ARTICLE ,:-/
Buruli ulcer in Malawi - a first report OO Komolafe Abstract One hundred aild sixty-one specimens swabbed from as many patients with chronic wounds/ulcers oyer a period of eight months yielded 3 acid-alcohol fast bacilli (AFB) organisms that stowly grew only at 320C on LowensteinJensen(LJ) medium producing creamy-yellow colonies between 39 and 45 days post-incubation. Mycobacterial organisms harvested from culture were strongly positive when subjected,to both catalase spot test and catalase heat stability test indicating the presence of Mycobacterium ulcerans,the aetiologicalagent ofBuruli ulcer. Introduction Mycobacteritunuk:erur,sint-ectionotherwisecalled BuruIi Lrlccr is the Ihird most comnron nrycobacterial inl'cctiorr rrl' hurnansa1'lcltubclcukrsis lncl lcplosyl. Thc imnrunoconrpctcnt i rrespecli vc ol' irgc. di seaseal-fectsothelwi sc hcaltlryi ndiv iclLrals
weekly for l2 weeks. Criteria for positive mycobacterialgrowth have been previously described by the Centre for Disease ControlT. Coloni'es of mycobacterial organisms harvested from 'spot'test and test for culture were subjectedto both catalase heat-stablecatalaseas previouslydescribed6.Briefly,2 dropsof freshly prepared Tween-peroxide solution were dropped on harvestedcoloniesof the test olganismsplacedon a microscope slide and the reactionwtrs observedfbr evolutionof bubblesfor a f-ewseconds. For the heat-stable catalase test, colonies of the mycobacterialgrowth were emulsified with M/15 phosphate buffer/PH 7.0 in a small test tube. The tube was immediately incubatedin a waterbathat 680Cfor 20 minutesand aftercooling at room temperature,0.-5nl of freshly preparedTween-peroxide was added.Tlre reactionwas obselvedfor bubblesand discarded alier about25 nrins. Resulls ns analysedwercAFB positive Thrcc ol' lhe l6 | (1.9q(,)specilne cither singly ol in witlr nrycobitclclialotgitnistnsoccttl't'itrg
and clurnps.All 3 slteirrrcrlsglcw orrlyat 320(lon LJ nreclirrtn scx and racelattdhas lapidly olelgctl as urr irnporlurrl causcol' 45 days r. Brrluli ulccr llrs l'rccrr evitlcrrccol'gtowtlr wus l'irslobservctlhctwcctt39 altd hunran rnorbitlityaround lhc rvor'ltl c olottiesp r l t l t l c i t r g c r c l t t n y y c l k r w i r t c t t h u l i og r rr i r t l t t t l l y r c p o r l c t l a n t l c o r t l ' i r t n e ri ln l l t c A t t t c r i c r r s( I i r l i v i l , l i l c r r c l r ; x r s t gl'cwltrxtrl'iantly al ttscditscottll'ttls trrlx'n'ttltt,tl,r' lllt'r'riltrrclt't'itutt ( i u y l n a ,M c x i c o .P c r u S , u r . i r t r r r rA c )s:i u( ( ' h i r r l .l r r t l i l .S l i - l ' . l n k r r . lcsl and Ilttwc-vct'. bollr thc .l70('with lrlccs oi'growlh al.32()('. I n d o n e s i uM , i r l i r y s i i rS, t u r a l t ' u ) i:r t t d i t t l l t e W c s t c n rI ' l r c i l i c c o r r l l i rol t ' g i t n i u t tl si r i l e t l o g t r r wr t l l 5 r ' ( ' i r t r t rl r c i t h c l ' t l itchl c t e s t (Arrsllrrlia K.l r i h a l i .l ) i t 1 ' t tNt ict r v( i r r i n c t r )l.k r w ' c v c rt .r u r sdl i s c i r s c pcliod. olglrrisrnsgrow al 371)('cvorllicr tr l2-wcek ittctthittion o c c u l si r r r r r l u lc c l l r l o l i u lA l l ' i c r w h c l c r r r r r l l i p lecr r t l c r r r il ci r c i 'l'hc.s1lol lapid cvolttlion of sltowcd a lirl citlitlitsc tcsl 'iulrcr(x)n. l r i r v c h e o r r c ; x r r l c t ll l r r r r l l c r r i r r .I h r l k i r r i rl i i r s o .