Aust. N.Z. J. Med. (1975). 5, pp. 162-169
REVIEW
Mycobacterium Ulcerans in Australia Anthony J. Radford” From the Department of Tropical Community Health, Liverpool School of Tropical Medicine, Liverpool, England
Summary: The epidemiology of 39 case reports of infection with Mycobacterium ulcerans published during the past 25 years in Australia is presented. A review is made of the laboratory findings of the strains found in Australia and of the contribution of Australian workers to the description, treatment and prevention of this disfiguring disease. Many diseases which are placed in the “tropical medicine” category, have in the past occurred or, indeed, still occur in endemic, epidemic or sporadic form in non-tropical areas. Lesions caused by Mycobacterium ulcerans are an example of such diseases. The first recognition of this disease as a clinical entity was made by two general practitioners, Alsop and Searls, from the area around Bairnsdale, a country town in southeastern Victoria at latitude 37”s (see map). They saw their first cases in the 1 9 3 0 ~ ’ ’ ~ and there is some evidence that it may also have occurred in Queensland at this time.3 The late Peter MacCallum, together with Jean Tolhurst, Glen Buckle and H. A. Sissons working in the laboratories of Melbourne University and the Alfred Hospital first described in detail the clinical and pathological aspects of the disease, together with the pathological features and experimental pathology of the organism.2 Ulcers were described in two patients in 1897 by Sir Albert Cook, the first European physician in Uganda, which ‘Senior Lecturer Correspondence: Dr. A. J. Radford. School of Medicine, Flinders University of South Australia South Australia 5042 Accepted for publication: 3 October, 1974
may have been the same disease4 and 81 cases were seen in Zaire (then the Belgian Congo) between 1942 and 1949.5 The disease occurs with highest incidence along parts of the River Nile in Uganda, from where two-thirds of the 1500 recorded reports have been made.4, Papua New Guinea has the third highest incidence.6 Cases have also been seen in Indonesia’, Malaysia*, Nigeria’ and Mexico.“ There have been several comprehensive reviews of the subject written Nomenclature
In the twenty-five years since the disease was first described it has been given more than a dozen eponyms. The propinquity of the early patients to Bairnsdale gave the disease its first cluster eponym, the “Bairnsdale ulcer”.’, 2, It is most commonly known as “Buruli ulcer” or “Buruli Disease” after the area of Uganda from where the greatest number of reports have been made.4. 3 2 9 3 5 It has also been called “Searls’ ulcer” after one of the two general practitioners who first reported cases.I6 It has
1975
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recently been suggested that all eponyms be discarded and the term Mvcobacteriun? ukerans, which was given to the organism by the early Australian workers in this field, be used to describe the disease.14, 5 2 Thus, in this paper the disease is described as “infections with Mycohacterium ulcerans”, by reference to the part of the body involved. Distribution
In Australia, the disease is most frequently reported from around Cairns in northern Queensland. Earlier it was most commonly reported from the Bairnsdale area of Victoria where the disease still occurs sporadically (see map). More than half the Australian case reports have been from Queensland where at least three small foci have o ~ c u r r e d .1~7 -. The Northern Territory had a small focus on Croker Island.21 Sporadic occurrences have also been reported
in Victoria, Northern Territory, Queensland and New South Wales. The history of the single patient from Sydney suggested that his infection may have been acquired in Papua New Guinea?’ Reservoir of Infection and Route oj Transmission “Clustering” of cases without evidence of direct contact spread was noted in the first report.2 Such clustering is typically related to rivers and lakes in most endemic areas, but this has not been a marked feature of Australian reports, indeed. three cases were reported from Croker Island, north of Darwin.” (These three cases, together with the single case from nearby Daru Island in the Western District of P a p ~ a appear ~ ~ , to be the only reports from small island situations). Understanding of the epidemiology of the disease remains incomplete. The usual route of transmission of the organism to man has not
TABLE Distribution of Australian reports by State, age and sex Number of cases reported
State
Comments
.
~
3 3 5 10
Victoria
2, 13, 26 16, 15, 45 10 70
__ -_ _ _
New South Wales
1
40
*
‘several” 1
Queensland
“8-1 0” 8 6
21 43. 4 53. 61 9, 15. 18. 57, 70 13. 6. 19. 35, 59, 66
__
Northern Territory TOTAL (incl.
