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Tchan BGO, Kakou-Ngazoa S, Dizoe S, Hammoudi N, Grine G, Ruimy R, Drancourt M. Mycobacterium ulcerans-Bordetella trematum chronic tropical cutaneous ulcer: A four-case series, Côte d'Ivoire. PLoS Negl Trop Dis 2023; 17:e0011413. [PMID: 38060465 PMCID: PMC10703317 DOI: 10.1371/journal.pntd.0011413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/10/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Chronic tropical cutaneous ulcers remain a neglected medical condition in West Africa, particularly Buruli ulcer, which is caused by mycolactone cytotoxin-secreting Mycobacterium ulcerans (M. ulcerans). Medical management of this highly debilitating and necrotising skin infection may be modified by colonisation and co-infection of the ulcer by opportunistic and pathogenic microorganisms, which considerably delays and increases the cost of treatment. METHODOLOGY/PRINCIPAL FINDING We diagnosed chronic tropical cutaneous ulcers in nine patients in Côte d'Ivoire using M. ulcerans-specific PCRs and culturomics. This revealed M. ulcerans in 7/9 ulcer swabs and 5/9 control swabs as well as an additional 122 bacterial species, 32 of which were specific to ulcers, 61 specifics to the controls, and 29 which were shared, adding 40 bacterial species to those previously reported. Whole genome sequencing of four Bordetella trematum (B. trematum) isolates in four Buruli ulcer swabs and no controls indicated cytolethal distending toxins, as confirmed by cytotoxic assay. CONCLUSIONS/SIGNIFICANCE In four cases of Buruli ulcer in Côte d'Ivoire, B. trematum was a co-pathogen which was resistant to rifampicin and clarithromycin, unmatching M. ulcerans antibiotic susceptibility profile and counteracting the current treatment of Buruli ulcer in West Africa and Australia. Thus, we report here chronic mixed M. ulcerans-B. trematum chronic tropical ulcer as a specific form of Buruli ulcer in West Africa.
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Affiliation(s)
- Bi Goré Oscar Tchan
- Aix-Marseille-Université, IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
- IHU Méditerranée Infection, Marseille, France
| | - Solange Kakou-Ngazoa
- Plateforme de biologie moléculaire, Institut Pasteur de Côte d’Ivoire, Abidjan, Côte d’Ivoire
| | - Sylveste Dizoe
- National Buruli ulcer Control Program, Abidjan, Côte d’Ivoire
| | - Nassim Hammoudi
- Aix-Marseille-Université, IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
- IHU Méditerranée Infection, Marseille, France
| | - Ghiles Grine
- Aix-Marseille-Université, IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
- IHU Méditerranée Infection, Marseille, France
| | - Raymond Ruimy
- Department of Bacteriology, Nice Academic Hospital, Nice, France
- Université Côte D’Azur, CHU de Nice, Nice, France
| | - Michel Drancourt
- Aix-Marseille-Université, IRD, MEPHI, IHU Méditerranée Infection, Marseille, France
- IHU Méditerranée Infection, Marseille, France
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Ishwarlall TZ, Okpeku M, Adeniyi AA, Adeleke MA. The search for a Buruli Ulcer vaccine and the effectiveness of the Bacillus Calmette-Guérin vaccine. Acta Trop 2022; 228:106323. [PMID: 35065013 DOI: 10.1016/j.actatropica.2022.106323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 01/16/2022] [Accepted: 01/18/2022] [Indexed: 11/01/2022]
Abstract
Buruli Ulcer is a neglected tropical disease that is caused by Mycobacterium ulcerans. It is not fatal; however, it manifests a range of devastating symptoms on the hosts' bodies. Various drugs and treatments are available for the disease; however, they are often costly and have adverse effects. There is still much uncertainty regarding the mode of transmission, vectors, and reservoir. At present, there are no official vector control methods, prevention methods, or a vaccine licensed to prevent infection. The Bacillus Calmette-Guérin vaccine developed against tuberculosis has some effectiveness against M. ulcerans. However, it is unable to induce long-lasting protection. Various types of vaccines have been developed based specifically against M. ulcerans; however, to date, none has entered clinical trials or has been released for public use. Additional awareness and funding are needed for research in this field and the development of more treatments, diagnostic tools, and vaccines.