( solutiotrlo ll.tc ol'ltklingTVcett-1'lct'oxide wi[hirrsceorttls ( ' t l r g r r . ( ' o t c r l i l v o r ., c' 1 , a i r t{'r r o w l ) R ( ' t . l i t ; r r i r l i r r l ( i r r i r r t ' u , lruhhlcs lirllowingthe witsobsct'vctl orgunisrrrs iutdit sirtrilll t-citctiott tcsl ( i u l x r r r(.l l r i u r i r(.i t t i r r c i rl . i h c l i i r N . i g c r i r rS, i e l l i tl . c o r r c . ' l i r g o , 'l'lrc r c s t t l t so l ' l h i s s l u c l y a r c l c s l l i r r ' l r c i r ls l u b l c c i t l a l i t s c . U u l r r r r li r rt t t S l L t r l i t t tA l . t t i t t t l c xc r t s ci r t v o l v i t t rgt ( r y c r uo l t l c l r i k l l c p r c s c r r l c rilr r l l r c l l r h l t ' . A l l . 1 A F B - p o s i t i v e t t l c c r s l t a c l i r r A r r g o l : rh l r s i r l s o l r c o r l c l t o r l c r l 5 . ' l ' i tl l i r l c .l l r t : r t ' i s r r o r r r t l c l r r r i r r c t le t l g c s w i t i r g r r o t r o t r t t c c dy c l l o w i s hu ' h i t c . t l o c r r r l c r r l ct 'rr.'li t l c t t cot lr l l u l t r I it t l e c ti t t M l l l w i . c ' o l l o n w o ol il k c r r c c l o l i ch c ( l( [ i i g t i t ' ( ' ) I r r t l r i , sc o t t u t t r r t i c l i l i , rttl tr.e r t l e r r t i l i r ' r t l ioolt tl l t t c c c l t s t so l A / . r r l t ' l r t t t t i, rt r l e c t i o rl irr l k r u ' i r rrgt l u c t c t ' i o l o g i c si rcl r c c r r i r rogl l ( r l chrorricrvourrrls/ulcct's irl tltc Quce'rtliliz:rhcth('crrtritllkrspitirl ( Q l j ( l t l ) , l l r c l a r g c srtc l ' c r r i rl rl o s p i t ai rl r M l l u w i . i s l c p o l l c t l . iVlethrxls Wounds ol' rnorc tlran zl wccks durali()n wcrc swirbl.rctlll'orrr outpatiortsprcscntirrg wountlslir tlrcssingll lhc QECtl lrril thc to thc Miclobiology spccinrerrswcrc tlrclcal'tct'tlansl'ct't'cd collcction,all plcscrrting laboratory.Huwcvcr,priorto sl.tccintcn thc ulcerswereclosclycxanrincdwhilc inlirrrllliutt concct'ning patients age, village, occupation,source,dulation and the painfulnessor otherwiseof the wountlswerc obtuinet.l.Previous treatmentsappliedbeforeconsultirrgthe hospitalwerealsonoted. specimens were subjected to Ziehl-Neelsen Figure. Three casesof Mycobacteriumulceraresinfection. (a) staining6and patie-ntswith AFB-positive.ulcerswere invited to Leiion from a 45-yearold woman involving the baseof all four fingers and half of the middle finger of the right hand. Note the the laboratory where fresh sampleswere taken and immediately unaffectedmedial nerve (arrow) of the middle finger. The ulcer .subculturedon Lowenstein-Jensen(LD medium with the had undergonea'surgical intervention prior to this study. (b and c) Buruli ulcer on the left leg of two other outpatients. Note the appropriatecontrols. All cultureswere incubatedwithin minutes cottonwool-like necrotic bed at the centre of the ulcers. ofinoculation at250C,32oC and 370Crespectivelyand observed All
