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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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Narh CA, Mosi L, Quaye C, Tay SC, Bonfoh B, de Souza DK. Genotyping Tools for Mycobacterium ulcerans-Drawbacks and Future Prospects. ACTA ACUST UNITED AC 2014; 4:1000149. [PMID: 24900947 PMCID: PMC4040416 DOI: 10.4172/2161-1068.1000149] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Mycobacterium ulcerans infection (Buruli ulcer) is a neglected but treatable skin disease endemic in over 30 countries. M. ulcerans is an environmental mycobacteria with an elusive mode of transmission to humans. Ecological and Molecular epidemiological studies to identify reservoirs and transmission vectors are important for source tracking infections especially during outbreaks and elucidating transmission routes. Research efforts have therefore focused on genotyping strains of the mycobacteria from clinical and environmental samples. This review discusses genotyping tools for differentiating M. ulcerans strains from other environmental and Mycolactone Producing Mycobacteria (MPMs). We highlight tools that have been adapted from related fields and propose ways these could be enhanced to resolve intra-species variation for epidemiological, transmission, evolutionary studies, and detection of emerging drug resistant strains. In the wake of increasing cases of Buruli ulcer, cumulative efforts including improvement in diagnostic methods and fine-tuning of genotyping tools are crucial to complement public health efforts in reducing infections.
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Affiliation(s)
- Charles A Narh
- Parasitology Department, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana ; Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Ivory Coast ; Clinical Microbiology Department, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Ghana
| | - Lydia Mosi
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Ivory Coast ; Biochemistry, Cell and Molecular Biology Department, University of Ghana
| | - Charles Quaye
- Parasitology Department, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana ; Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Ivory Coast
| | - Samuel Ck Tay
- Clinical Microbiology Department, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Ghana
| | - Bassirou Bonfoh
- Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Ivory Coast
| | - Dziedzom K de Souza
- Parasitology Department, Noguchi Memorial Institute for Medical Research, University of Ghana, Ghana
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O'Brien DP, Walton A, Hughes AJ, Friedman ND, McDonald A, Callan P, Rhadon R, Holten I, Athan E. Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort. Med J Aust 2013; 198:436-9. [DOI: 10.5694/mja12.11708] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/01/2013] [Indexed: 11/17/2022]
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Beissner M, Symank D, Phillips RO, Amoako YA, Awua-Boateng NY, Sarfo FS, Jansson M, Huber KL, Herbinger KH, Battke F, Löscher T, Adjei O, Bretzel G. Detection of viable Mycobacterium ulcerans in clinical samples by a novel combined 16S rRNA reverse transcriptase/IS2404 real-time qPCR assay. PLoS Negl Trop Dis 2012; 6:e1756. [PMID: 22953006 PMCID: PMC3429398 DOI: 10.1371/journal.pntd.0001756] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Marcus Beissner
- Department of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig-Maximilians University, Munich, Germany.
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Herbinger KH, Brieske D, Nitschke J, Siegmund V, Thompson W, Klutse E, Awua-Boateng NY, Bruhl E, Kunaa L, Schunk M, Adjei O, Löscher T, Bretzel G. Excision of pre-ulcerative forms of Buruli ulcer disease: a curative treatment? Infection 2008; 37:20-5. [PMID: 19139811 DOI: 10.1007/s15010-008-8073-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Accepted: 06/24/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Previous investigations have revealed that Mycobacterium ulcerans is extensively distributed spatially throughout ulcerative lesions, including in the margins of excised tissue. In contrast, bacilli in pre-ulcerative lesions are assumed to be concentrated in the center of the lesion. In order to assess the extent to which the surgical excision of pre-ulcerative lesions is capable of removing all infected tissue, we subjected the excision margins of pre-ulcerative lesions to laboratory analysis. PATIENTS AND METHODS Eleven patients with laboratory-confirmed pre-ulcerative lesions were included in the study. The diameter of the lesion and excised tissue and the "surgical distance" between the border of the lesion and excision margin were measured. The entire excision margin was cut into segments and subjected to IS2404 PCR. RESULTS The results from the PCR analysis on the samples of excision margins were highly significantly associated with the surgical distance (p < 0.001). The margin samples of nodules were significantly more often PCR positive than the plaques (p = 0.025). The size of the lesion and the size of the excised tissue did not significantly influence the PCR results. Statistically, a surgical distance of more than 9 mm was found to reduce the risk of remaining infected tissue to less than 10%, that of 13 mm to reduce the risk to less than 5%, and that of 25 mm to reduce the risk to nearly 0%. CONCLUSION The results of this study show that in preulcerative Buruli ulcer disease, bacilli may extend beyond the actual size of the lesion and that there is a strong correlation between the presence of M. ulcerans in the margin samples and the surgical distance. Excision with a surgical distance of 25 mm avoided the risk of remaining mycobacteria in this study. However, no recurrences occurred in the patients with M. ulcerans-positive excision margins. The need of postoperative antimycobacterial treatment in these patients remains to be determined.
