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Buruli Ulcer Differential Diagnoses

  • Author: Aaron Z Hoover, MD, FAAD; Chief Editor: William D James, MD  more...
 
Updated: Jul 17, 2014
 
 
 
Contributor Information and Disclosures
Author

Aaron Z Hoover, MD, FAAD Staff Dermatologist/Dermatopathologist, Front Range Dermatology Associates

Aaron Z Hoover, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Christian Medical and Dental Associations, International Society of Dermatopathology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Humira.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Franklin Flowers, MD Department of Dermatology, Professor Emeritus Affiliate Associate Professor of Pathology, University of Florida College of Medicine

Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Surgery

Disclosure: Nothing to disclose.

Acknowledgements

Special thanks to Ms Carmen Urich for helping me obtain articles needed to update this publication.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of the following previous authors, Brian P. Green, DO, MS, PA-C; Sean T. Gunning, MD; and Mary K. Mather, MD, to the development and writing of this article.

The authors and editors of Medscape Reference would also like to thank Wayne M. Meyers, MD, for his clinical images from his article with Douglas S. Walsh, MD, in Transactions of the Royal Society of Tropical Medicine and Hygiene.[3]

References
  1. Sizaire V, Nackers F, Comte E, Portaels F. Mycobacterium ulcerans infection: control, diagnosis, and treatment. Lancet Infect Dis. 2006 May. 6(5):288-96. [Medline].

  2. World Health Organization. Buruli ulcer disease (Mycobacterium ulcerans infection). World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs199/en/. Accessed: December 3, 2008.

  3. Walsh DS, Portaels F, Meyers WM. Buruli ulcer (Mycobacterium ulcerans infection). Trans R Soc Trop Med Hyg. 2008 Oct. 102(10):969-78. [Medline].

  4. Wansbrough-Jones M, Phillips R. Buruli ulcer: emerging from obscurity. Lancet. 2006 Jun 3. 367(9525):1849-58. [Medline].

  5. George KM, Chatterjee D, Gunawardana G, et al. Mycolactone: a polyketide toxin from Mycobacterium ulcerans required for virulence. Science. 1999 Feb 5. 283(5403):854-7. [Medline].

  6. Walsh DS, Meyers WM, Portaels F, et al. High rates of apoptosis in human Mycobacterium ulcerans culture-positive buruli ulcer skin lesions. Am J Trop Med Hyg. 2005 Aug. 73(2):410-5. [Medline].

  7. Pimsler M, Sponsler TA, Meyers WM. Immunosuppressive properties of the soluble toxin from Mycobacterium ulcerans. J Infect Dis. 1988 Mar. 157(3):577-80. [Medline].

  8. Phillips R, Sarfo FS, Guenin-Macé L, Decalf J, Wansbrough-Jones M, Albert ML, et al. Immunosuppressive signature of cutaneous Mycobacterium ulcerans infection in the peripheral blood of patients with buruli ulcer disease. J Infect Dis. 2009 Dec 1. 200(11):1675-84. [Medline].

  9. Boleira M, Lupi O, Lehman L, Asiedu KB, Kiszewski AE. Buruli ulcer. An Bras Dermatol. 2010 Jun. 85(3):281-298; quiz 299-301. [Medline]. [Full Text].

  10. Guenin-Macé L, Veyron-Churlet R, Thoulouze MI, Romet-Lemonne G, Hong H, Leadlay PF, et al. Mycolactone activation of Wiskott-Aldrich syndrome proteins underpins Buruli ulcer formation. J Clin Invest. 2013 Apr 1. 123(4):1501-12. [Medline]. [Full Text].

  11. Stienstra Y, van der Werf TS, Oosterom E, et al. Susceptibility to Buruli ulcer is associated with the SLC11A1 (NRAMP1) D543N polymorphism. Genes Immun. 2006 Apr. 7(3):185-9. [Medline].

  12. Guedenom A, Zinsou C, Josse R, et al. Traditional treatment of Buruli ulcer in Benin. Arch Dermatol. 1995 Jun. 131(6):741-2. [Medline].

  13. Aiga H, Amano T, Cairncross S, Adomako J, Nanas OK, Coleman S. Assessing water-related risk factors for Buruli ulcer: a case-control study in Ghana. Am J Trop Med Hyg. 2004 Oct. 71(4):387-92. [Medline].

  14. Meyers WM, Tignokpa N, Priuli GB, Portaels F. Mycobacterium ulcerans infection (Buruli ulcer): first reported patients in Togo. Br J Dermatol. 1996 Jun. 134(6):1116-21. [Medline].