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ARTICLE Discussiofi' With regardsto patient/ulcer demography(Table 1), ,11 ult'(ruts int'ectionor Buruli ulcerhas hitherto .t't'obuctt,r'iutrt therewere2 malesand I female,all adultsaged32,38and 45 n o t b e e n c l o c l u m e n t ei dn N I a l a wi a l t h o u g h c e r t a i n u l c e r yearsrespectively. They all agreedto haveusedlocalherbsfor p r c s e n t a t i ( )t1e1nsdt o s u p p o rtth e p r c ' s e n coef t h e d i s e a s ien t h e trertmentbefbrepresenting to the hospital.All the ulcerswere c o u n t r yl P r o f L i o r n b ai p e r s o n acl o n r r n u n i c a t i t tE n )x.c e p tf b r on the extrernitiesand none could rememberthe sourceof ; 1 1l1r n l y 'c a s er e p o r t e df i o r n A n g o l a ra c o u n t r yo n t h e s a n t e h i s i h e ru l c e r . l l t i t u d el r i t h N l a l a r i i .B u r u l iu l c e rh l s n o t b c e nl c p o r t e dl r o u r Presently, the epidemiology and modes of t l r eS o u t l A t I ' r i e ; . \rur rb l c - ! i ( ) n . transrriission of M. ulcerutisarenot entirelyknown but thereis I n t h e p r e s e nst t u d 1 ,t .h e i d e n t i t i c a t i oonf 3 p i r i n l e s s a s t r o n ge v i d e n c et h a t ,b e i n ga n e n v i r o n m e n t a o lr g a n i s mM , . u l c e l sl v i t hu n d e r n r i n ebdo a r d e rasn da p r o n o u r r c ende c r t l t ibc e d probablyentersthe body throughsmall breaksin the LrlLt'ntit.s c o u p l e dw i t h t h e i s o l a t i o no l n r y c o b a c t e r i ral lr g a n i s r ntsh a t skin fl'orrrcontaminatedsoil, water or ve-setation. This may t y p i c a l l yg r e ws l o w l y( 3 9 - - i -d5a y s )r t S r o c ] .a n dt h ei n a b i l i t yo f p a r t so f t h e e r p l a i nw h y n r o s ti n t ' e c t i oonc c u r so n t h ee x p o s e d s a n t et o s r o w a t e i t h e r3 7 0 C( l i k eM . t u b a r t ' u l o . soi .rsl .)5 i ) C( l i k e b o d y e s p e c i a l l yt h e e x t r e m i t i e sw i t h t h e l o w e r l i m b s m o r e tl'|. rrllrirruttt)are characteristics contpatiblewith M. ult'erurt.s. frequentlyintectedthanthe upperr.The only fenralepatientin B e i n g a s l o r v g r o w e r , t h e t e s t o r g a n i s n tc a n b e f u r t h e r this study,a vegetabletraderrnight have beenparticularlyat difl'erenciated lionr &/. trnrittutttwhich is l fast grower(5- l4 l i s k b y r i r t u eo l ' h e rv o e u t i o n . days) at 30of{'. It is also interestingto n()tethat one of the In conclusion,the prevalence of M. ulceran.g inf'ection patients.a 45-yearold woman(fig la) hada historyof surgical i n t h i ss t u d yw a s 1 . 