Mulcerans.htm

Buruli ulcer in Australia

(August 15th 2016) Short URL: goo.gl/h3a0b4

 

What is Buruli ulcer? Buruli ulcer, Bairnsdale ulcer, Mossman ulcer and Daintree ulcer are all local names given to the same disease that is caused by Mycobacterium ulcerans--a mycobacterium related to those that cause TB and leprosy. “Buruli ulcer” or just “Buruli” is the official name preferred by WHO. Mycobacterium ulcerans produces a toxin that damages skin and subcutaneous fat tissue. The infection occurs in humans in more than 32 countries.

 

Which areas in Australia and New Zealand are endemic? Buruli is a geographically restricted infection so only occurs following contact with specific “endemic” areas. In Australia these include coastal Victoria, north Queensland near Mossman, the Capricorn Coast of Queensland near Yeppoon and the tropical north coast near Darwin (see map). So far no cases have been linked to Tasmania, South Australia, southern Western Australia or the ACT. There have been a handful of cases in Southern New South Wales near the border with Victoria. Buruli does not occur in New Zealand.

 

How do you get infected? Travel to an endemic area even for just a few hours is enough to pick up the infection. The median incubation period is 4.5 months with a range of 3 weeks to almost a year. In Victoria (southeastern Australia) there is evidence that mosquitoes transmit the infection, but other biting arthropods may be involved, or there may be more than one mode of transmission. Mycobacterium ulcerans does not appear to spread from person to person.

 

How common? In 2013-14 there were 163 confirmed cases of Buruli ulcer in Australia, giving an annual national incidence of < 1 per 100,000. However in endemic regions this can be up to 100 times higher. Overseas there have been thousands of cases of Buruli, predominantly in rural areas in west and central Africa.

 

Map: Confirmed cases Australia since 1939 (Courtesy A/Prof John Hayman: circle size indicative only).

 

 

Map: Confirmed cases Australia, 2013-14 (WHO Meeting on Buruli ulcer, March 2015, Geneva). Circle sizes are to scale in this map

 

 

Graph: Confirmed cases in Victoria by year. [Acknowledgement: A/Prof John Hayman, cases prior to 1993].

 

 

Figure: Overlaid Google Earth image, likely place of infection, confirmed cases Victoria, 2013-14 (WHO Meeting on Buruli ulcer, March 2015, Geneva).

Circle sizes are to scale in this map.

 

 

When to suspect Buruli ulcer? “Buruli” may be a better term than Buruli ulcer, as not all lesions are ulcers and this can confuse patients and doctors.

 

Buruli usually starts as a small spot (lesion) on or under the skin that enlarges over days to weeks. Lesions are typically solitary and typically occur around the ankles, backs of calves or elbows. However, they can be anywhere. Sometimes an insect bite or episode of trauma is recalled. Lesions are usually painless, and fever or other symptoms are usually absent. Eventually the spot breaks down and a slowly enlarging undermined ulcer appears but appearances can be variable and Buruli ulcer is difficult to diagnose if your doctor is not familiar with the condition.

 

Some patients present with a raised reddish plaque rather than an ulcer or develop swelling of the whole limb or whole abdominal wall without an identifiable nodule, plaque or ulcer.  Buruli progresses over days to weeks (not hours). Most severe cases of Buruli ulcer result from delayed diagnosis.

 

How is Buruli ulcer treated? Buruli ulcer is slow moving and always curable although it can be quite destructive. A 2-month course of antibiotics appears able to kill the bacteria. Lesions may paradoxically worsen during antibiotic treatment. Surgery and antibiotics are often used in combination to achieve optimal outcomes. Recently updated treatment guidelines for Australian clinicians are available here.

 

Pictures (confirmed cases from Australia)

Ear: 2 year-old, coastal Victoria, Australia [Photo Clinical Photography, Royal Children’s Hospital, Melbourne]

image003.jpg

 

Leg, adult female, early diagnosis.  [Photo: Dr. Paul Flood, Phillip Island].

 

 

Elbow ulcer, 9 year-old girl, delayed diagnosis.  [Photo: Clinical Photography, Royal Children’s Hospital, Melbourne]

elbow.jpg

 

 

 

Lower back ulcer - 12 year-old boy. The markings show the area of palpable induration (swelling) that is more extensive than the ulcer itself.

[Photo: Mr. John Buntine, Melbourne]

lower back.jpg

 

 

Notes on diagnosis for clinicians

IF THERE IS AN ULCER OR DISCHARGING LESION:

Rapid accurate diagnosis can be made by PCR directly from swab of an ulcer. Make sure you get some biological material on the send of the swab by running it around the undermined edge of the ulcer.

If there is a plug of necrotic tissue, moisten this with saline. If there is biological material on the swab, the PCR is almost always positive.

Specify “Mycobacterium ulcerans” or  Bairnsdale/Buruli ulcer” and “PCR” clearly in clinical notes on the request slip.