  15. Chany AC, Tresse C, Casarotto V, Blanchard N. History, biology and chemistry of Mycobacterium ulcerans infections (Buruli ulcer disease). Nat Prod Rep. 2013 Dec. 30(12):1527-67. [Medline].

  16. Jacobsen KH, Padgett JJ. Risk factors for Mycobacterium ulcerans infection. Int J Infect Dis. 2010 Aug. 14(8):e677-81. [Medline].

  17. Trubiano JA, Lavender CJ, Fyfe JA, Bittmann S, Johnson PD. The incubation period of Buruli ulcer (Mycobacterium ulcerans infection). PLoS Negl Trop Dis. 2013. 7(10):e2463. [Medline]. [Full Text].

  18. [Guideline] Guidance on sampling techniques for laboratory-confirmation of Mycobacterium ulcerans infection (Buruli ulcer disease). Available at http://www.who.int/buruli/Guidance_sampling_techniques_MU_infection.pdf?ua=1.

  19. Eddyani M, Ofori-Adjei D, Teugels G, et al. Potential role for fish in transmission of Mycobacterium ulcerans disease (Buruli ulcer): an environmental study. Appl Environ Microbiol. 2004 Sep. 70(9):5679-81. [Medline].

  20. Marsollier L, Severin T, Aubry J, et al. Aquatic snails, passive hosts of Mycobacterium ulcerans. Appl Environ Microbiol. 2004 Oct. 70(10):6296-8. [Medline].

  21. Marsollier L, Stinear T, Aubry J, et al. Aquatic plants stimulate the growth of and biofilm formation by Mycobacterium ulcerans in axenic culture and harbor these bacteria in the environment. Appl Environ Microbiol. 2004 Feb. 70(2):1097-103. [Medline].

  22. Raghunathan PL, Whitney EA, et al. Risk factors for Buruli ulcer disease (Mycobacterium ulcerans Infection): results from a case-control study in Ghana. Clin Infect Dis. 2005 May 15. 40(10):1445-53. [Medline].

  23. Meyers WM, Shelly WM, Connor DH, Meyers EK. Human Mycobacterium ulcerans infections developing at sites of trauma to skin. Am J Trop Med Hyg. 1974 Sep. 23(5):919-23. [Medline].

  24. Landier J, Boisier P, Fotso Piam F, Noumen-Djeunga B, Simé J, Wantong FG, et al. Adequate wound care and use of bed nets as protective factors against Buruli Ulcer: results from a case control study in Cameroon. PLoS Negl Trop Dis. 2011 Nov. 5(11):e1392. [Medline]. [Full Text].

  25. Johnson PD, Azuolas J, Lavender CJ, et al. Mycobacterium ulcerans in mosquitoes captured during outbreak of Buruli ulcer, southeastern Australia. Emerg Infect Dis. 2007 Nov. 13(11):1653-60. [Medline].

  26. Fyfe JA, Lavender CJ, Handasyde KA, Legione AR, O'Brien CR, Stinear TP, et al. A major role for mammals in the ecology of Mycobacterium ulcerans. PLoS Negl Trop Dis. 2010 Aug 10. 4(8):e791. [Medline]. [Full Text].

  27. Merritt RW, Walker ED, Small PL, Wallace JR, Johnson PD, Benbow ME, et al. Ecology and transmission of Buruli ulcer disease: a systematic review. PLoS Negl Trop Dis. 2010 Dec 14. 4(12):e911. [Medline]. [Full Text].

  28. Wilson MD, Boakye DA, Mosi L, Asiedu K. In the case of transmission of mycobacterium ulcerans in buruli ulcer disease acanthamoeba species stand accused. Ghana Med J. 2011 Mar. 45(1):31-4. [Medline].

  29. Silva MT, Portaels F, Pedrosa J. Pathogenetic mechanisms of the intracellular parasite Mycobacterium ulcerans leading to Buruli ulcer. Lancet Infect Dis. 2009 Nov. 9(11):699-710. [Medline].

  30. Walsh DS, Portaels F, Meyers WM. Buruli ulcer: Advances in understanding Mycobacterium ulcerans infection. Dermatol Clin. 2011 Jan. 29(1):1-8. [Medline].

  31. Yeboah-Manu D, Asante-Poku A, Asan-Ampah K, Ampadu ED, Pluschke G. Combining PCR with microscopy to reduce costs of laboratory diagnosis of Buruli ulcer. Am J Trop Med Hyg. 2011 Nov. 85(5):900-4. [Medline]. [Full Text].