8 6 7 (o3 l l 6 l ) w h i c hp r o b a b l yc o u l dh a v e intenentionas a treatmentpanacea tbr her ulcer,which is also beenhigherif all specimenshad beenculturedto detectAFB the treatmentof choicefbr Buruli ulcerl.l. srnear-negative otherwisepositive specimensor if the PCR Contrary to earlier reports that M. ulceruts is techniquehad beenused. On the other hand,QECH being a fastidiousand grows with difflculty in culture,8.e organism ret'erral hospital,too muchimportance shouldnot be attached to culturein this studywas achievedwith relativeeaseprobably the high prevalence of Buruli ulcerobservedin this studyas it becausepatientspresented to the laboratorytbr samplesto be does not representthe nationalaverage.On the basisof this collectedand thereafterthesesampleswererapidlyinoculated resulthowever,theremay be needto carry out a largersurvey onto culturemedia. By so doing,the useof transportmedium of M-t-cobacteriurn ulcerans inf'ection in Malawi so as to was excluded,specimenstoragewas avoidedand specimen determineits true prevalence and the possiblesocio-economic exposureperiod to deleteriousenvironmental conditionswas impacton the populace. drasticallyreduced,thusmaximallypreserving theintegrityand viabilityof the testorganismsunderstudy. Acknowledgements In the absenceof polymerasechain reaction(pCR) I vvish to gratefully acknowleclgethe assistance of Mrs techniqueadjudgedmostefficientin M. ulceransdetectiont0the Chagomelana(OPD II, QECH) in specimencollection and the catalasespot test and catalasehear-stabilirytest describedby technicalassistanceof N Chilewaniand M Ndileke,technicians Konemanet al6 were usedin this study. The positivereaction in the Microbiologylaboratory-,Collegeof Medicine. exhibited by the test organisms further eliminated M. tuberculosisandM. marinum (which are catalasenesativeat O O Komolat'e, Department of Microbiology, 680C)6as the casualagentsof the infections. College of Medicine, P/Bag360,Blantyre. lable. Patrent-ulcer demography Patient Sex
Age(yrs) Vocation
Village
Wound site
Right hand involving4 fingers Left leg
Female 45
Trading on vegetables
Thyolo
B
Male
JL
Ntcheu
C
Male
38
Retrenched civil servant Labourer
Nkhatabay
History of surgical
No
Yes
Unknown
>5 months
No
No
Leii leg Unknown (mediai side)
>4 months
No
No
Asiedu K. M\cobuLteriun ulL?ranr inieclion: Buruli Ulcer. Atr Hlth (2{XI))22, 3: l9- 2l 2. JobnsonPDR,StinearTP,HaymtnIA.Mttobatteriu,nulLzron*anini_revtew. J.Med. Microbi(t 1999; 48r 5ll-5ll 3.
HorsgurghCR Jr. Meles WM. Buruli ulcer In: HorsburghCR Jr, NelsonAM {eds) pathologyot Emerging Intecrions.Wtshing()n DC. ASM press 1997: ll9-126 4.
Asiedu K, ScherpbierR, RaviglioneM. Burull ulcer.WHO publicatx)n2(XX):pp 5-17 Bar W Ru*-h-CerdesR. Rilcher E. Diftmer C, Meyers W, Murquezde Bar, pasdortH, Sbsiek p, de Rijk PB' Poftaels F. Mvobucteriuu rlcsratrr inflctions in a chird tiom Angola: diagnosrs by direct
5.
detecrionand culture.Trop Med lnt He{lth l99t; 3: lttg-196 Koneman EW, Allen SD, Dowcll VR, JanduW M. SonrmersH M, Winn W C. Mycobacreria. tn: colour Atlas und rexrbook of DiagnosricMicrobiology. 3rd ed. J B Lippincorrcomprny, phihdcrphia
\
Pain (Yes/No)
> 7 months
L
Malawi Medical Joumal
Duration
Unknown
Relerences
6.
Source of wound
( l9ttlt) pp 532-572 7.
