the mycolactone toxin, and confirm the role of human host machinery in triggering effective local immune responses by the detection of anti-mycolactone antibodies in patients with Buruli ulcer. Our findings pave the way for substantial advances in both the diagnosis and treatment of Buruli ulcer in accordance with the most recent challenges issued by the World Health Organization.
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Affiliation(s)
- Mélanie Foulon
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
| | - Amélie Pouchin
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
| | - Jérémy Manry
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR-1163, Paris, France
- Imagine Institute, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - Fida Khater
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
| | - Marie Robbe-Saule
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
| | - Amandine Durand
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
| | - Lucille Esnault
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
| | - Yves Delneste
- Equipe 07, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
- CHU Angers, Département d'Immunologie et Allergologie, Angers, France
| | - Pascale Jeannin
- Equipe 07, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
- CHU Angers, Département d'Immunologie et Allergologie, Angers, France
| | | | - Anne Croué
- Pathology Department, University Hospital of Angers, 49933 Angers, France
| | - Frederic Altare
- Equipe 05, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université d’Angers, Université de Nantes, Nantes, France
| | - Laurent Abel
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR-1163, Paris, France
- Imagine Institute, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - Alexandre Alcaïs
- Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche Médicale (INSERM) UMR-1163, Paris, France
- Imagine Institute, Paris Descartes-Sorbonne Paris Cité University, Paris, France
| | - Estelle Marion
- Equipe ATOMycA, U1232 CRCINA, Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Nantes, Université d’Angers, Angers, France
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14
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Chen CH, Cheng YH, Chen FJ, Huang EY, Liu PM, Kung CT, Su CH, Chen SH, Chien PC, Hsieh CH. Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study). Risk Manag Healthc Policy 2019; 12:307-315. [PMID: 31849547 PMCID: PMC6911809 DOI: 10.2147/rmhp.s232983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms. Methods Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form. Results The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent. Conclusion This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.
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Affiliation(s)
- Chih-Hung Chen
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung 802, Taiwan
| | - Ya-Hui Cheng
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, 736, Taiwan
| | - Fen-Ju Chen
- Department of Healthcare Administration, I-Shou University Medical Campus, Kaohsiung 824, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Po-Ming Liu
- Department of Emergency Medicine, Kaohsiung 802, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Chao-Hui Su
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Shu-Hwa Chen
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,School of Nursing, Fooyin University, Kaohsiung 831, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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15
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Wadagni AC, Steinhorst J, Barogui YT, Catraye PM, Gnimavo R, Abass KM, Amofa G, Frimpong M, Sarpong FN, van der Werf TS, Phillips R, Sopoh GE, Johnson CR, Stienstra Y. Buruli ulcer treatment: Rate of surgical intervention differs highly between treatment centers in West Africa. PLoS Negl Trop Dis 2019; 13:e0007866. [PMID: 31658295 PMCID: PMC6855495 DOI: 10.1371/journal.pntd.0007866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 11/14/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022] Open
Abstract
Background Antibiotic treatment proved itself as the mainstay of treatment for Buruli ulcer disease. This neglected tropical disease is caused by Mycobacterium ulcerans. Surgery persists as an adjunct therapy intended to reduce the mycobacterial load. In an earlier clinical trial, patients benefited from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic. Methods A retrospective study was conducted in six different Buruli ulcer (BU) treatment centers in Benin and Ghana. BU patients clinically diagnosed between January 2012 and December 2016 were included and surgical interventions during the follow-up period, at least one year after diagnosis, were recorded. Logistic regression analysis was carried out to estimate the effect of the treatment center on the decision to perform surgery, while controlling for interaction and confounders. Results A total of 1193 patients, 612 from Benin and 581 from Ghana, were included. In Benin, lesions were most frequently (42%) categorized as the most severe lesions (WHO criteria, category III), whereas in Ghana lesions were most frequently (44%) categorized as small lesions (WHO criteria, category I). In total 344 (29%) patients received surgical intervention. The percentage of patients receiving surgical intervention varied between hospitals from 1.5% to 72%. Patients treated in one of the centers in Benin were much more likely to have surgery compared to the clinic in Ghana with the lowest rate of surgical intervention (RR = 46.7 CI 95% [17.5–124.8]). Even after adjusting for confounders (severity of disease, age, sex, limitation of movement at joint at time of diagnosis, ulcer and critical sites), rates of surgical interventions varied highly. Conclusion The decision to perform surgery to reduce the mycobacterial load in BU varies highly per clinic. Evidence based guidelines are needed to guide the role of surgery in the treatment of BU Buruli ulcer is a necrotizing and disabling skin infection, caused by Mycobacterium ulcerans. The infection, a skin-related Neglected Tropical Diseases, affects mostly people living in limited resources settings. Since the introduction of rifampicin based combination antibiotic therapy as standard care, the role of surgery as adjunct therapy to kill M. ulcerans is less defined and understood. A randomized controlled trial showed benefit from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic. We present the differences in rate of surgical interventions in six different Buruli ulcer treatment centers in Ghana and Benin. We demonstrate that these differences mainly depend on the opinion of the health care workers working in the treatment centers even after adjusting for disease severity.