4
12 from Victoria)
8 13. 16, 18 =
-__
References
I . MacCallum et al.. 1948’ 2. Fenner and Leach, 195236 3. Francis, 1957’’ 4. Alsop, 1972’
Had been in New Guinea periodically up to 5 months before ulcer appeared.
5. Forbes et al., 195422
“Around 6. Rockhampton”. 7. 4 clustered from one 8. area “just north of 9. Brisbane”. Cairns (2), LO. Nambour (3), Maryborough, Sarina “around Cairns”.
__ ___
_ ..
Several crossreferences occur in the Victorian reports. Total =- at least 12. Most at Bairnsdale but sporadic cases at Colac and Yallourn.
Cilento, 19423 Lane. 196419 Abrahams and Tonge, 196420 Abrahams, 1Y73I7 Glynn, 197218
3 from Croker Island. 11. Quinn and Crotty, 196321
at least 39, excluding “several around Rockhampton”.
*Data unavailable for several cases.
___ - __
164 ____._I___
-_
RADF OK11
been identified. Australians were aniong the first to speculate that inoculation of the organism might occur through an insect vector as distinct from direct trauma, and also that soil or vegetation might be the natural habitat of the organism. 21 One patient from Queensland claimed that her ulcer had appeared following a “pineapple prick”.” Much effort has been put into testing this hypothesis. Bassett and Cahi1124 failed to isolate any mycobacteria similar to M. ulcerans from the riverine environment of the most endemic area of Papua and workers in Africa have obtained numerous cultures of mycobacteria from the soil and g r a w s of endemic areas, a few of which have some characteristics similar to those of M . ulcerans.13,2 5 Citing the parallel distribution of certain grasses with the incidence of disease, they have postulated that such habitats may be the natural reservoir of the organism but the findings of Australian laboratory workers have suggested that N . ulceranr may not be a saprophyte (see below). Neither has an animal reservoir been discovered. Recently Buckle26postulated that insectivorous bats, which are common around Bairnsdale and over much of New Guinea, may be the principal reservoir of M . ulcerans and that the bed-bug (Cimex), which is shared by both bats and man, may be the principal vector. Such a hypothesis, however, fails to explain the very patchy distribution of the disease in areas where human settlement is widespread and the bats are ubiquitous. Herpetofauna have recently been proposed as a possible natural reservoir following the successful estabblishment of infection in several species.27 Direct transmission of disease has occurred between laboratory animals (see below) and there are two reports of its probable occurrence in man.”” Nevertheless, it does not seem to be the usual mode of transmission. On one occasion in Queensland, father and daughter presented simultaneously. l 7 The occurrence of the disease in more than one member of a family either simultaneously or, more commonly, at different times is reported in areas of high incidence in Africa and New Guinea. As the natural reservoir and route of transmission have not been identified, the incubation 3 3
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period for the disease has not been accurately delineated. Animal experiments report figures varying from one week to well over a year according to size of the inoculating dose and previous BCG experience.’. 29 Retrospective estimates relating the appearance of disease from the date of entry of patients into known endemic areas suggest that 6-12 weeks is the usual period but it may be as short as two weeks.23 Age, Sex and Race Characteristics The most common age incidence reported for infections with Mycobacteriwn ulcerans is in 5-8 year olds. In Australia, however. the mean age of 29 patients was 28 ’ 6 years (range: 1-70), with one third of patients being 40 years or older and only four being under the age of 10 years. Although presentation has been most common in the second decade of life, the mean age of occurrence is considerably higher than that reported from all other countries with the exception of a small series from I n d o n e ~ i a .In~ no other series is the age distribution so scattered. Figure 1 illustrates the distribution by age of cases in Australia compared with those of Papua New Guinea. The male : female ratio in Australia is 1 . 3 : 1 and this is comparable to that found elsewhere. Four cases (10%) are known to have occurred in Aborigines who comprise approximately 1% of the total Australian population and about 3% of the population of the Northern Territory and Queensland. Outside Australia only five cases have been documented in Caucasians,
? f l L.