Kcnl BD, Kubicil CP
Public HealrhMycoblderiology. A guide fi). the level III laborarory.Atlanra
Deprftlnent for Diseas Control, l9ti5 ti. PettitJHS,MrrcheteNJ.ReesRJW.MIcobacteriunulteransinilction. Clinicalandbaclerioloqical study of d1etlrst cdsesrecognizedin South EastAsia.BrirJ Dermaktogy 1996;78: 187-197. 9. Po(aels R Agulrr J, FonreyneP A, Fissfte K, de Been houwer H, CuedenonA. SteunouC. Zinou C, Meyer WM, Dumonceu JM. Dtrect det{tion and identification \Jf M\-&)baLreiun ulcerar! in clinicai specimensby PCR dnd oligonucleoride- speciflccaprureplareshybridizarion.J clin Microbi(t 1997:35i 3420- 3422 10. Ross B C, Marino L. Oppedisanr) F, EdwardsR, Robins-BrowneR M, JohnsonpDR. Develooment of a PCR assty ti)r rupid diagnosisol Mytobactcriunt r/czrarJ jnfretion. J Clin. Microbiol 1997: 35: 1696-I 7()()
38
Buruli ulcer in Malawi - a first report OO Komolafe Abstract One hundred aild sixty-one specimens swabbed from as many patients with chronic wounds/ulcers oyer a period of eight months yielded 3 acid-alcohol fast bacilli (AFB) organisms that stowly grew only at 320C on LowensteinJensen(LJ) medium producing creamy-yellow colonies between 39 and 45 days post-incubation. Mycobacterial organisms harvested from culture were strongly positive when subjected,to both catalase spot test and catalase heat stability test indicating the presence of Mycobacterium ulcerans,the aetiologicalagent ofBuruli ulcer. Introduction Mycobacteritunuk:erur,sint-ectionotherwisecalled BuruIi Lrlccr is the Ihird most comnron nrycobacterial inl'cctiorr rrl' hurnansa1'lcltubclcukrsis lncl lcplosyl. Thc imnrunoconrpctcnt i rrespecli vc ol' irgc. di seaseal-fectsothelwi sc hcaltlryi ndiv iclLrals
weekly for l2 weeks. Criteria for positive mycobacterialgrowth have been previously described by the Centre for Disease ControlT. Coloni'es of mycobacterial organisms harvested from 'spot'test and test for culture were subjectedto both catalase heat-stablecatalaseas previouslydescribed6.Briefly,2 dropsof freshly prepared Tween-peroxide solution were dropped on harvestedcoloniesof the test olganismsplacedon a microscope slide and the reactionwtrs observedfbr evolutionof bubblesfor a f-ewseconds. For the heat-stable catalase test, colonies of the mycobacterialgrowth were emulsified with M/15 phosphate buffer/PH 7.0 in a small test tube. The tube was immediately incubatedin a waterbathat 680Cfor 20 minutesand aftercooling at room temperature,0.-5nl of freshly preparedTween-peroxide was added.Tlre reactionwas obselvedfor bubblesand discarded alier about25 nrins. Resulls ns analysedwercAFB positive Thrcc ol' lhe l6 | (1.9q(,)specilne cither singly ol in witlr nrycobitclclialotgitnistnsoccttl't'itrg
and clurnps.All 3 slteirrrcrlsglcw orrlyat 320(lon LJ nreclirrtn scx and racelattdhas lapidly olelgctl as urr irnporlurrl causcol' 45 days r. Brrluli ulccr llrs l'rccrr evitlcrrccol'gtowtlr wus l'irslobservctlhctwcctt39 altd hunran rnorbitlityaround lhc rvor'ltl c olottiesp r l t l t l c i t r g c r c l t t n y y c l k r w i r t c t t h u l i og r rr i r t l t t t l l y r c p o r l c t l a n t l c o r t l ' i r t n e ri ln l l t c A t t t c r i c r r s( I i r l i v i l , l i l c r r c l r ; x r s t gl'cwltrxtrl'iantly al ttscditscottll'ttls trrlx'n'ttltt,tl,r' lllt'r'riltrrclt't'itutt ( i u y l n a ,M c x i c o .P c r u S , u r . i r t r r r rA c )s:i u( ( ' h i r r l .l r r t l i l .S l i - l ' . l n k r r . lcsl and Ilttwc-vct'. bollr thc .l70('with lrlccs oi'growlh