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Dhungel L, Burcham L, Park JY, Sampathkumar HD, Cudjoe A, Seo KS, Jordan H. Responses to chemical cross-talk between the Mycobacterium ulcerans toxin, mycolactone, and Staphylococcus aureus. Sci Rep 2021; 11:11746. [PMID: 34083568 PMCID: PMC8175560 DOI: 10.1038/s41598-021-89177-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/22/2021] [Indexed: 02/01/2023] Open
Abstract
Buruli ulcer is a neglected tropical disease caused by the environmental pathogen, Mycobacterium ulcerans whose major virulence factor is mycolactone, a lipid cytotoxic molecule. Buruli ulcer has high morbidity, particularly in rural West Africa where the disease is endemic. Data have shown that infected lesions of Buruli ulcer patients can be colonized by quorum sensing bacteria such as Staphylococcus aureus, S. epidermidis, and Pseudomonas aeruginosa, but without typical pathology associated with those pathogens' colonization. M. ulcerans pathogenesis may not only be an individual act but may also be dependent on synergistic or antagonistic mechanisms within a polymicrobial network. Furthermore, co-colonization by these pathogens may promote delayed wound healing, especially after the initiation of antibiotic therapy. Hence, it is important to understand the interaction of M. ulcerans with other bacteria encountered during skin infection. We added mycolactone to S. aureus and incubated for 3, 6 and 24 h. At each timepoint, S. aureus growth and hemolytic activity was measured, and RNA was isolated to measure virulence gene expression through qPCR and RNASeq analyses. Results showed that mycolactone reduced S. aureus hemolytic activity, suppressed hla promoter activity, and attenuated virulence genes, but did not affect S. aureus growth. RNASeq data showed mycolactone greatly impacted S. aureus metabolism. These data are relevant and significant as mycolactone and S. aureus sensing and response at the transcriptional, translational and regulation levels will provide insight into biological mechanisms of interspecific interactions that may play a role in regulation of responses such as effects between M. ulcerans, mycolactone, and S. aureus virulence that will be useful for treatment and prevention.
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Affiliation(s)
- Laxmi Dhungel
- Department of Biological Sciences, Mississippi State University, P.O. Box GY, Starkville, MS, 39762, USA
| | - Lindsey Burcham
- Department of Biological Sciences, Mississippi State University, P.O. Box GY, Starkville, MS, 39762, USA
| | - Joo Youn Park
- Department of Biological Sciences, Mississippi State University, P.O. Box GY, Starkville, MS, 39762, USA
| | - Harshini Devi Sampathkumar
- Department of Biological Sciences, Mississippi State University, P.O. Box GY, Starkville, MS, 39762, USA
| | | | - Keun Seok Seo
- Department of Biological Sciences, Mississippi State University, P.O. Box GY, Starkville, MS, 39762, USA
| | - Heather Jordan
- Department of Biological Sciences, Mississippi State University, P.O. Box GY, Starkville, MS, 39762, USA.
