Mycobacterium ulcerans infection (Buruli ulcer, Bairnsdale ulcer, Daintree ulcer, Flesh Eating Bug) (last updated February 2009) Contents: What is Mycobacterium ulcerans infection?                           How do you get infected? Endemic areas (Australia) What are the symptoms and signs? Treatment Pictures (confirmed cases from Australia) Useful links Notes for Clinicians (on diagnosis) About this website What is Mycobacterium ulcerans infection? Buruli ulcer, Bairnsdale ulcer and Daintree ulcer are all local names given to the same disease which is caused by a bacterium called Mycobacterium ulcerans. This mycobacterium produces a toxin that slowly damages and destroys skin and underlying tissue. The infection occurs in humans, possums, koalas, potoroos and occasional other species.  In the popular press the infection is sometimes called the “the flesh-eating bug”. While the toxin produced by Mycobacterium ulcerans does kill tissue (flesh), the process is slow--Mycobacterium ulcerans infection is not a medical emergency. How do you get infected? The infection is transmitted from the environment but only in specific “endemic” areas,  In Victoria (southeastern Australia) there is new evidence that mosquitoes transmit the infection in certain specific “endemic areas”. Mycobacterium ulcerans does not spread from person to person.   Which areas are endemic? In Australia a few cases occur most years in east Gippsland (Victoria), far north Queensland, the wet tropics and increasingly in coast towns near Melbourne. The incidence varies considerably For example while there 66 known cases in Australia in 2006, 61 of whom were from Victoria, there were only 17 for the whole country in 2007. This year-to-year variation is probably explained by weather events that influence mosquito numbers in endemic areas. In 2008 there were 39 known cases of Buruli ulcer in Australia; 35 were from Victoria, 27 of these were from the Bellarine peninsula, and 13 were linked to Point Lonsdale. Clusters of cases have also occurred at Phillip Island, the Mornington Peninsula and St. Leonard's, Ocean Grove and Barwon Heads.  Overseas, Buruli ulcer is an emerging disease in rural West and sub-saharan Africa where there have been tens of thousands of cases in the last 20 years. The disease is notifiable in Victoria and updated case numbers can be viewed on the Victorian Department of Human Services daily reports (see link to “Daily Reports” below). What are the symptoms and signs? The infection usually starts as a small spot attached to the skin that enlarges over days to weeks.  Some patients describe a dry scab that won't heal which then breaks down into an ulcer.  Sometimes an insect bite is remembered but this is not universal. In Africa, a nodule (mobile lump) beneath the skin may be the first sign. In Australia lesions are typically solitary and mostly occur on the lower leg or arm. However, they can be anywhere. They are usually (but not always) painless and fever or other symptoms of infection are usually absent. Eventually the spot breaks down at the centre and a slowly enlarging undermined ulcer appears. A recent case had a plaque-like patch on her ankle with no ulcer. Occasional patients present with an acute swelling of the whole limb or whole abdominal wall, without an identifiable nodule or ulcer.   How is Buruli ulcer treated? Early intervention leads to minimal scarring. There is a link to detailed treatment guidelines below. Buruli ulcer is curable, but may require a combination of plastic surgery and prolonged antibiotics. Pictures (confirmed cases from Australia) Ear: 2 year old child, coastal Victoria, Australia [Photo Dr. Jonathan Carapetis, RCH, Melbourne]  Leg, 11 year old boy, coastal Victoria, Australia [Photo: Dr. Paul Johnson, Austin Hospital, Melbourne].  Elbow, 75 year old man, surgical photo showing resection of ulcer [Photo A/Prof. John Hayman and Mr. John Buntine, Melbourne].  Leg, adult female, early diagnosis.  [Photo: Courtesy Dr. Paul Flood, Phillip Island].  Elbow, 9 year old girl, late diagnosis.  [Photo: Dr. Paul Johnson, RCH, Melbourne]  Shoulder, 5 year old girl, Mornington, Victoria; 2006; late diagnosis.  Photo courtesy of her parents.    Ankle - 23 yo woman, plaque-like lesion (no ulcer apparent when diagnosed by biopsy)  Lower back - 12 yo boy. The markings show the area of palpable induration (swelling) which is more extensive than the ulcer itself.  