al.32()('. I n d o n e s i uM , i r l i r y s i i rS, t u r a l t ' u ) i:r t t d i t t l l t e W c s t c n rI ' l r c i l i c c o r r l l i rol t ' g i t n i u t tl si r i l e t l o g t r r wr t l l 5 r ' ( ' i r t r t rl r c i t h c l ' t l itchl c t e s t (Arrsllrrlia K.l r i h a l i .l ) i t 1 ' t tNt ict r v( i r r i n c t r )l.k r w ' c v c rt .r u r sdl i s c i r s c pcliod. olglrrisrnsgrow al 371)('cvorllicr tr l2-wcek ittctthittion o c c u l si r r r r r l u lc c l l r l o l i u lA l l ' i c r w h c l c r r r r r l l i p lecr r t l c r r r il ci r c i 'l'hc.s1lol lapid cvolttlion of sltowcd a lirl citlitlitsc tcsl 'iulrcr(x)n. l r i r v c h e o r r c ; x r r l c t ll l r r r r l l c r r i r r .I h r l k i r r i rl i i r s o .( solutiotrlo ll.tc ol'ltklingTVcett-1'lct'oxide wi[hirrsceorttls ( ' t l r g r r . ( ' o t c r l i l v o r ., c' 1 , a i r t{'r r o w l ) R ( ' t . l i t ; r r i r l i r r l ( i r r i r r t ' u , lruhhlcs lirllowingthe witsobsct'vctl orgunisrrrs iutdit sirtrilll t-citctiott tcsl ( i u l x r r r(.l l r i u r i r(.i t t i r r c i rl . i h c l i i r N . i g c r i r rS, i e l l i tl . c o r r c . ' l i r g o , 'l'lrc r c s t t l t so l ' l h i s s l u c l y a r c l c s l l i r r ' l r c i r ls l u b l c c i t l a l i t s c . U u l r r r r li r rt t t S l L t r l i t t tA l . t t i t t t l c xc r t s ci r t v o l v i t t rgt ( r y c r uo l t l c l r i k l l c p r c s c r r l c rilr r l l r c l l r h l t ' . A l l . 1 A F B - p o s i t i v e t t l c c r s l t a c l i r r A r r g o l : rh l r s i r l s o l r c o r l c l t o r l c r l 5 . ' l ' i tl l i r l c .l l r t : r t ' i s r r o r r r t l c l r r r i r r c t le t l g c s w i t i r g r r o t r o t r t t c c dy c l l o w i s hu ' h i t c . t l o c r r r l c r r l ct 'rr.'li t l c t t cot lr l l u l t r I it t l e c ti t t M l l l w i . c ' o l l o n w o ol il k c r r c c l o l i ch c ( l( [ i i g t i t ' ( ' ) I r r t l r i , sc o t t u t t r r t i c l i l i , rttl tr.e r t l e r r t i l i r ' r t l ioolt tl l t t c c c l t s t so l A / . r r l t ' l r t t t t i, rt r l e c t i o rl irr l k r u ' i r rrgt l u c t c t ' i o l o g i c si rcl r c c r r i r rogl l ( r l chrorricrvourrrls/ulcct's irl tltc Quce'rtliliz:rhcth('crrtritllkrspitirl ( Q l j ( l t l ) , l l r c l a r g c srtc l ' c r r i rl rl o s p i t ai rl r M l l u w i . i s l c p o l l c t l . iVlethrxls Wounds ol' rnorc tlran zl wccks durali()n wcrc swirbl.rctlll'orrr outpatiortsprcscntirrg wountlslir tlrcssingll lhc QECtl lrril thc to thc Miclobiology spccinrerrswcrc tlrclcal'tct'tlansl'ct't'cd collcction,all plcscrrting laboratory.Huwcvcr,priorto sl.tccintcn thc ulcerswereclosclycxanrincdwhilc inlirrrllliutt concct'ning patients age, village, occupation,source,dulation and the painfulnessor otherwiseof the wountlswerc obtuinet.l.Previous treatmentsappliedbeforeconsultirrgthe hospitalwerealsonoted. specimens were subjected to Ziehl-Neelsen Figure. Three casesof Mycobacteriumulceraresinfection. (a) staining6and patie-ntswith AFB-positive.ulcerswere invited to Leiion from a 45-yearold woman involving the baseof all four fingers and half of the middle finger of the right hand. Note the the laboratory where fresh sampleswere taken and immediately unaffectedmedial nerve (arrow) of the middle finger. The ulcer .subculturedon Lowenstein-Jensen(LD medium with the had undergonea'surgical intervention prior to this study. (b and c) Buruli ulcer on the left leg of two other outpatients. Note the appropriatecontrols. All cultureswere incubatedwithin minutes cottonwool-like necrotic bed at the centre of the ulcers. ofinoculation at250C,32oC and 370Crespectivelyand observed All