  32. Herbinger KH, Adjei O, Awua-Boateng NY, Nienhuis WA, Kunaa L, Siegmund V, et al. Comparative study of the sensitivity of different diagnostic methods for the laboratory diagnosis of Buruli ulcer disease. Clin Infect Dis. 2009 Apr 15. 48(8):1055-64. [Medline].

  33. Herbinger KH, Beissner M, Huber K, Awua-Boateng NY, Nitschke J, Thompson W, et al. Efficiency of fine-needle aspiration compared with other sampling techniques for laboratory diagnosis of Buruli ulcer disease. J Clin Microbiol. 2010 Oct. 48(10):3732-4. [Medline]. [Full Text].

  34. Phillips R, Horsfield C, Kuijper S, et al. Sensitivity of PCR targeting the IS2404 insertion sequence of Mycobacterium ulcerans in an Assay using punch biopsy specimens for diagnosis of Buruli ulcer. J Clin Microbiol. 2005 Aug. 43(8):3650-6. [Medline].

  35. 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 Nov. 44(11):4273-5. [Medline].

  36. Siegmund V, Adjei O, Nitschke J, et al. Dry reagent-based polymerase chain reaction compared with other laboratory methods available for the diagnosis of Buruli ulcer disease. Clin Infect Dis. 2007 Jul 1. 45(1):68-75. [Medline].

  37. Gordon CL, Buntine JA, Hayman JA, Lavender CJ, Fyfe JA, Hosking P, et al. All-oral antibiotic treatment for buruli ulcer: a report of four patients. PLoS Negl Trop Dis. 2010 Nov 30. 4(11):e770. [Medline]. [Full Text].

  38. Leigheb G, Cammarota T, Zavattaro E, et al. Ultrasonography for the monitoring of subcutaneous damage in Mycobacterium ulcerans infection (Buruli ulcer). Ultrasound Med Biol. 2008 Oct. 34(10):1554-63. [Medline].

  39. Converse PJ, Nuermberger EL, Almeida DV, Grosset JH. Treating Mycobacterium ulcerans disease (Buruli ulcer): from surgery to antibiotics, is the pill mightier than the knife?. Future Microbiol. 2011 Oct. 6(10):1185-98. [Medline]. [Full Text].

  40. Chauty A, Ardant MF, Adeye A, et al. Promising clinical efficacy of streptomycin-rifampin combination for treatment of buruli ulcer (Mycobacterium ulcerans disease). Antimicrob Agents Chemother. 2007 Nov. 51(11):4029-35. [Medline].

  41. Etuaful S, Carbonnelle B, Grosset J, et al. Efficacy of the combination rifampin-streptomycin in preventing growth of Mycobacterium ulcerans in early lesions of Buruli ulcer in humans. Antimicrob Agents Chemother. 2005 Aug. 49(8):3182-6. [Medline].

  42. Sarfo FS, Phillips R, Asiedu K, Ampadu E, Bobi N, Adentwe E, et al. Clinical efficacy of combination of rifampin and streptomycin for treatment of Mycobacterium ulcerans disease. Antimicrob Agents Chemother. 2010 Sep. 54(9):3678-85. [Medline]. [Full Text].

  43. [Guideline] World Health Organization. Treatment of mycobaterium ulcerans disease (Buruli ulcer): guidance for health workers:. World Health Organization. Available at http://ttp://www.who.int/iris/bitstream/10665/77771/1/9789241503402_eng.pdf. Accessed: March 2013.

  44. Nienhuis WA, Stienstra Y, Thompson WA, et al. Antimicrobial treatment for early, limited Mycobacterium ulcerans infection: a randomised controlled trial. Lancet. 2010 Feb 20. 375(9715):664-72. [Medline].

  45. Johnson PD, Hayman JA, Quek TY, et al. Consensus recommendations for the diagnosis, treatment and control of Mycobacterium ulcerans infection (Bairnsdale or Buruli ulcer) in Victoria, Australia. Med J Aust. 2007 Jan 15. 186(2):64-8. [Medline].

  46. Friedman ND, Athan E, Hughes AJ, Khajehnoori M, McDonald A, Callan P, et al. Mycobacterium ulcerans disease: experience with primary oral medical therapy in an Australian cohort. PLoS Negl Trop Dis. 2013. 7(7):e2315. [Medline]. [Full Text].

  47. O'Brien DP, Robson ME, Callan PP, McDonald AH. "Paradoxical" immune-mediated reactions to Mycobacterium ulcerans during antibiotic treatment: a result of treatment success, not failure. Med J Aust. 2009 Nov 16. 191(10):564-6. [Medline].

  48. O'Brien DP, Walton A, Hughes AJ, Friedman ND, McDonald A, Callan P, et al. Risk factors for recurrent Mycobacterium ulcerans disease after exclusive surgical treatment in an Australian cohort. Med J Aust. 2013 May 6. 198(8):436-9. [Medline].