Links to guidelines, articles and useful sites World Health Organization World Health Organization Buruli ulcer webpage Provisional antibiotic treatment guidelines, WHO Emerging Infectious Diseases (Journal) Mycobacterium ulcerans and Mosquitoes (Point Lonsdale) Risk factors of Mycobacterium ulcerans infection in southeastern Australia Public Library of Science (PLoS Medicine Journal) Buruli ulcer (review) Medical Journal of Australia Consensus statment on diagnosis, treatment and control of Bairnsdale/ Buruli ulcer in Victoria, Australia 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) Mycobacterium ulcerans infection: factors influencing diagnostic delay Outcomes for Mycobacterium ulcerans infection with combined surgery and antibiotic therapy: findings from a south-eastern Australian case series. PNAS (Journal) Virulence genes of Mycobacterium ulcerans are encoded on giant plasmid Genome Research (Journal) Full genome sequence of Mycobacterium ulcerans Other articles PubMed (search published papers; enter: “ulcerans”) The Age (Newspaper) Flesh-eating ulcer claims new species Localised Mycobacterium ulcerans infection in a cat in Australia. Department of Human Services (Victorian State Govt.) Victorian Department of Human Services Daily Reports DHS Victoria Health Alert DHS Victoria, Mycobacterium ulcerans: the facts Mycobacterium ulcerans at Point Lonsdale   Notes on diagnosis for clinicians  DIAGNOSIS FROM A SWAB...     •    Obtain a smear for acid fast bacilli (AFBs) using a swab that is run around the undermined edge of an ulcer (if present).     •    Ask for routine microscopy and culture and an AFB stain and culture for M. ulcerans.     •    If the smear is positive, the diagnosis is reasonably likely.     •    If the smear is negative, the diagnosis has not been excluded.      •    A diagnostic PCR is now available which can confirm the diagnosis in a few days if AFBs were visible on the smear. You can do the PCR straight from an ulcer swab.     •    If there is still doubt, or if there is a suspicious necrotic skin lesion that has not ulcerated, perform an incisional or excisional biopsy.     •    Histological sections show extensive necrosis, and there are often large numbers of AFBs.  PCR and culture of the biopsy specimens usually confirms the diagnosis. Granulomatous inflammation is sometimes seen in lesions that have been present for some time, and may herald the onset of healing.      •    Culture is the gold standard, which takes 8-12 weeks, but you will need to treat the patient before culture results are available. PCR is generally more sensitive than culture.     •    NOTE: Negative swabs, and even negative incisional biopsies do not absolutely exclude the diagnosis because the organisms may not be spread evenly through the lesion.  If in doubt, repeat biopsies. Microscopy: Acid fast bacilli (M. ulcerans ) in a smear taken from  a swab of an ulcer.  The bacteria can be clearly seen as red clumps on a blue background. This result can be available within 2 hours from a swab; if smear-positive the diagnosis is likely; a negative smear result does not rule it out and a PCR performed on the same swab may still confirm the diagnosis.   About this website This is a privately funded website provided as a community service. The information is intended as a guide only and should not replace personalised medical advice from your doctor. Latest update February 2009 If you have questions/concerns about the contents or accuracy of this website please contact Paul Johnson by email:     Paul DOT Johnson AT austin DOT org DOT au (this email address is disguised to avoid automated SPAM; it can be recreated by replacing words in capitals with the corresponding symbols and removing the spaces).   http://www.who.int/buruli/en/http://www.who.int/buruli/information/antibiotics/en/index.htmlhttp://www.cdc.gov/eid/content/13/11/1653.htmhttp://www.cdc.gov/eid/content/13/11/1661.htmhttp://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020108http://mja.com.au/public/issues/186_02_150107/joh10634_fm.htmlhttp://mja.com.au/public/issues/186_02_150107/joh10634_fm.htmlhttp://www.mja.com.au/public/issues/176_04_180202/jen10309.htmlhttp://www.mja.com.au/public/issues/185_03_070806/letters_070806_fm-4.htmlhttp://mja.com.au/public/issues/186_02_150107/lav10784_fm.htmlhttp://www.mja.com.au/public/issues/187_01_020707/letters_020707_fm-8.htmlhttp://www.mja.com.au/public/issues/186_02_150107/contents_150107.htmlhttp://www.mja.com.au/public/issues/187_10_191107/que10395_fm.htmlhttp://www.mja.com.au/public/issues/186_02_150107/obr10433_fm.htmlhttp://www.mja.com.au/public/issues/186_02_150107/obr10433_fm.htmlhttp://www.pnas.org/cgi/content/abstract/0305877101v1http://www.genome.org/cgi/content/full/17/2/192http://www.ncbi.nlm.nih.gov/entrez/query.fcgihttp://www.theage.com.au/national/flesheating-ulcer-claims-new-species-20090107-7c0m.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/18495511?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSumhttp://www.health.vic.gov.au/ideas/downloads/daily_reports/statewide/rptVictorianSummary.pdfhttp://www.health.vic.gov.au/chiefhealthofficer/alerts/mycobacterium.htmhttp://www.health.vic.gov.au/ideas/diseases/myco_facts.htmhttp://www.health.vic.gov.au/ideas/downloads/bulletin/vidbv8i1.pdfshapeimage_1_link_0shapeimage_1_link_1shapeimage_1_link_2shapeimage_1_link_3shapeimage_1_link_4shapeimage_1_link_5shapeimage_1_link_6shapeimage_1_link_7shapeimage_1_link_8shapeimage_1_link_9shapeimage_1_link_10shapeimage_1_link_11shapeimage_1_link_12shapeimage_1_link_13shapeimage_1_link_14shapeimage_1_link_15shapeimage_1_link_16shapeimage_1_link_17shapeimage_1_link_18shapeimage_1_link_19shapeimage_1_link_20shapeimage_1_link_21shapeimage_1_link_22shapeimage_1_link_23