11
Malawi Medical Joumal
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ARTICLE Discussiofi' With regardsto patient/ulcer demography(Table 1), ,11 ult'(ruts int'ectionor Buruli ulcerhas hitherto .t't'obuctt,r'iutrt therewere2 malesand I female,all adultsaged32,38and 45 n o t b e e n c l o c l u m e n t ei dn N I a l a wi a l t h o u g h c e r t a i n u l c e r yearsrespectively. They all agreedto haveusedlocalherbsfor p r c s e n t a t i ( )t1e1nsdt o s u p p o rtth e p r c ' s e n coef t h e d i s e a s ien t h e trertmentbefbrepresenting to the hospital.All the ulcerswere c o u n t r yl P r o f L i o r n b ai p e r s o n acl o n r r n u n i c a t i t tE n )x.c e p tf b r on the extrernitiesand none could rememberthe sourceof ; 1 1l1r n l y 'c a s er e p o r t e df i o r n A n g o l a ra c o u n t r yo n t h e s a n t e h i s i h e ru l c e r . l l t i t u d el r i t h N l a l a r i i .B u r u l iu l c e rh l s n o t b c e nl c p o r t e dl r o u r Presently, the epidemiology and modes of t l r eS o u t l A t I ' r i e ; . \rur rb l c - ! i ( ) n . transrriission of M. ulcerutisarenot entirelyknown but thereis I n t h e p r e s e nst t u d 1 ,t .h e i d e n t i t i c a t i oonf 3 p i r i n l e s s a s t r o n ge v i d e n c et h a t ,b e i n ga n e n v i r o n m e n t a o lr g a n i s mM , . u l c e l sl v i t hu n d e r n r i n ebdo a r d e rasn da p r o n o u r r c ende c r t l t ibc e d probablyentersthe body throughsmall breaksin the LrlLt'ntit.s c o u p l e dw i t h t h e i s o l a t i o no l n r y c o b a c t e r i ral lr g a n i s r ntsh a t skin fl'orrrcontaminatedsoil, water or ve-setation. This may t y p i c a l l yg r e ws l o w l y( 3 9 - - i -d5a y s )r t S r o c ] .a n dt h ei n a b i l i t yo f p a r t so f t h e e r p l a i nw h y n r o s ti n t ' e c t i oonc c u r so n t h ee x p o s e d s a n t et o s r o w a t e i t h e r3 7 0 C( l i k eM . t u b a r t ' u l o . soi .rsl .)5 i ) C( l i k e b o d y e s p e c i a l l yt h e e x t r e m i t i e sw i t h t h e l o w e r l i m b s m o r e tl'|. rrllrirruttt)are characteristics contpatiblewith M. ult'erurt.s. frequentlyintectedthanthe upperr.The only fenralepatientin B e i n g a s l o r v g r o w e r , t h e t e s t o r g a n i s n tc a n b e f u r t h e r this study,a vegetabletraderrnight have beenparticularlyat difl'erenciated lionr &/. trnrittutttwhich is l fast grower(5- l4 l i s k b y r i r t u eo l ' h e rv o e u t i o n . days) at 30of{'. It is also interestingto n()tethat one of the In conclusion,the prevalence of M. ulceran.g inf'ection patients.a 45-yearold woman(fig la) hada historyof surgical i n t h i ss t u d yw a s 1 . 8 6 7 (o3 l l 6 l ) w h i c hp r o b a b l yc o u l dh a v e intenentionas a treatmentpanacea tbr her ulcer,which is also beenhigherif all specimenshad beenculturedto detectAFB the treatmentof choicefbr Buruli ulcerl.l. srnear-negative otherwisepositive specimensor if the PCR Contrary to earlier reports that M. ulceruts is techniquehad beenused. On the other hand,QECH being a fastidiousand grows with difflculty in culture,8.e organism ret'erral hospital,too muchimportance shouldnot be attached to culturein this studywas achievedwith relativeeaseprobably the high prevalence of Buruli ulcerobservedin this studyas it becausepatientspresented to