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Affiliation(s)
- K-H Herbinger
- Department of Infectious Diseases and Tropical Medicine (DITM), Ludwig-Maximilian University Munich, Leopoldstrasse 5, 80802, Munich, Germany.
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Mensah-Quainoo E, Yeboah-Manu D, Asebi C, Patafuor F, Ofori-Adjei D, Junghanss T, Pluschke G. Diagnosis of Mycobacterium ulcerans infection (Buruli ulcer) at a treatment centre in Ghana: a retrospective analysis of laboratory results of clinically diagnosed cases. Trop Med Int Health 2008; 13:191-8. [PMID: 18304265 DOI: 10.1111/j.1365-3156.2007.01990.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Clinical diagnosis of Mycobacterium ulcerans infection is currently accepted as sufficient basis for treating the disease. Inadequate laboratory resources in the highly endemic areas of Africa often limit possibilities for in-country confirmation of clinical judgement. We analysed records of 99 Buruli ulcer (BU) patients diagnosed clinically and treated surgically at Amasaman Health Centre in Ghana, for whom post-treatment diagnostic laboratory tests were performed. Comparison of clinical diagnoses with test results obtained by an in-country laboratory on samples of excised tissue showed a high specificity of clinical judgement. Among lesions with three laboratory tests (microscopy for acid fast bacilli, culture and IS2404 polymerase chain reaction) done, 94% tested positive at least once and 83% twice. Thus correct clinical diagnosis of BU by well trained health workers is achievable, although the quality of clinical diagnosis should be monitored by intermittent testing in national reference laboratories. However, being retrospective, this study did not permit sensitivity and negative predictive value analysis.
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Kibadi K. [Mycobacterium ulcerans infection treated by Rifater, pyrazynamide, Myambutol, and surgery: a case report with a 6-year follow-up]. Med Mal Infect 2007; 38:156-8. [PMID: 18079081 DOI: 10.1016/j.medmal.2007.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 09/25/2007] [Indexed: 11/28/2022]
Abstract
The author reports a case of pleuritis associated with a large homolateral Buruli thorax ulcer in a nine-year old female patient, in the Democratic Republic of Congo. Smears on Ziehl-Neelsen revealed acid-alcohol-resistant bacilli. The pathological histology confirmed a Mycobacterium ulcerans infection (Buruli ulcer). The treatment was surgical (excision-dressing-grafting) associated to antibiotic therapy (Rifater, Pyrazynamide, and Myambutol). After six years of follow up, no relapse was observed.
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Affiliation(s)
- K Kibadi
- Département de Chirurgie, Cliniques Universitaires, Université de Kinshasa, Kinshasa XI, Democratic Republic of Congo.