  49. O'Brien DP, Robson M, Friedman ND, Walton A, McDonald A, Callan P, et al. Incidence, clinical spectrum, diagnostic features, treatment and predictors of paradoxical reactions during antibiotic treatment of Mycobacterium ulcerans infections. BMC Infect Dis. 2013 Sep 5. 13:416. [Medline]. [Full Text].

  50. Friedman ND, McDonald AH, Robson ME, O'Brien DP. Corticosteroid use for paradoxical reactions during antibiotic treatment for Mycobacterium ulcerans. PLoS Negl Trop Dis. 2012. 6(9):e1767. [Medline]. [Full Text].

  51. Meyers WM, Shelly WM, Connor DH. Heat treatment of Mycobacterium ulcerans infections without surgical excision. Am J Trop Med Hyg. 1974 Sep. 23(5):924-9. [Medline].

  52. Junghanss T, Um Boock A, Vogel M, Schuette D, Weinlaeder H, Pluschke G. Phase change material for thermotherapy of Buruli ulcer: a prospective observational single centre proof-of-principle trial. PLoS Negl Trop Dis. 2009. 3(2):e380. [Medline]. [Full Text].

  53. Krieg RE, Wolcott JH, Confer A. Treatment of Mycobacterium ulcerans infection by hyperbaric oxygenation. Aviat Space Environ Med. 1975 Oct. 46(10):1241-5. [Medline].

  54. Bertolotti A, Izzo A, Grigolato PG, Iabichella ML. The use of ozone therapy in Buruli ulcer had an excellent outcome. BMJ Case Rep. 2013 Jan 31. 2013:[Medline].

  55. Nackers F, Dramaix M, Johnson RC, et al. BCG vaccine effectiveness against Buruli ulcer: a case-control study in Benin. Am J Trop Med Hyg. 2006 Oct. 75(4):768-74. [Medline].

  56. van der Werf TS, Stienstra Y, Johnson RC, et al. Mycobacterium ulcerans disease. Bull World Health Organ. 2005 Oct. 83(10):785-91. [Medline].

  57. Barclay L. IDSA: skin and soft tissue infections guidelines updated. Medscape Medical News. Available at http://www.medscape.com/viewarticle/827399. Accessed: June 26, 2014.

  58. [Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline]. [Full Text].

  59. Adu E, Ampadu E, Acheampong D. Surgical management of buruli ulcer disease: a four-year experience from four endemic districts in ghana. Ghana Med J. 2011 Mar. 45(1):4-9. [Medline]. [Full Text].

  60. Bretzel G, Siegmund V, Racz P, et al. Post-surgical assessment of excised tissue from patients with Buruli ulcer disease: progression of infection in macroscopically healthy tissue. Trop Med Int Health. 2005 Nov. 10(11):1199-206. [Medline].

  61. [Guideline] Valérie Simonet. Prevention of disability in Buruli ulcer:basic rehabilitationPractical field guide. Available at http://whqlibdoc.who.int/hq/2008/WHO_HTM_NTD_IDM_GBUI_2008.1_eng.pdf. Accessed: May 28 2012.

  62. Phanzu DM, Suykerbuyk P, Imposo DB, Lukanu PN, Minuku JB, Lehman LF, et al. Effect of a control project on clinical profiles and outcomes in buruli ulcer: a before/after study in Bas-Congo, Democratic Republic of Congo. PLoS Negl Trop Dis. 2011 Dec. 5(12):e1402. [Medline]. [Full Text].

  63. Buruli ulcer: first programme review meeting for west Africa--summary report. Wkly Epidemiol Rec. 2009 Feb 6. 84(6):43-8. [Medline].

  64. Ackumey MM, Kwakye-Maclean C, Ampadu EO, de Savigny D, Weiss MG. Health services for Buruli ulcer control: lessons from a field study in Ghana. PLoS Negl Trop Dis. 2011 Jun. 5(6):e1187. [Medline]. [Full Text].

  65. Minutilli E, Orefici G, Pardini M, et al. Squamous cell carcinoma secondary to buruli ulcer. Dermatol Surg. 2007 Jul. 33(7):872-5. [Medline].

  66. Ackumey MM, Kwakye-Maclean C, Ampadu EO, de Savigny D, Weiss MG. Health services for Buruli ulcer control: lessons from a field study in Ghana. PLoS Negl Trop Dis. 2011 Jun. 5(6):e1187. [Medline]. [Full Text].

