What are the other Names for this Condition? (Also known as/Synonyms)

• Daintree Ulcer
• Kumasi Ulcer
• Searles Ulcer

What is Buruli Ulcer? (Definition/Background Information)

• Buruli Ulcer is a bacterial skin infection that results in painless tissue death (necrosis) at the site of the skin lesion. The causative bacterium is Mycobacterium ulcerans and the infection is observed in certain parts of Africa, Asia, and Australia, mostly affecting individuals of low socioeconomic status
• The cause of transmission of the bacteria to humans is not clearly established. However, Buruli Ulcer can cause extensive ulceration and necrosis without appropriate and early intervention. The condition is typically managed through a combination of antibiotics and aggressive wound care

Who gets Buruli Ulcer? (Age and Sex Distribution)

• Buruli Ulcer are generally observed in children below 15 years of age. However, it can be observed in a wide age range of individuals
• Both males and females are affected
• Worldwide, there is no racial or ethnic preference observed

Most of the cases are reported from sub-Saharan Africa (central and western parts). Other nations that report infection include central and south America, south east Asia, and parts of Australia.

What are the Risk Factors for Buruli Ulcer? (Predisposing Factors)

The risk factors for Buruli Ulcer include:

• Living in poverty and overcrowded unclean surroundings, particularly near swamps and marshes
• Living near stagnant waterbodies
• Open wounds
• Poor personal and oral hygiene

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Buruli Ulcer? (Etiology)

Buruli Ulcer is the result of infection by the pathogen Mycobacterium ulcerans. The mode of transmission of the bacteria to humans is not understood.

• It is believed that individuals with open wounds may develop the ulcer at the wound site following infection from contaminated waters or soil
• It is speculated that the bacteria may even be transmitted to humans through wild animals or insect bites
• Some researchers have proposed genetic vulnerability to the infection

When the causative bacteria enters human skin, it begins to grow and multiply, forming a painless nodule. The bacteria release a toxin, called mycolactone, into skin tissues which through a complex process, result in cell/tissue death leading to the formation of Buruli Ulcer. Simultaneously, the toxins stop cell signaling that activates the immune system. White blood cells that fight the infection are also destroyed by the toxin. This results in a painless and progressive necrotic process with extensive skin tissue involvement.

What are the Signs and Symptoms of Buruli Ulcer?

The onset of Buruli Ulcer may occur within a few weeks to months following infection. The signs and symptoms of the condition include:

• Initial appearance of a small firm and painless nodule on skin 
• The nodule grows to about 1-2 cm in size
• After a few weeks, the nodule ruptures to form an ulcer that is characterized by a lack of pain and tissue destruction
• Even though tissue death may extend far beyond the original ulcer boundary, the overlying skin may appear intact
• The necrosis can involve the deep skin tissues, muscles, blood vessels, and nerves
• In rare cases, even the bone beneath the ulcer may be destroyed
• This painless ulcer usually involves the lower limbs, and may grow to over 15 cm in size (or more)

No systemic signs and symptoms such as fever, chills, fatigue, or general feeling of illness is noted.

How is Buruli Ulcer Diagnosed?

A diagnosis of Buruli Ulcer may involve the following exams and procedures:

• Physical examination of the individual and medical history evaluation; a visual examination of the ulcer (especially in the endemic regions) may be sufficient to diagnose the condition
• Blood tests, analysis of pus, and culture of the fluid being drained (for causative pathogen), as needed
• Polymerase chain reaction (PCR) test
• Dermoscopy: Dermoscopy is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
• Skin biopsy: A skin biopsy is performed and sent to a laboratory for a pathological examination. The pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis

Note: It is reported that swab culture obtained from the ulcer may take between 6-8 weeks for analysis and issue of lab reports, as mycobacteria grow very slowly. However, it is important to begin treatment as early as possible.

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Buruli Ulcer?

The possible complications due to Buruli Ulcer include:

• Extensive tissue necrosis (destruction)
• Superimposed bacterial and fungal skin infections
• Bone infection (osteomyelitis)
• Spread of infection to multiple sites, including to the joints and genitalia
• Severe scarring on healing; permanent disfigurement
• Long-term disability
• Loss of limb
• Treatment complications - inflammatory reaction to antibiotic therapy is reported

How is Buruli Ulcer Treated?

The World Health Organization (WHO) recommends the following treatment measures for Buruli Ulcer:

• Antibiotic therapy using a combination of antibiotics, typically rifampicin with either of streptomycin/clarithromycin/ciprofloxacin
• Due to an inflammatory reaction, termed paradoxical flare-up, oral steroids may be prescribed
• Surgical debridement of dead or necrotic tissue is usually necessary
• Regular dressing changes and wound care, as needed
• Skin grafting and correction of deformities, as required
• Rehabilitation to cope up with disability

Regular follow up visits with the healthcare provider is important and recommended.

How can Buruli Ulcer be Prevented?

Buruli Ulcer may be prevented by considering the following steps:

• Maintaining basic personal/community hygiene and proper sanitation is highly important, particularly in the endemic zones
• Minimizing exposure to contaminated waters in the endemic regions
• Ensuring that wounds and skin ulcers are properly treated and dressed/covered
• Using insect repellents to prevent insects from entering residences
• Wearing long-sleeved shirts and full length trousers

Availing BCG vaccine, which is seen to offer about 12 months of protection from the infection.

What is the Prognosis of Buruli Ulcer? (Outcomes/Resolutions)

• The prognosis of Buruli Ulcer depends primarily on the severity of the infection and access to proper medical treatment
• The outcomes are good for individuals with small-sized lesions (less than 5 cm), who are treated promptly and adequately

Additional and Relevant Useful Information for Buruli Ulcer:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/healthy-living/skin-disorders/