Austmlion (29cOSe5) Popuon&NewGuineon ( 112 coses)
mi I - I
Figure 1
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four in Africa30 Guinea.6
165
MYCOBACTER1I;M ULCERANS
__
33.
and one in Papua New
Clinical Feature.\ The condition is first noticed as a blind “boil” or subcutaneous lump particularly on an exposed surface. This may itch, but is usually painless. A history of preceding trauma is occasionally given. After a variable period of weeks. the lump breaks down with the escape ofa gelatinous ooze revealing a shallow ulcer with a necrotic base. In some lesions the fluid is semi-purulent. Particularly in areas of extensive subcutaneous fat, such as the buttocks. considerable thickening and induration may occur prior to ulceration. The edges of such ulcers resemble and have the consistency of orange peel. The condition becomes indolent over a period of weeks or months. Ulcers tend to show five characteristics. They are painless. Asymmetrical undermining may extend many centimetres subcutaneously in any direction. The granulation tissue which develops is brownpink in colour. “blubbery” in nature and easily removed. Involvement of fatty tissue changes it from its normal moist, light yellow, vascular nature to a dry, avascular white substance similar to that of the fat of uncooked bacon rashers. The surrounding skin may become hyperpigmented. Satellite nodules and ulcers may develop. Lymph gland enlargement only occurs when secondary infection is superimposed, although the late Jean Tolhurst and colleagues found lymphadenitis in lesions induced in cattle in V i ~ t 0 r i a .Lesions j~ tend to be relatively painless unless secondary infection or extension below the deep fascia occurs or the lesion is of the oedematous type. Patients usually remain afebrile and without systemic upsets when secondary infection is absent. i.e. the lesions are “cold”. Distribution of Lesions Only in one case of this series did ulceration occur on the trunk and this was reported to follow trauma to the area.” Lesions have occurred on the left side twice as frequently as on the right, with the left leg being the site of predeliction (Fig. 2). It is interesting to
Figure 2
speculate whether the centrifugal distribution of lesions supports the hypothesis of direct inoculation of the organism at the most exposed sites or if it represents the sites where, due to lower temperature gradients, the organism can more easily establish itself, or both. Multiple lesions have been reported twice in Australia.’, 2 2 In Zaire they occur in u p to a quarter of cases.5 In some places 20% of lesions are reported to extend below the deep fascia.6 In this series it was only recorded three times and in only one of these was it breached prior to surgical interference. Elsewhere lesions have involved tendon, muscle, nerve tissue and bone. In Africa “metastatic” bone and joint lesions have been r e p ~ r t e d . ~ Local or distant osteomyelitis is characterised by marked osteolysis and the development of sequestra but no new bone formation. It is probable that in Australia patients tend to report earlier for treatment than in some other countries. Puthology The main features of acute lesions include necrosis, especially of fatty tissue, oedema, infiltration with lymphocytes, plasma cells and macrophages, and a variable increase in fibrous
166
RADFORD
tissue. Polymorphonuclear leucocytes are not present in large numbers except where pyogenic bacteria are also present. Acid-fast bacilli are characteristically clumped together in oval or round masses in avascular, necrotic areas and under the edges of ulcers. They may also be found in small groups or singly and may occasionally be seen inside macrophages. Occasional giant cells are sometimes reported but the characteristic caseating chronic inflammatory reaction of tuberculous lesions has not been seen except in experimentally induced lesions in cattle. 34 Calcium is occasionally deposited in fatty tissue. In early lesions a reactive phase characterised by epithelial and giant cell systems of the tuberculous type with minimal lesions and Sew acid-fast bacilli is reported from Africa.35 This type may normally regress spontaneously. Patients with such lesions give positive skin tests to material prepared from M . ulcerans colonies called “Burulin”. Spontaneous healing in one area of a lesion, or indeed a whole lesion, may occur and partial re-epithelialisation of undermined edges is not an uncommon feature. In other countries primary healing with extensive scarring, contraction and lymphoedema may occur in lesions of long standing. Bacteriology, Serology and Animal Experiments The initial description of the organism and its characteristics, in particular the hypothermic conditions (32-33°C) required for culture, and the macroscopic and microscopic pathology of the disease were originally described in Melbourne by MacCallum, Tolhurst, Buckle and Sissons.’ These workers also proposed the name Mycobacterium ulcerans for the organism.” Extensive serological, culture and sensitivity experiments were carried out by Fenner and Leach36, 3 8 , 39, 4 2 , 5 0 , 5 1, and Fisher3’ in the early 1950s. Using heat-killed bacteria and the direct complement fixation test, Fenner and Leach36by cross-absorption techniques showed that M . ulcerans was “antigenically distinct” from other mycobacteria tested and that it appeared to be more closely related to mammalian tubercule bacilli than to M . avium,