  67. Barogui Y, Johnson RC, van der Werf TS, Sopoh G, Dossou A, Dijkstra PU, et al. Functional limitations after surgical or antibiotic treatment for Buruli ulcer in Benin. Am J Trop Med Hyg. 2009 Jul. 81(1):82-7. [Medline].

  68. Connor DH, Meyers WM, Kreig RE. Infection by Mycobacterium ulcerans. Binford CH, Connor DH, eds. Pathology of Tropical and Extraordinary Diseases. Washington, DC: Armed Forces Institute of Pathology; 1976. 226-35.

  69. de Souza DK, Quaye C, Mosi L, Addo P, Boakye DA. A quick and cost effective method for the diagnosis of Mycobacterium ulcerans infection. BMC Infect Dis. Jan 2012. 12:Jan 18. [Medline]. [Full Text].

  70. Meyers WM. Atypical mycobacteria skin infections. Strickland GT, ed. Hunter's Tropical Medicine. Philadelphia, Pa: WB Saunders; 1991. 495-6.

  71. Simpson C, O'Brien DP, McDonald A, Callan P. Mycobacterium ulcerans infection: evolution in clinical management. ANZ J Surg. 2013 Jul. 83(7-8):523-6. [Medline].

  72. Trubiano JA, Lavender CJ, Fyfe JA, Bittmann S, Johnson PD. The incubation period of Buruli ulcer (Mycobacterium ulcerans infection). PLoS Negl Trop Dis. 2013. 7(10):e2463. [Medline]. [Full Text].

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Buruli ulcer can extend to 15% of a person's skin surface and may destroy nerves and blood vessels. Metastatic bone lesions may develop.
An edematous Buruli ulcer in a 9-year-old Togolese girl. Courtesy of Wayne M. Meyers, MD.
Photo of Tongolese girl taken 5 years after the Buruli ulcer had been excised and repaired with autologous split-skin graft by G.B. Priuli, MD. Courtesy of Wayne M. Meyers, MD.
Table 1. Pros and Cons of Sampling Techniques From the WHO[18]
Method Pros Cons
Direct smear examination• Easy to perform at local level



• Does not require expensive materials and equipment



• Rapid results



• Uses swabs, fine-needle aspiration, and biopsy samples



• Low sensitivity (< 60%)



• Needs trained personnel



• Needs external quality assurance



Polymerase chain reaction• Results fairly rapid



• Uses swabs, fine-needle aspiration, and biopsy samples



• High sensitivity (>95%)



• Requires a sophisticated laboratory



• Expensive to perform



• Needs trained personnel



• Requires strict quality control



Culture of M ulcerans• Uses swabs, fine-needle aspiration, and biopsy samples• Requires a sophisticated



laboratory



• Needs trained personnel



• Results take >8 weeks



• Low sensitivity (20-60%)



• Not useful for immediate patient management



Histopathology• Sensitivity is about 90%



• Results fairly rapid (if services are available)



• Useful in establishing differential diagnosis and monitoring unexpected response to treatment



• Requires a sophisticated laboratory



• Expensive to perform



• Needs trained personnel



• Requires invasive procedure (ie, biopsy)



Table 2. Categories of Treatment[43]
CategoryForm of DiseaseTreatmentPrimary AimSecondary Aimlevel of Health Care SystemDiagnosis
ISmall early lesion (eg, nodules, papules, plaques, ulcers < 5 cm in diameter)Complete antibiotics



If at or near a joint, maintain same movement as on unaffected side



If surgery is needed in noncritical areas, consider this after 8 weeks of antibiotic treatment



Cure without surgery



Cure without movement limitations



Reduce or prevent recurrenceCommunity health centers and district hospitalsStrong clinical diagnosis (with or without laboratory confirmation)
IINonulcerative and ulcerative plaque and edematous forms



Single large ulcerative lesion 5-15 cm in diameter



Complete antibiotics, before surgery (if possible)



If at or near a joint, maintain same movement as on unaffected side



Cure without surgery



Reduce extent of the surgical debridement when needed



Cure without movement limitations



Reduce or prevent recurrenceHealth centers, district and tertiary hospitalsStrong clinical diagnosis (with or without laboratory confirmation)
IIILesions in the head and neck region, particularly the face



Disseminated/mixed forms (eg, osteitis, osteomyelitis, joint involvement)



Multiple lesions and



osteomyelitis



Extensive lesion >15 cm



Complete antibiotics, before surgery (if possible)



If at or near a joint, maintain same movement as on unaffected side



Cure without surgery



Cure without movement limitations



Reduce or prevent recurrenceDistrict and tertiary hospitalsStrong clinical diagnosis (with or without laboratory confirmation)
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