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Affiliation(s)
- Anita C. Wadagni
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
- * E-mail:
| | - Jonathan Steinhorst
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
| | - Yves T. Barogui
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - P. M. Catraye
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - Ronald Gnimavo
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | | | | | - Michael Frimpong
- Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences and Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Francisca N. Sarpong
- Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences and Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Tjip S. van der Werf
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
| | - Richard Phillips
- Kwame Nkrumah University of Science and Technology (KNUST), School of Medical Sciences and Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR), Kumasi, Ghana
| | - Ghislain E. Sopoh
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - Christian R. Johnson
- Programme National de Lutte contre la Lèpre et L'Ulcère de Buruli, Ministère de la Santé, Cotonou, République du Bénin
| | - Ymkje Stienstra
- University of Groningen, University Medical Center Groningen, Department of Internal Medicine/Infectious Diseases, Groningen, The Netherlands
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16
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The paediatric participation scale measuring participation restrictions among former Buruli Ulcer patients under the age of 15 in Ghana and Benin: Development and first validation results. PLoS Negl Trop Dis 2019; 13:e0007273. [PMID: 30870426 PMCID: PMC6435175 DOI: 10.1371/journal.pntd.0007273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 03/26/2019] [Accepted: 02/28/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Buruli Ulcer (BU) is a neglected tropical disease caused by Mycobacterium ulcerans. Former BU patients may experience participation restrictions due to physical limitations, stigmatization and other social factors. A scale that measures participation restrictions among children, who represent almost half of the affected population, has not been developed yet. Here, we present the development of a scale that measures participation restrictions in former BU paediatric patients, the psychometric properties of this scale and the scales' results. METHODS Items were selected and a scale was developed based on interviews with health care workers and former BU patients in and around the BU treatment centre in Lalo, Benin. Construct validity was tested using six a priori formulated hypotheses. Former BU patients under 15 years of age who received treatment in one of the BU treatment centres in Ghana and Benin between 2007-2012 were interviewed. RESULTS A feasible 16-item scale that measures the concept of participation among children under 15 years of age was developed. In total, 109 (Ghana) and 90 (Benin) former BU patients were interviewed between 2012-2017. Five construct validity hypotheses were confirmed of which 2 hypotheses related to associations with existing questionnaires were statistically significant (p<0.05). In Ghana 77% of the former patients had a Paediatric Participation (PP) scale score of 0 compared to 22% in Benin. More severe lesions related to BU were seen in Benin. Most of the reported participation problems were related to sports, mainly in playing games with others, going to the playfield and doing sports at school. CONCLUSION The preliminary results of the PP-scale validation are promising but further validation is needed. The developed PP-scale may be valid for use in patients with more severe BU lesions. This is the first research to confirm that former BU patients under 15-year face participation restrictions in important aspects of their lives.