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M . ranae or M . phlei. “The highest titres were obtained with homologous or closely related strains but cross-reactions with quite dissimilar strains were often strong.” Fenner and Leach found that BCG absorbed all the antibody to M . ulcerans strains from sera produced against them. Of the other bacteria only M. ulcerans and bovine strains did this completely. They could find no evidence to confirm Fisher’s36 suggestion, based on haemolytic titres using sensitised cells, that M . ulcerans resembled M . phlei more closely than other st rains. Fisher found an antibody against cells sensitised with human tubercule bacilli in the sera of rabbits immunised against M. ulcerans. He also found a similar antibody in the sera of six leprosy patients but not in the sera of nonleprous controls. MacCallum et a/.’ had noted some cases, including one child, with no evidence of tuberculosis but who gave positive Mantoux reactions. The literature reveals no consistent response to tuberculin skin-testing in this disease. Conversion has occurred with experimental lesions in cattle in Victoria to both human and avian tuberculin and to a specific antigen named “ulceranin”. Fenner38 was not able to distinguish between four strains of M . ulceruns using a standardised skin-test in guinea pigs which had been sensitised by intraperitoneal injections with a standard dose of M . u1ceran.s antigen. The reactions of the strains were consistent and distinct from those of M . avium, M. ranae, M . phlei, M . paratuberculosis and BCG. The reactions to mammalian PPD in animals sensitised to M. ukerans were very strong, as they were to an homologous preparation. The next strongest reaction was to avian PPD. Using M . ulcerans as a challenge, the strongest reactions were in animals sensitised to homologous and paratuberculous bacilli. In culture using Dubos’ medium, M . ulcerans showed characteristics which supported a closer relationship to mammalian mycobacteria than to other species.39 Colony morphology was indistinguishable from virulent mammalian tubercule bacilli although the M. ulcerans generation time was longer, even at temperatures
APRIL
1975
MYCORACTERIlJM ULCERAM
below 37°C. M. ulcerans colonies in alkaline suspension bound strongly with neutral red unlike avirulent and non-pathogenic mycobacteria. This distinguished M . ulcerans from M . balnei and confirmed the Scandinavian belief that these were separate species although both grow best at low temperature^.^' Mycobacterium ulcerans is unusual amongst mycobacteria in that it gives consistently negative results to most of the biochemical tests used to differentiate this genus. M . ulcerans, unlike any other mycobacterid tested to date, has recently been found to degrade the aminoacid hydr~xyproline.~’ In the first published in vivo experiments, Tolhur: and Buckle’, produced lesions in rats, mice and rabbits and later in cattle.34 Lesions could not be produced in guinea pigs, fowls or lizards although lesions have been induced recently in a wide range of herpeto-fauna in the western hemi~phere.’~Subcutaneous injections produced only localised lesions whilst intraperitoneal and intracerebral inocula produced widespread and sometimes fatal disease. The incubation period following subcutaneous injection of infected material varied from 7-20 months. MacCallum et al.’, found that foot-pad lesions could be produced in mice within a few days with heavy inocula (several million organisms per millilitre) but Fenner 4 2 was able to induce lesions after 150 days with inocula of only 5 - 10 organisms. Inocula of live material did not always produce lesions and it was postulated that the site of inoculation may be important in producing disease. Forbes -et al.” produced only local lesions with subcutaneous injections; disseminated infections occurring with intraperitoneal inoculations. Fenner4’ also studied the behaviour of the organism in developing chick embryos and was able to produce lesions in the livers of chicks which were incubated at 33°C but not at 37°C. Bolliger, Forbes and Kirkland43 reported the first apparently natural spread of the disease from experimentally infected possums to their non-infected cage members with incubation periods of up to six months. Similar animal experiments to those of MacCallum and colleagues were repeated by Forbes et aL2’ who 293
167
also found that the small possum, the phalanger (Trichosurus vulpecula). was a good experimental model. Sensitivity was originally tested to four drugs. Four M. ulcerans strains were insensitive to thiosemicarbazone and also to isoniazid, except in concentrations of 10 pg/ml. Three strains were partly sensitive to para-aminosalicylic acid (PAS) at concentrations of 10pg/ml and one strain was completely insensitive at this strength.39 Forbes, Wannon and Kirkland2’. found in vitro sensitivity of their strain to “sulphetrone” and PAS. They believed that local applications of PAS may have assisted the healing process of their case. Quinn and Crotty2’, found the organism from one of their patients strongly sensitive to streptomycin and cycloserine but only weakly sensitive to isoniazid and PAS. All Australian strains tested have been found to be sensitive to streptomycin, as they have been elsewhere. All strains tested by Fenner and Leach were “very sensitive” to con.~~ this centrations of 1 p g / d in ~ i t r o Despite in vitro sensitivity. well established lesions do not respond readily to streptomycin therapy. One case is said to have “responded” to systemic s t r e p t ~ m y c i n and ~ ~ this drug has been efficient in preventing mice foot-pad lesions from developing if given simultaneously with the infecting inocula. It has also been effective in healing “early lesions” in animals.34 Six out of eight recently tested Australian strains were sensitive to cycloserine, four out of five to ethambutol, three out of six to ethionamide and one out of four to rifampicin. The only strain tested against diamino-diphenylsulphone (“dapsone”) was found to be sensitive.45 Treatment
If the condition is recognised early enough, excision of the initial nodule and primary closure can be effected. Radical excision of the ulcer, extending into normal tissue, followed by skin grafting was originally recommended by Maclure to Searls and Alsop, and has remained the principal line of therapy in this country and elsewhere.’’ 1 8 , 2 3 Chemotherapy alone has been disappointing.