the laboratorytbr samplesto be does not representthe nationalaverage.On the basisof this collectedand thereafterthesesampleswererapidlyinoculated resulthowever,theremay be needto carry out a largersurvey onto culturemedia. By so doing,the useof transportmedium of M-t-cobacteriurn ulcerans inf'ection in Malawi so as to was excluded,specimenstoragewas avoidedand specimen determineits true prevalence and the possiblesocio-economic exposureperiod to deleteriousenvironmental conditionswas impacton the populace. drasticallyreduced,thusmaximallypreserving theintegrityand viabilityof the testorganismsunderstudy. Acknowledgements In the absenceof polymerasechain reaction(pCR) I vvish to gratefully acknowleclgethe assistance of Mrs techniqueadjudgedmostefficientin M. ulceransdetectiont0the Chagomelana(OPD II, QECH) in specimencollection and the catalasespot test and catalasehear-stabilirytest describedby technicalassistanceof N Chilewaniand M Ndileke,technicians Konemanet al6 were usedin this study. The positivereaction in the Microbiologylaboratory-,Collegeof Medicine. exhibited by the test organisms further eliminated M. tuberculosisandM. marinum (which are catalasenesativeat O O Komolat'e, Department of Microbiology, 680C)6as the casualagentsof the infections. College of Medicine, P/Bag360,Blantyre. lable. Patrent-ulcer demography Patient Sex
Age(yrs) Vocation
Village
Wound site
Right hand involving4 fingers Left leg
Female 45
Trading on vegetables
Thyolo
B
Male
JL
Ntcheu
C
Male
38
Retrenched civil servant Labourer
Nkhatabay
History of surgical
No
Yes
Unknown
>5 months
No
No
Leii leg Unknown (mediai side)
>4 months
No
No
Asiedu K. M\cobuLteriun ulL?ranr inieclion: Buruli Ulcer. Atr Hlth (2{XI))22, 3: l9- 2l 2. JobnsonPDR,StinearTP,HaymtnIA.Mttobatteriu,nulLzron*anini_revtew. J.Med. Microbi(t 1999; 48r 5ll-5ll 3.
HorsgurghCR Jr. Meles WM. Buruli ulcer In: HorsburghCR Jr, NelsonAM {eds) pathologyot Emerging Intecrions.Wtshing()n DC. ASM press 1997: ll9-126 4.
Asiedu K, ScherpbierR, RaviglioneM. Burull ulcer.WHO publicatx)n2(XX):pp 5-17 Bar W Ru*-h-CerdesR. Rilcher E. Diftmer C, Meyers W, Murquezde Bar, pasdortH, Sbsiek p, de Rijk PB' Poftaels F. Mvobucteriuu rlcsratrr inflctions in a chird tiom Angola: diagnosrs by direct
5.
detecrionand culture.Trop Med lnt He{lth l99t; 3: lttg-196 Koneman EW, Allen SD, Dowcll VR, JanduW M. SonrmersH M, Winn W C. Mycobacreria. tn: colour Atlas und rexrbook of DiagnosricMicrobiology. 3rd ed. J B Lippincorrcomprny, phihdcrphia
\
Pain (Yes/No)
> 7 months
L
Malawi Medical Joumal
Duration
Unknown
Relerences
6.
Source of wound
( l9ttlt) pp 532-572 7.
Kcnl BD, Kubicil CP
Public HealrhMycoblderiology. A guide fi). the level III laborarory.Atlanra
Deprftlnent for Diseas Control, l9ti5 ti. PettitJHS,MrrcheteNJ.ReesRJW.MIcobacteriunulteransinilction. Clinicalandbaclerioloqical study of d1etlrst cdsesrecognizedin South EastAsia.BrirJ Dermaktogy 1996;78: 187-197. 9. Po(aels R Agulrr J, FonreyneP A, Fissfte K, de Been houwer H, CuedenonA. SteunouC. Zinou C, Meyer WM, Dumonceu JM. Dtrect det{tion and identification \Jf M\-&)baLreiun ulcerar! in clinicai specimensby PCR dnd oligonucleoride- speciflccaprureplareshybridizarion.J clin Microbi(t 1997:35i 3420- 3422 10. Ross B C, Marino L. Oppedisanr) F, EdwardsR, Robins-BrowneR M, JohnsonpDR. Develooment of a PCR assty ti)r rupid diagnosisol Mytobactcriunt r/czrarJ jnfretion. J Clin. Microbiol 1997: 35: 1696-I 7()()
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