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Gyamfi E, Narh CA, Quaye C, Abbass A, Dzudzor B, Mosi L. Microbiology of secondary infections in Buruli ulcer lesions; implications for therapeutic interventions. BMC Microbiol 2021; 21:4. [PMID: 33402095 PMCID: PMC7783985 DOI: 10.1186/s12866-020-02070-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
Background Buruli ulcer (BU) is a skin disease caused by Mycobacterium ulcerans and is the second most common mycobacterial disease after tuberculosis in Ghana and Côte d’Ivoire. M. ulcerans produces mycolactone, an immunosuppressant macrolide toxin, responsible for the characteristic painless nature of the infection. Secondary infection of ulcers before, during and after treatment has been associated with delayed wound healing and resistance to streptomycin and rifampicin. However, not much is known of the bacteria causing these infections as well as antimicrobial drugs for treating the secondary microorganism. This study sought to identify secondary microbial infections in BU lesions and to determine their levels of antibiotic resistance due to the prolonged antibiotic therapy required for Buruli ulcer. Results Swabs from fifty-one suspected BU cases were sampled in the Amansie Central District from St. Peters Hospital (Jacobu) and through an active case surveillance. Forty of the samples were M. ulcerans (BU) positive. Secondary bacteria were identified in all sampled lesions (N = 51). The predominant bacteria identified in both BU and Non-BU groups were Staphylococci spp and Bacilli spp. The most diverse secondary bacteria were detected among BU patients who were not yet on antibiotic treatment. Fungal species identified were Candida spp, Penicillium spp and Trichodema spp. Selected secondary bacteria isolates were all susceptible to clarithromycin and amikacin among both BU and Non-BU patients. Majority, however, had high resistance to streptomycin. Conclusions Microorganisms other than M. ulcerans colonize and proliferate on BU lesions. Secondary microorganisms of BU wounds were mainly Staphylococcus spp, Bacillus spp and Pseudomonas spp. These secondary microorganisms were less predominant in BU patients under treatment compared to those without treatment. The delay in healing that are experienced by some BU patients could be as a result of these bacteria and fungi colonizing and proliferating in BU lesions. Clarithromycin and amikacin are likely suitable drugs for clearance of secondary infection of Buruli ulcer.
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Affiliation(s)
- Elizabeth Gyamfi
- Department of Medical Biochemistry, University of Ghana Medical School, Korle Bu, Accra, Ghana.,Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana.,West African Center for Cell Biology of Infectious Pathogens, University of Ghana, Legon, Accra, Ghana
| | - Charles A Narh
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana.,Burnet Institute for Medical Research, Melbourne, Australia
| | - Charles Quaye
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana
| | - Adiza Abbass
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana.,West African Center for Cell Biology of Infectious Pathogens, University of Ghana, Legon, Accra, Ghana
| | - Bartholomew Dzudzor
- Department of Medical Biochemistry, University of Ghana Medical School, Korle Bu, Accra, Ghana
| | - Lydia Mosi
- Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana. .,West African Center for Cell Biology of Infectious Pathogens, University of Ghana, Legon, Accra, Ghana.
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Nwafor CC, Meka A, Chukwu JN, Ekeke N, Alphonsus C, Mbah O, Madichie NO, Aduh U, Ogbeifo M, IseOluwa-Adelokiki BO, Edochie JE, Ushaka J, Ukwaja KN. Assessment of community knowledge, attitude, and stigma of Buruli ulcer disease in Southern Nigeria. Afr Health Sci 2019; 19:2100-2111. [PMID: 31656494 PMCID: PMC6794545 DOI: 10.4314/ahs.v19i2.