168
RADFORD
A less radical surgical approach involving excision of only necrotic tissue and extensive curettage of all involved surfaces after laying the lesion open, combined with chemotherapy, has been described.6x4fiShattock was able to effect cure with curettage alone.7 If chemotherapy is used the most appropriate regime is streptomycin and dapsone, possibly combined with ethambutol and should be continued for at least two weeks after healing appears complete. Recent controlled trials in Africa have found both clofazimine and rifampicin i n e f f e ~ t i v e .4~8 ~ , Heliotherapy was used in one of the patients of the earliest series.2 Because of the unusual temperature requirements for culture, several Australian workers have advocated locally applied heat.16,’8’23The last two used a heat cradle as an adjunct to healing following surgery. Hyperthermia was first used in West Africa and Though this procedure has not been proven to be of definitive value it may have assisted healing in some cases.
NO.
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Addendum
An additional report was recently made of an infection in a 19 year old male from Brisbane. The organism was isolated by culture from an ulcer which developed following trauma to the wrist.53 References 1 2.
3 4. 5. 6
7. 8. 9.
10. 11
Fenner5’, 5 1 succeeded in making mice resistant to infections with M . ulcerans by immunising them with BCG. This resistance was complete against low dose inocula but less successful against higher doses. The data on the Australian cases does not allow an assessment of the number of cases who have received BCG immunisation prior to the development of lesions, though positive Mantoux reactions without any other evidence of tuberculosis were recorded on several occasions. In one case of these cases the patient was only two years old.’ On two occasions a definite negative skin reaction was noted. In an attempt to obtain cross-immunity, BCG immunisation was first carried out in an endemic area of Papua New Guinea in 19666 and in Uganda a year later.35 Some protection appears to have been afforded by this measure. Until more is known of the method of infection of this disease, no other preventive measure is available.
12
The helpful criticisms of Dr. G. Pringle and Dr. F. M. Shattock are acknowledged. My thanks are also due to
5,
Mr. J. Brady of the Audio-visual unit of the Liverpool School of Tropical Medicine who produced the map and figure, and to Miss C. Marsden for her secretarial assistance. I am grateful to Dr. E. W. Abrahams, Director of Tuberculosis Services. Queensland, for information regarding case reports from Queensland.
Prevention
Acknowledgements
VOL..
13. 14. 15. 16.
17. 18.
19. 20. 21.
22 23. 24. 25
26. 27.
28. 29.
30.
31. 32.
