Buruli ulcer; diagnostic; Ghana
Memórias do Instituto Oswaldo Cruz
Vol. 92(1), Jan./Feb. 1997
Buruli Ulcer in Ghana
Vol. 92(1): 31-32
Ernesto Montoro+, Virginia Capó, María E Rodríguez, Aroldo Ruíz,
Instituto de Medicina Tropical Pedro Kourí, Apdo 601, Marianao 13, La Habana, Cuba
Keys words: Buruli ulcer - diagnostic - Ghana
Buruli ulcer (BU) was first described in 1897 in the present territory of Uganda and Mycobacterium ulcerans was first reported to be the etiologic agent by Mac Callum in 1948, in Australia (P Mac Callum et al. 1948 J Pathol Bacteriol 60 : 93-122). So far has been described in several tropical and subtropical countries (WM Meyers et al. 1974 Am J Trop Med Hyg 23 : 919-923). The disease is defined as an ulcer with undermined borders, necrosis of the underlying subcutaneous tissue and a shiny hyperpigmented skin surrounding the ulcer (TS van der Werf et al. 1987 Trans R Soc Trop Med Hyg 83 : 410-413). Muelderk describes four clinical stages: nodule, necrotizing paniculitis, ulcer and scar (K Muelder et al. 1992 Int J Dermatol 1 : 25-26).
Although the disease was reported in Ghana in 1971 (AC Bayley 1971 Br Med J 2 : 401-402), the first case was diagnosed in 1969 according to Ghanian health care officials. Since then, the BU has extended to other regions of the country such as the Amansie West District where 90 cases were reported (GK Amofah et al. 1991 Trans R Soc Trop Med Hyg 87 : 644-645).
In December 1993, a multidisciplinary task force from the Tropical Medicine Institute "Pedro Kourí" (IPK) of Cuba, began a research project in the Amansie West District (Tontokrom), Ghana. This study was carried out in a sylvan area, where there's no health care unit; there is only a place called "dressing house", where personnel are trained for healing people. This was the first time that specialized medical care was offered in Tontokrom.
A total of 105 patients with BU were studied. The clinical description was established by categorizing the different clinical stages of the disease (Muelder et al. loc. cit .). Each patient was examined by a clinician and a dermatologist.
A questionnaire was completed for each patient collecting data regarding age, sex, living conditions, time elapsed since the appearance of the first symptoms, occupation and other questions of any clinic-epidemiologic interest (A Llop et al. 1994 Rev Cubana Med Trop 46 : 120-126).
Informed consent was obtained from 15 patients, who had an open ulcer or a suspicious lump. Blood samples were taken from each of these patients. Fine needle aspiration and skin biopsy samples for microbiologic and histologic studies were also done.
All the samples were sent to the Microbiologic Laboratory at IPK in Havana, Cuba, for isolation of M. ulcerans and to exclude the presence of any other microorganisms. Blood smears were examined for parasites and serum samples were tested for HIV by ELISA.
We were unable to isolate M. ulcerans from any of the specimens obtained, instead all of the cultures grew other organisms, 73.33% Enterobacteria ( Proteus, Enterobacter and Citrobacter ) and in 26.6% grew Pseudomonas spp. No fungal growth was observed.
Using the Zielh-Neelsen staining method a large number of acid-fast bacilli (AFB) was obtained from the swab of the ulcer of one patient. However, no mycobacterial growth was observed in Lowenstein-Jensen medium and Middlebrook 7H9 at 32oC for the 12 weeks. The reference strain ( M. ulcerans ATCC 19 423) from IPK collection was used as positive control. One patient was HIV-1 seropositive (6.66%). Plasmodium falciparum was found by Giemsa staining in five patients (33.33%).
The histologic findings of 14 (93%) samples corresponded to chronic skin ulcers. Epithelial hyperplasia at the ulcer edges, granulomatous tissue under the skin overlaps, and fibrosis of the subcutis under the ulcers bottoms were found in every sample. A diffuse chronic inflammatory infiltrate was observed at the bottom of the ulcers. Giant cells epithelioid granulomas were evident at the periphery of the ulcer in the samples of two different patients. Another patient had a large ulcer with a cotton-like tissue at the bottom of the ulcer on the right scapula area. Histologically, this tissue corresponded to necrotic adipous and fibrous tissue with clouds of AFB.
There are many factors contributing to the difficulties encountered upon culturing M. ulcerans . They are not easy to isolate due to their slow growth, sometimes as long as 12 weeks (PT Kent et al. 1985 Public Health Mycobacteriology: A guide for the Level III Laboratory . Atlanta, Center for Disease Control, PHS, USDHHS, 207 pp.). However we believe that the most likely cause was the long clinical evolution of the ulcers (from 4 months to 7 years). According to patient's information, the survey showed that all patients have received some local or systemic treatment, and they were not able to determine with precision which drug was used.
Another factor which might have been associated was the delay between samples' acquisition and processing (10 days), what could explain the fact that in the patient with the positive baciloscopy there was no growth of M. ulcerans. Our results are similar to previous studies, being unable to grow M. ulcerans from BU patients (BJ Marston et al. 1995 Am Soc Trop Med Hyg 52 : 219-223); instead, a large number of bacterial growth causing secondary infections was found (Amofah et al. loc. cit .). In a study made by Van der Werf in West Africa, M. ulcerans was isolated in 5 of 26 biopsies of BU patients, probably due to the short evolution of the disease (TS van der Werf et al. 1990 Lancet 8 : 1440).
In relation to the finding of HIV-1 and P. falciparum, they are the most frequent pathogenic agents in this region, although there is few information about the relationship between BU and these agents, three co-infected patients with BU and HIV infection were reported in Zaire (S Allen 1992 Int J Dermatol 31 : 744-745).
BU has become a major health problem; not only for Ghana but also for West Africa. So it is necessary to implement urgent effective therapeutical measures and to perform investigations to identify environmental reservoirs of M. ulcerans . It is also important to state the predisposition factors for acquiring this disease and to avoid sequelae that threats the current and future economy of the affected, the family and the community.
ACKNOWLEDGEMENTS : to Drs GK Amofah and EH Frimpon, Ministry of Public Health of Ghana, Agroyesum Hospital, University Hospital of Kumasi and Tata OMA (GPA) for their collaboration.
+Corresponding author. Fax: +53-7-33.6051
Received 12 April 1996
Accepted 29 September 1996
Publication in this collection
14 Oct 1998
Date of issue
12 Apr 1996
29 Sept 1996