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Poor knowledge can influence timely care-seeking among persons with Buruli ulcer disease (BUD). Objectives To assess community knowledge, attitude and stigma towards persons with BUD in endemic settings of Southern Nigeria. Methods This was a cross-sectional survey conducted among adult community members in four States of Southern Nigeria. A semi-structured interviewer-administered questionnaire was administered to all participants. Results Of 491 adults who completed the survey, 315 (64.2%) belonged to the ≤40 years age group, 257 (52.3%) were males and 415 (84.5%) had some formal education. The overall mean (SD) knowledge score was 5.5±2.3 (maximum 10). Only 172 (35.0%) of the participants had a good knowledge of BUD. A total of 327 (66.6%) considered BUD as a very serious illness. Also, there was a high-level of stigma against BUD patients; 372 (75.8%) of the participants felt compassion for and desire to help them, 77 (15.7%) felt compassion but tended to stay away from them, and 53 (10.8%) feared them because they may infect them with the disease. Having a formal education and ethnicity were independent predictors of good knowledge of BUD. Conclusion There is poor community knowledge of BUD in endemic settings of Southern Nigeria which influenced the attitude and perceptions of community members towards persons with BUD
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Affiliation(s)
| | - Anthony Meka
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State, Nigeria
| | - Joseph Ngozi Chukwu
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State, Nigeria
| | - Ngozi Ekeke
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State, Nigeria
| | - Chukwuka Alphonsus
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State, Nigeria
| | - Obinna Mbah
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State, Nigeria
| | | | - Ufuoma Aduh
- Delta State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Delta State, Nigeria
| | - Matthew Ogbeifo
- Delta State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Delta State, Nigeria
| | | | | | - Joseph Ushaka
- Cross River State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Cross River State, Nigeria
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Frimpong M, Ahor HS, Wahed AAE, Agbavor B, Sarpong FN, Laing K, Wansbrough-Jones M, Phillips RO. Rapid detection of Mycobacterium ulcerans with isothermal recombinase polymerase amplification assay. PLoS Negl Trop Dis 2019; 13:e0007155. [PMID: 30707706 PMCID: PMC6373974 DOI: 10.1371/journal.pntd.0007155] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/13/2019] [Accepted: 01/14/2019] [Indexed: 01/05/2023] Open
Abstract
Background Access to an accurate diagnostic test for Buruli ulcer (BU) is a research priority according to the World Health Organization. Nucleic acid amplification of insertion sequence IS2404 by polymerase chain reaction (PCR) is the most sensitive and specific method to detect Mycobacterium ulcerans (M. ulcerans), the causative agent of BU. However, PCR is not always available in endemic communities in Africa due to its cost and technological sophistication. Isothermal DNA amplification systems such as the recombinase polymerase amplification (RPA) have emerged as a molecular diagnostic tool with similar accuracy to PCR but having the advantage of amplifying a template DNA at a constant lower temperature in a shorter time. The aim of this study was to develop RPA for the detection of M. ulcerans and evaluate its use in Buruli ulcer disease. Methodology and principal findings A specific fragment of IS2404 of M. ulcerans was amplified within 15 minutes at a constant 42°C using RPA method. The detection limit was 45 copies of IS2404 molecular DNA standard per reaction. The assay was highly specific as all 7 strains of M. ulcerans tested were detected, and no cross reactivity was observed to other mycobacteria or clinically relevant bacteria species. The clinical performance of the M. ulcerans (Mu-RPA) assay was evaluated using DNA extracted from fine needle aspirates or swabs taken from 67 patients in whom BU was suspected and 12 patients with clinically confirmed non-BU lesions. All results were compared to a highly sensitive real-time PCR. The clinical specificity of the Mu-RPA assay was 100% (95% CI, 84–100), whiles the sensitivity was 88% (95% CI, 77–95). Conclusion The Mu-RPA assay represents an alternative to PCR, especially in areas with limited infrastructure. Current diagnostic methods to detect M. ulcerans suffer from delayed time-to-results in most endemic countries by the prolonged period of time for the shipment and storage of samples to a distant, centralized laboratory. The M. ulcerans recombinase polymerase amplification assay (Mu-RPA) is a new, rapid diagnostic test developed for the detection of M. ulcerans infection, known commonly as Buruli ulcer, a chronic, debilitating, necrotizing disease of the skin and soft tissues. This assay is suitable for use on a portable detection device, with the potential to be used for quick diagnosis at the point of need, providing timely results to health workers at Buruli ulcer treatment clinics.