ALanp, D. G. (19721: The Baimsdale ulcer. Aust. N . Z . J SurR. 41. 317 MACCALL~.M. P.. TOLHCRST. J. C.. BCCKI-E.G and Sls\ol;s. H. A. (1948). A new mrcobacterial infection :n man. J. Poth. Bnct 60. 93. Cii.ENm. R (19421: Tropical Direores in Austrulosm. 2nd ed., Smith and Paterson, Brishane, 306. LUNZ,H. F., C O N ~ O D. R , H., WII.KS,N. E , BARNIEY. G. R . KAMUNVI, F, CLANcFu. J . K. and BE^, I. D. A (1965). Buruli (mycobacteriall ulceration Ln Uganda, E . Afr. rned. J. 12, (61, 275 JA X S S ~ NP. S . G.. Q L ~ R T I ~ K J X MT . .1.. S I E N I A W ~JK. Iand . GATTI,F. (1959) Necrotic tropical ulcers and mycobacterial causative agent\. Trop. jirogr. Med. 11,293 R 4 l ) f . o ~ A. ~ . J. (19740): Mvcnbucterrum uirrruns in Papua New Guinea. Pnpuo N Guinen mrd. J 17, (2). 145 SHATTOCK. F M. (1965): Mgcohacterial skin ulceration, E A,fr. mrd .I. 42, 548 PFTTIT,J H S.. MARrHETTF. N. J. and RhhS, R. J. W. (1966) M ~ c o hocterium uicrruns infection. Clinical and bactcriological study of thc first cases recognised in South-East Asia, Brit. J. Derm. 78, 187. GRAY.H. H., KINGMA,S. and KOK. S. H. (19671 Mycobacterial skin ulcers in Nigeria, Truns. m y . Soc. frop.. Med. H y g . 61. (3,712. LAVALLEAGUKAU. P.. MAR0UEZ-lTLRRlRARRIA. F. and MIIIDI.ERROOK. G (1953): Un case de infection humana por A4ycohocter~umulcerans en el hemisferio occidental, nora previa. Inr. J. Lepprorv 21, 469. RADFOUD. A J (1974h): Mycohnrterium ulreranr A review I . Epidemiology. P u p a N Glrrneu med J. 17, (2), 129. RAIIFORI), A J (1974~):Myrohncterium ulctmns. I 1 Clinical features. histopathologg. treatment and prevention. Papua N Gurneu med J 17, (2). 133. BARKER.D. J . P. (1973): Epidemiology of M.vcoburteriwn dreruns infection, Trans. roy. [email protected]. Med. Hpg. 67, (I). 43. JANTSENS. P. G. (1972): Skin ulcers caused by acid-fast bacilli, In Essuys on Tropical Dermutology, ed. J. Marshall, Excerpta Medica Monograph, Amsterdam, 264. EDITORIAL (1972): The Baimsdale ulcer, Med. J . Aust. 2, 858. F R A X YJ.~ ,K.(1957): Scarl‘s ulcer: Report of further ca5e of indolent cutaneom ulceration due to infection with Mycobocrerium ulcerun,. Alfred Horpitol Clin. Rep. (Melbourne) 1, 87. ABRAHAMS, E. W. (1973): Personal communication. G L Y ~ NP., 1. (19721: The use of surgery and local temperature elevafion In Mycohucrerium ulcerans infection. Aust. N Z.J Surp. 41, 312. LANE. D. (1964): Mycobacteriol ulcerans infections in Queensland. Med. J . Ausf. 1 , 124. ABRAHAYS, E. W. and TOUGE, J . 1. (1964): Mqcohncrerium ulcerunr in Queensland, .Wed. J . Aust. 1, 334. Q U I N NJ., V. and CROTTY, J M. (1963). Mycohucrerium u l c ~ r a ninfection ~ in the Northern Territory. Med. J. Aust. 2, 317. FORBES, B. R. V., WANSON.I. S. and KIRKLAND, W B. (1954): Indolent cutaneous ulceration due to infectton with Mrcohucterrum u/cerun.s. Med. J Aust. 1, 475. &ID, 1. S (1967). Mpcobacterium ulcerans infection: A report of 13 cases at the Port Moresby General Hospital, Papua, Med J . Aust. I, 472 BASSETT,H. and CAH~LL, M. (1966): Personal communication. BARKER, D. J. P.. CLANCEY, I. K., MORROW,R. H. and RAO. S . (1970): Transmission of Buruh disease. Brrr. med. J . 2, 558. BUCKLE,G. (1972): Nates on Mycobarlerium ulcerunr, Aidst. N Z . J . Surg. 41, 320. MARTUS.L. C., STOTTMEIER, K. D. and MORROW, R. H. (1973). Experimental infection of herpetofauna with Mycohocterrwn ulceruns. Paper presented to Conference on Mycobonerium ulceruns. Middlesex Hospital London, July 5-6th. F c n ~ t J, . (1973): Personal communication. FENNER,F. (1950): The significance of incubation period in infectious diseases, Med. J Aust. 2, 813. VAN OYE E. and BALLION, M. (1950): Faudra-t-il tenir compte d‘une nouveile affection bacilles acido-resistants en Afrique? (Note preliminaire). (Is there any new disease due to acid-fast bacilli in Africa? Preliminam. note). . Ann. So?. belae. Med. rrop. 30, 619. JANSSENS. P. G.,PATTUN,S. R., BovEROurLE, M. T H , QCERTINMOST. J. and DF MCYSCK,A. (1963): Un ulcire necrotique tropical nriginaire du Bas-Katanga, Ann. SOC.belge. Wed. trap. 5, 129 FARBER.E. R. and TSANG,A. (1967): Mycobacterial (“Buruli”) ulcer in Peace Corps worker, Arch Surg. 95, 297. 2 %
APRlL 33 34
35. 36 37.