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Minutilli E, Orefici G, Pardini M, Giannoni F, Muscardin LM, Massi G, Sanguinetti M, Fadda G, Di Miceli D, Doglietto GB. Squamous cell carcinoma secondary to buruli ulcer. Dermatol Surg 2007; 33:872-5. [PMID: 17598858 DOI: 10.1111/j.1524-4725.2007.33186.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Squamous Cell Carcinoma Secondary to Buruli Ulcer. Dermatol Surg 2007. [DOI: 10.1097/00042728-200707000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bretzel G, Siegmund V, Nitschke J, Herbinger KH, Thompson W, Klutse E, Crofts K, Massavon W, Etuaful S, Thompson R, Asamoah-Opare K, Racz P, Vloten F, van Berberich C, Kruppa T, Ampadu E, Fleischer B, Adjei O. A stepwise approach to the laboratory diagnosis of Buruli ulcer disease. Trop Med Int Health 2007; 12:89-96. [PMID: 17207152 DOI: 10.1111/j.1365-3156.2006.01761.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In view of technical and financial limitations in areas of endemicity, the current practice and recommendations for the laboratory diagnosis of Buruli ulcer disease (BUD) may have to be reconsidered. We reviewed diagnostic results in order to explore options for a modified, more practicable, cost-effective and timely approach to the laboratory diagnosis of BUD. METHODS Diagnostic specimens from 161 clinically diagnosed BUD patients from four different treatment centres in Ghana were subjected to laboratory analysis. The positivity rates of the laboratory assays were compared. RESULTS The number of laboratory-confirmed clinically diagnosed BUD cases with one positive confirmative test was 20% higher than that with two positive confirmative tests. The specificity of microscopy (MIC) and PCR was 96.6% and 100%, respectively. Subsequent analysis of specimens from surgically excised pre-ulcerative tissue-by-tissue MIC and tissue PCR rendered 65% laboratory-confirmed BUD cases. Subsequent analysis of diagnostic swabs from ulcerative lesions by swab smear MIC and swab PCR rendered 70% of laboratory-confirmed BUD cases. CONCLUSIONS The specificity of the diagnostic tests used in this study suggests that one positive diagnostic test may be considered sufficient for the laboratory confirmation of BUD. Subsequent application of different diagnostic tests rendered a laboratory confirmation of 65% pre-ulcerative and of 70% ulcerative lesions. Implementation of a stepwise, subsequent analysis of diagnostic specimens will result in considerable cost saving compared with simultaneous testing of specimens by several diagnostic assays.
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Affiliation(s)
- G Bretzel
- Department of Infectious Diseases and Tropical Medicine (DITM), University of Munich, Munich, Germany.
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Chin-Lenn L, Ying D, Leong J, Ross D, Wu T, Nazaretian S, Donahoe S, Silfen R. Mycobacterium ulcerans ulcers: a proposed surgical management algorithm. Ann Plast Surg 2006; 57:65-9. [PMID: 16799311 DOI: 10.1097/01.sap.0000209031.57727.e4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Mycobacterium ulcerans (MU) is the third common mycobacterial infection after tuberculosis and leprosy. In endemic areas, MU ulcers should be considered in the differential diagnosis of any unusual or nonhealing lesion or ulcer. Diagnosis and treatment should be instigated promptly. Delay may lead to disfiguring or disabling scars. Surgical management, therefore, should aim towards early excision, with clear margins of the ulcer. We present 4 consecutive patients treated by our department within a 6-month period for MU ulcers. The presentation, diagnosis and surgical management are described. Based on our experience and after reviewing the literature, we have developed a surgical algorithm for the management of MU ulcers.
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Affiliation(s)
- Laura Chin-Lenn
- Department of Plastic & Reconstructive Surgery, Southern Health Network, and Monash University, Clayton, Victoria, Australia
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Rondini S, Mensah-Quainoo E, Junghanss T, Pluschke G. What does detection of Mycobacterium ulcerans DNA in the margin of an excised Buruli ulcer lesion tell us? J Clin Microbiol 2006; 44:4273-5. [PMID: 16928966 PMCID: PMC1698343 DOI: 10.1128/jcm.00970-06] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We determined by real-time PCR the distribution of Mycobacterium ulcerans DNA in the excised lesion of a Buruli ulcer patient. A new lesion developed adjacent to the site of excision in the patient. The excised margin around the primary lesion contained a small amount of mycobacterial DNA in the area where the secondary lesion developed. These results suggest that a relatively small number of infiltrating mycobacteria can lead to the development of a recurrence.
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Affiliation(s)
- Simona Rondini
- Molecular Immunology, Swiss Tropical Institute, Basel, Switzerland
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