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Affiliation(s)
- Michael Frimpong
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- * E-mail:
| | - Hubert Senanu Ahor
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ahmed Abd El Wahed
- Division of Microbiology and Animal Hygiene, Georg-August University, Goettingen, Germany
| | - Bernadette Agbavor
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Francisca Naana Sarpong
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kenneth Laing
- Institute for Infection and Immunity, St. George’s University of London, London, United Kingdom
| | - Mark Wansbrough-Jones
- Institute for Infection and Immunity, St. George’s University of London, London, United Kingdom
| | - Richard Odame Phillips
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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7
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Aboagye SY, Kpeli G, Tuffour J, Yeboah‐Manu D. Challenges associated with the treatment of Buruli ulcer. J Leukoc Biol 2018; 105:233-242. [PMID: 30168876 DOI: 10.1002/jlb.mr0318-128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/19/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Sammy Yaw Aboagye
- Noguchi Memorial Institute for Medical ResearchUniversity of Ghana Accra Ghana
| | - Grace Kpeli
- University of Allied Health Sciences Ho Ghana
| | | | - Dorothy Yeboah‐Manu
- Noguchi Memorial Institute for Medical ResearchUniversity of Ghana Accra Ghana
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Ekeke N, Meka AO, Chukwu JN, Nwafor CC, Alphonsus C, Mbah OK, Madichie NO, Aduh U, Ogbeifo M, IseOluwa-Adelokiki BO, Edochie JE, Ushaka J, Ukwaja KN. Assessment of health care workers' knowledge, attitude and risk perception of Buruli ulcer disease in Southern Nigeria. Trans R Soc Trop Med Hyg 2018; 111:226-232. [PMID: 28957473 DOI: 10.1093/trstmh/trx049] [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: 06/22/2017] [Accepted: 07/27/2017] [Indexed: 11/13/2022] Open
Abstract
Background Poor knowledge of health care workers may be responsible for the under-diagnosis and low notification of Buruli ulcer (BU) in high-burden settings. This study assessed health care workers' knowledge, attitude and risk perception of BU in Southern Nigeria. Methods We conducted a cross-sectional survey among 186 health care workers recruited from 58 health facilities in four states of Southern Nigeria. A semi-structured interviewer-administered questionnaire was administered to all participants. Results The overall mean knowledge score was 8.8±2.7 (maximum 15). Only 29.0% (54/186) of the respondents had a good knowledge of BU. The mean (SD) attitude score was 4.5±1.2 (maximum 6). Also, 61.3% (114/) of the respondents had a good attitude towards BU. The overall mean (SD) risk perception score was 2.6±1.3 (maximum 5). Only 26.3% (49/) of the respondents had a good risk perception of BU disease. Previous training was an independent predictor of good knowledge (aOR 4.6), good attitude (aOR 3.8) and good risk perception (aOR 2.9) to BU. Conclusions Health care workers in endemic settings of Nigeria have poor knowledge of and poor risk perception of BU disease. Training of health care workers is recommended to address the identified gaps to ensure earlier diagnosis and referral to specialist centres.
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Affiliation(s)
- Ngozi Ekeke
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State
| | - Anthony O Meka
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State
| | - Joseph N Chukwu
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State
| | - Charles C Nwafor
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State
| | - Chukwuka Alphonsus
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State
| | - Obinna K Mbah
- Medical Department, German Leprosy and Tuberculosis Relief Association, Enugu State
| | | | - Ufuoma Aduh
- Delta State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Delta State
| | - Matthew Ogbeifo
- Delta State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Delta State
| | | | - Joseph E Edochie
- Anambra State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Anambra State
| | - Joseph Ushaka
- Cross River State Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Cross River State
| | - Kingsley N Ukwaja
- Department of Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria
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Abstract
Background Nigeria is one of the countries endemic for Buruli ulcer (BU) in West Africa but did not have a control programme until recently. As a result, BU patients often access treatment services in neighbouring Benin where dedicated health facilities have been established to provide treatment free of charge for BU patients. This study aimed to describe the epidemiological, clinical, biological and therapeutic characteristics of cases from Nigeria treated in three of the four treatment centers in Benin. Methodology/Principal findings A series of 82 BU cases from Nigeria were treated in three centres in Benin during 2006–2016 and are retrospectively described. The majority of these patients came from Ogun and Lagos States which border Benin. Most of the cases were diagnosed with ulcerative lesions (80.5%) and WHO category III lesions (82.9%); 97.5% were healed after a median hospital stay of 46 days (interquartile range [IQR]: 32–176 days). Conclusions/Significance This report adds to the epidemiological understanding of BU in Nigeria in the hope that the programme will intensify efforts aimed at early case detection and treatment. Buruli ulcer (BU) is a neglected tropical disease that mainly affects the skin. The disease results from infection with Mycobacterium ulcerans, an environmental bacterium. In Benin, the BU treatment centres usually receive patients from Nigeria. In 2014, a study from one of the treatment centres (CDTUB, Pobe) which borders south-western Nigeria reported on a cohort of 127 PCR-confirmed cases between 2005 and 2013. We describe the epidemiological, clinical, biological and therapeutic characteristics of BU cases from Nigeria treated in the three other CDTUBs.
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