 

MU swab for web.jpg

 

Details--DIAGNOSIS FROM A SWAB...PCR can be performed straight from the swab; make sure you get biological material on the swab (see picture). Moisten and rub with saline if necessary.

 

Microscopy: Acid-fast bacilli (Mycobacterium ulcerans) in a smear taken directly from a swab of an ulcer.  The bacteria can be clearly seen as red clumps on a blue background.  PCR confirmed this is M. ulcerans

 

afb smear.jpg

 

If there is concern about a non-ulcerative form of Buruli, fresh tissue from an incisional biopsy, punch biopsy, fine needle aspirate or excisional biopsy will be needed. Remember to ask for Mycobacterium ulcerans PCR microscopy and culture. Histology is also very helpful.

 

Ankle - 23 year-old woman, plaque lesion (no ulcer apparent; diagnosed by histology and PCR on a incisional biopsy)

 

image009.jpg

 

Links to guidelines, articles and useful sites

 

Department of Health (Victorian State Government)

 

·      Notifiable infections in Victoria - weekly case numbers of Buruli ulcer

 

·      DHS Victoria Health Alert August 2016

 

·      DHS Victoria, Mycobacterium ulcerans: the facts

 

·   Mycobacterium ulcerans and mosquitoes

 

   Publications about Buruli ulcer in Victoria, Australia

 

·      Mycobacterium ulcerans and Mosquitoes (Point Lonsdale)

 

·      Risk factors of Mycobacterium ulcerans infection in southeastern Australia

 

·      Mosquitoes, Buruli ulcer and other vector borne diseases in Victoria, Australia

 

·      Possums and Buruli ulcer on the Bellarine Peninsula

 

·      Possums and Buruli ulcer on the Mornington Peninsula

 

·     Mosquitoes and risk of Buruli ulcer on the Bellarine Peninsula, Victoria

 

·      Mycobacterium ulcerans infection: factors influencing diagnostic delay

 

·      Outcomes for Mycobacterium ulcerans infection with combined surgery and antibiotic therapy: findings from a southeastern Australian case series.

 

·      Paradoxical reactions (apparent worsening) during antibiotic treatment

 

·      Spontaneous clearance of Mycobacterium ulcerans in a case of Buruli ulcer

 

·      Mycobacterium ulcerans infection: can duration of antibiotic treatment be reduced in selected patients?

 

·      Mycobacterium ulcerans in the elderly

 

   Buruli ulcer in Far North Queensland

 

·      A case of acute edematous Buruli ulcer (Daintree ulcer) in far north Queensland

 

·      Mycobacterium ulcerans infection in North Queensland:  the ‘Daintree ulcer’

 

   Buruli ulcer in central Queensland

 

·      Mycobacterium ulcerans in central coastal Queensland

 

   World Health Organization

 

·      Buruli ulcer - WHO

 

·      Provisional antibiotic treatment guidelines, WHO

 

·      WHO Collaborating Centre for Mycobacterium ulcerans (WHO website)

 

·      WHO Collaborating Centre for Mycobacterium ulcerans (VIDRL, Melbourne)

 

   Public Library of Science (Journal)

 

·      Buruli ulcer (review)

 

·     All oral antibiotics for the treatment of Bairnsdale/Buruli ulcer

 

·      The incubation period of Buruli ulcer

 

    Medical Journal of Australia

 

·      Consensus statement on diagnosis, treatment and control of Bairnsdale/ Buruli ulcer in Victoria, Australia (updated)

 

·      Mycobacterium ulcerans in far North Queensland

 

·      Mycobacterium ulcerans in central coastal Queensland

 

·      First case in New South Wales

 

·      What is in a name? Note on naming of Buruli ulcer

 

·      Editorial, pictures, 3 articles (January 15th 2007 edition)

 

·      Outcomes for Mycobacterium ulcerans infection with combined surgery and antibiotic therapy: findings from a southeastern Australian case series.

 

·      Buruli ulcer on the Bellarine Peninsula

 

   Proceedings of the National Academy of Science (Journal)

 

·      Virulence genes of Mycobacterium ulcerans are encoded on giant plasmid

 

   Genome Research (Journal)

 

·      Full genome sequence of Mycobacterium ulcerans

 

   Other articles

 

·      The Age (Newspaper) Flesh-eating ulcer claims new species

 

·      The Age (Newspaper) Ulcer linked to Mosquitoes

 

·      Mycobacterium ulcerans infection in a cat in Australia.

 

·      The Age Newspaper: Jan Smith (mountaineer) and Buruli ulcer

 

      About this website

      short URL: http://goo.gl/h3a0b4

This is a privately funded website provided as a community service. The information is intended as a guide only and should not replace medical advice from your doctor. Latest update August 2016. If you have questions/concerns about the contents or accuracy of this website please contact me by email: Paul.JohnsonATaustin.org.au Professor Paul Johnson (Austin Health Link)

 

Professor Paul Johnson

Austin Health & University of Melbourne

 

 

 

 

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