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41
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ULLMANX. U (1973) Mycobacrerrum ulceram in B European Paper presented to Conference on .Mycohacteriem ulceram Middlesex Hospital, London, July 5 -6th. TOLHURIT, J C., BCCKIF,G. and W E L L l N t i r i l N , N. A. M. (1959) The experimental infection of calves with M . ulceruns. J. Hyg. (Lund.1 67, 47. UGWIIABLRULI GROCP (1969): BCG vaccination against Mycohocrrrium uleerans infection (Buruli ulcer), Lancet 1. 111. Fchhfn, F. and L t a m . R. H. (19521: Studies on Mvvcohacrerlum ulceranb. 1. Serological relationship usith other mycobacteria. Aurr. J. exp. Biol. med. Sci. 30, 1. FISHER,S. (1951)’ Antigenic relationships of erythrocyte absorbable reactions of some mycobacteria. Ausl. J . rxp. R i d med S i i 29, I FESNER. F (1952) Studies on Mvcohocrerrum ulceram 11. Cross reactivity in guinea pigs sensitized with Mi.cohotrrrium ulreronr, Ausr J F X ~ Bid . med. Sci. 30, 11. LLACH.R H. and FENSER.F. (1954). Studies on M ulcvrani and :+I. bolner. 111. Growth in the semi-synthetic culture media of Dubos and drug sensitivity in wfro and in vivo. Ausr. J . e.xp. B i d med. Sci. 32, 835 LINNIIS.F and N O R D ~ A ~ .N(1952): , A new rype of pathogenic mycobacterium. N o d Med 47, 681 GRAXGI.J. M. (1973). A possible key test for hfycubacierium ulcerans based o n an amino-acid utilisation test Paper presented to Conference on Mycohucrerium ulcerans. Middlesex Hospital. London. July 5-6th FEXNER, F. (1956): The pathogenic behaviour of Mqcohaclerrum ulccrans, and Mycoboelrrium halnei in the mouse and the developing chick embryo. Amer. Rev. Tuberc. 73, 650 BOI.I.IGER.A,. FORBES. 8. R V and KIRKIAND. W B. (1950): Transnimion oia recently isolated mycobacterium t o phalangers (Trrchosurw vulprculu), Ausr. J . Sci. 12, (4). 146
-~
44.
45.
46. 47.
48.
49. 50. 51
52.
53
P E X N I N ~A~ TH.O11957) ~ . in Feldman and Karlson 11957) iU>mbactrriurn ulcerans infections Response to chcmotherapy In mice. Amrr. Reu. Tubrrc 75. 266. FFLOMAX, W. H and KARLSO%. A G (1957). Myrobocrer!wn ulcerans infections. Response lo chemotherapy in mice. A m u R r t . Tuherc 75. 266 Li 3s. H F and RFES, R J . W (19b41 ‘Treatment of Mycohacterial skin ulcers in Cganda with a riminophenazine derivative (8663). Lrincri 1.247 REVILL, W. D. L (1967): Treatment of Mjeohocrerum ulcerom infection. Paper presented to Conference on Mgcohorrermm ulcerons, Middlesex Hospital. London, July 5-6th. , R ~ ~ I LW. L .D. L., PIKE.M. C , MORKOW,R H. and A T ~ ~ J.G (19731 A controlled trial of trealment of ,Mycohacrerium ulcerons infection with Clofazimine, Lancer 2, 873. M ~ L ~ N EF. Y .and JOHNSON. B. A. (1950): Supplemcntdr). repolt of a ca.% of chronic ulceration of the foot due to a new pathogenic mycohelxe. Med. rrop. 30, :499. bacterium (MacCalluml, Ann. SOC. FFNNER.F. (1953): Two recently discovered mycobacter~awhich cause skin ulceration in man (M.ulcerans and M . habieii. VI. Internal. Cnngr. Microbiol., Rome. IV, 395 FIN~FR F.. (1957). Homologous and heterologous immunity in Infections of mice with Mycubacfrrium ulcerons and Wycohocterrum balm!, Amer. 1.Tuherc. 76, 79. RADFlinl>. A. J. (1973): The nomenclature of mycobacteriuni ulcerans infections, Trans. roy Soc. rrop Wed. Hyg. 67, ( 6 ) . 885. Ann Rep of the Health and Medical Services of the State of Queensland, 1973-74, p 79.