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Arenaz-Callao MP, González del Río R, Lucía Quintana A, Thompson CJ, Mendoza-Losana A, Ramón-García S. Triple oral beta-lactam containing therapy for Buruli ulcer treatment shortening. PLoS Negl Trop Dis 2019; 13:e0007126. [PMID: 30689630 PMCID: PMC6366712 DOI: 10.1371/journal.pntd.0007126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 02/07/2019] [Accepted: 01/04/2019] [Indexed: 12/04/2022] Open
Abstract
The potential use of clinically approved beta-lactams for Buruli ulcer (BU) treatment was investigated with representative classes analyzed in vitro for activity against Mycobacterium ulcerans. Beta-lactams tested were effective alone and displayed a strong synergistic profile in combination with antibiotics currently used to treat BU, i.e. rifampicin and clarithromycin; this activity was further potentiated in the presence of the beta-lactamase inhibitor clavulanate. In addition, quadruple combinations of rifampicin, clarithromycin, clavulanate and beta-lactams resulted in multiplicative reductions in their minimal inhibitory concentration (MIC) values. The MIC of amoxicillin against a panel of clinical isolates decreased more than 200-fold within this quadruple combination. Amoxicillin/clavulanate formulations are readily available with clinical pedigree, low toxicity, and orally and pediatric available; thus, supporting its potential inclusion as a new anti-BU drug in current combination therapies. Buruli ulcer (BU) is a chronic debilitating disease of the skin and soft tissue, mainly affecting children and young adults in tropical regions. Before 2004, the only treatment option was surgery; a major breakthrough was the discovery that BU could be cured in most cases with a standard treatment that involved 8 weeks of combination therapy with rifampicin and streptomycin. However, the use of streptomycin is often associated with severe side effects such as ototoxicity, or nephrotoxicity. More recently, a clinical trial demonstrated equipotency of replacing the injectable streptomycin by the clarithromycin, which is orally available and associated with fewer side effects. BU treatment is now moving toward a full orally available treatment of clarithromycin-rifampicin. Although effective and mostly well tolerated, this new treatment is still associated with side effects and only moxifloxacin is additionally recommended by WHO for BU therapy. New drugs are thus needed to increase the number of available treatments, reduce side effects, and improve efficacy with treatments shorter than 8 weeks. In this work, we describe for the first time the potential inclusion of beta-lactams in BU therapy. More specifically, we propose the use of amoxicillin/clavulanate since it is oral, suitable for the treatment of children, and readily available with a long track record of clinical pedigree. Its inclusion in a triple oral therapy complementing current combinatorial rifampicin-clarithromycin treatment has the potential to counteract resistance development and to reduce length of treatment and time to cure.
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Affiliation(s)
- María Pilar Arenaz-Callao
- Research & Development Agency of Aragon (ARAID) Foundation, Zaragoza, Spain
- Global Health R&D, GlaxoSmithKline, Tres Cantos, Madrid, Spain
| | | | - Ainhoa Lucía Quintana
- Mycobacterial Genetics Group. Department of Microbiology, Preventive Medicine and Public Health. Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
| | - Charles J. Thompson
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, B.C. Canada
| | | | - Santiago Ramón-García
- Research & Development Agency of Aragon (ARAID) Foundation, Zaragoza, Spain
- Global Health R&D, GlaxoSmithKline, Tres Cantos, Madrid, Spain
- Mycobacterial Genetics Group. Department of Microbiology, Preventive Medicine and Public Health. Faculty of Medicine, University of Zaragoza, Zaragoza, Spain
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, B.C. Canada
- * E-mail: (AML); (SRG)
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18
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Omansen TF, Stienstra Y, van der Werf TS. Treatment for Buruli ulcer: the long and winding road to antimicrobials-first. Cochrane Database Syst Rev 2018; 12:ED000128. [PMID: 30556580 PMCID: PMC10284315 DOI: 10.1002/14651858.ed000128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Till F Omansen
- University of Groningen, University Medical Center GroningenThe Netherlands
| | - Ymkje Stienstra
- University of Groningen, University Medical Center GroningenThe Netherlands
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Guerra Laso JM, Nebreda Mayoral T, Palacios Gutiérrez JJ, Samaniego González É, Rodríguez Martín B, Barrio Rodríguez L, Alonso Orcajo N, Magaz García E, Stinear T, Buultjens AH, Pérez Molina JA. Buruli ulcers in a Spanish aid worker after a stay in Peru. Int J Infect Dis 2018; 78:99-102. [PMID: 30497990 DOI: 10.1016/j.ijid.2018.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/15/2018] [Accepted: 10/19/2018] [Indexed: 11/30/2022] Open
Abstract
Buruli ulcer (BU) is a chronic and destructive infection of the skin and soft tissues caused by Mycobacterium ulcerans. Recently, population flows have triggered the appearance of several sporadic cases of BU in non-endemic countries. This represents a significant diagnostic challenge for clinicians and microbiologists. We describe the first case of BU imported to Spain. The patient was a Spanish woman who had stayed 5 months in the jungle of Peru.
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Affiliation(s)
| | - Teresa Nebreda Mayoral
- Microbiology Service, Complejo Asistencial Universitario de León, Avda Altos de Nava s/n, 47075 León, Spain.
| | - Juan José Palacios Gutiérrez
- Regional Reference Unit of Mycobacteria, Microbiology Service, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Élia Samaniego González
- Dermatology Service, Complejo Asistencial Universitario de León, Universidad de Leon, León, Spain
| | | | | | - Nieves Alonso Orcajo
- Pathological Anatomy Service, Complejo Asistencial Universitario de León, León, Spain
| | - Elena Magaz García
- Internal Medicine Service, Complejo Asistencial Universitario de León, León, Spain
| | - Timothy Stinear
- Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Andrew H Buultjens
- Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia
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20
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O'Brien DP, Callan P, Friedman ND, Athan E, Hughes A, McDonald A. Mycobacterium ulcerans disease management in Australian patients: the re-emergence of surgery as an important treatment modality. ANZ J Surg 2018; 89:653-658. [PMID: 30239097 DOI: 10.1111/ans.14829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 12/25/2022]
Abstract
With the demonstration of the effectiveness of antibiotic treatment, the management of Mycobacterium ulcerans disease has changed from a predominantly surgically to a predominantly medically treated disease. However, research among Australian patients has revealed that antibiotic treatment alone is associated with prolonged wound healing times, high rates of treatment toxicity, and the potential for significant tissue destruction associated with severe paradoxical reactions. We present the current state of M. ulcerans management in Barwon Health, Australia, where a close working relationship exists between the Plastic Surgical and Infectious Diseases units. Here treatment has evolved based on nearly 20 years of experience gained from managing more around 600 patients from a M. ulcerans epidemic on the nearby Bellarine and Mornington Peninsulas. In our experience, surgery has re-emerged to play an important role in the treatment of M. ulcerans in improving the rate of wound healing, minimizing antibiotic associated toxicity and preventing further tissue loss associated with severe paradoxical reactions. For selected small lesions surgery without antibiotics may also be an effective treatment option, however aggressive surgical resection of lesions with wide margins through uninvolved tissue should no longer be performed. Furthermore, extensive excisional surgery that will require the use of split skin grafts and vascularized tissue flaps to repair skin defects should be avoided if possible.
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Affiliation(s)
- Daniel P O'Brien
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.,Department of Medicine and Infectious Diseases, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Manson Unit, Médecins Sans Frontières, London, UK
| | - Peter Callan
- Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia
| | - N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Eugene Athan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Andrew Hughes
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Anthony McDonald
- Department of Plastic Surgery, Barwon Health, Geelong, Victoria, Australia
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21
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Meher-Homji Z, Johnson PDR. An Overview of the Treatment of Mycobacterium ulcerans Infection (Buruli Ulcer). CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yotsu RR, Suzuki K, Simmonds RE, Bedimo R, Ablordey A, Yeboah-Manu D, Phillips R, Asiedu K. Buruli Ulcer: a Review of the Current Knowledge. CURRENT TROPICAL MEDICINE REPORTS 2018; 5:247-256. [PMID: 30460172 PMCID: PMC6223704 DOI: 10.1007/s40475-018-0166-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Rie R. Yotsu
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Dermatology, National Suruga Sanatorium, Shizuoka, Japan
| | - Koichi Suzuki
- Department of Clinical Laboratory Science, Faculty of Medical Technology, Teikyo University, Tokyo, Japan
| | - Rachel E. Simmonds
- Department of Microbial Sciences, School of Bioscience and Medicine, University of Surrey, Surrey, UK
| | - Roger Bedimo
- Department of Medicine, VA North Texas Healthcare System, Dallas, TX USA
- Division of Infectious Diseases, University of Texas Dallas Southwestern, Dallas, TX USA
| | - Anthony Ablordey
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Dorothy Yeboah-Manu
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | - Richard Phillips
- Kumansi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kingsley Asiedu
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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