Aust N Z J Med (1975) 5, pp 169-170 __ _ _ I _ -
Comment CARCINOEMBRYONIC ANTIGEN (CEA): T E N YEARS‘ PERSPECTIVE
The case report by Professor Naim and his colleagues (December issue, page 531) reminds us again of the expectation that the immunology laboratory may yield diagnostic and therapeutic tools for the management of persons with cancer. The first such diagnostic test to become widely available has been the radioimmunoassay for carcinoembryonic antigen (GEA) in peripheral blood. CEA is a glycoprotein which was found in association with carcinoma of the colon as well as normal fetal gastrointestinal tissue ten years ago by Gold and Freedman’. While elevated levels of CEA in blood were first reported to be found exclusively in the blood of persons with carcinoma of the colon’, wider clinical testing showed that CEA was detectable in association with a variety of other cancers including stomach, pancreas, liver, breast and lungss. Several radioimmunoassays are now in use throughout the world for the detection of CEA in blood. The most widely available is that developed by Hansen6 which employs perchloric acid extraction of plasma to eliminate glycoproteins which crossreact with CEA, and zirconyl phosphate gel to precipitate the CEA-anti CEA complexes. The cut-off point for a “positive” test with this method, as well as with the Farr technique developed in Gold’s laborat o y 2 , is 2.5 ng/ml. The direct double antibody microradioimmunoassay developed at the Walter and Eliza Hall Institute is performed on whole serum without perchloric
acid extraction and gives a “positive” result at 5 ng/m13. The Todd assay which has been used extensively in clinical studies at the Chester Beatty Institute also is a direct assay, that is, perchloric acid extraction is not employed, and a “positive” result with this assay is 12.5 ng/ml or higher4. It is clear that the clinician should know the method which his laboratory employs as well as the arbitrary level chosen to designate an abnormal value. When CEA levels in serum or plasma are compared with the extent of spread of cancer, it is found that CEA elevation is infrequently detected when the cancer is at an early curable stage. A collaborative North American study’ which employed the Hansen technique for detection of CEA in persons with well documented carcinoma of colon showed “positive” tests in 18% of persons staged as Dukes A (localized to bowel wall) and 79% staged as Dukes C2 (widely metastatic). Similar results have been described by others ’. Persons with no clinically detectable cancer, but with inflammatory disease of the same organs in which CEAassociated cancers are found, may have elevated blood CEA levels. These diseases include ulcerative colitis’, pancreatitisg, hepatic cirrhosisg, chronic bronchitis and emphysema4, as well as chronic heavy smoking’“. It is apparent that interpretation by the physician of a positive test for CEA is made difficult for several reasons. Many of the non-cancerous diseases which are associated with an elevated level of CEA in blood are conditions which carry an associated increased risk to cancer, e.g. heavy
REVIEW
Mycobacterium Ulcerans in Australia Anthony J. Radford” From the Department of Tropical Community Health, Liverpool School of Tropical Medicine, Liverpool, England
Summary: The epidemiology of 39 case reports of infection with Mycobacterium ulcerans published during the past 25 years in Australia is presented. A review is made of the laboratory findings of the strains found in Australia and of the contribution of Australian workers to the description, treatment and prevention of this disfiguring disease. Many diseases which are placed in the “tropical medicine” category, have in the past occurred or, indeed, still occur in endemic, epidemic or sporadic form in non-tropical areas. Lesions caused by Mycobacterium ulcerans are an example of such diseases. The first recognition of this disease as a clinical entity was made by two general practitioners, Alsop and Searls, from the area around Bairnsdale, a country town in southeastern Victoria at latitude 37”s (see map). They saw their first cases in the 1 9 3 0 ~ ’ ’ ~ and there is some evidence that it may also have occurred in Queensland at this time.3 The late Peter MacCallum, together with Jean Tolhurst, Glen Buckle and H. A. Sissons working in the laboratories of Melbourne University and the Alfred Hospital first described in detail the clinical and pathological aspects of the disease, together with the pathological features and experimental pathology of the organism.2 Ulcers were described in two patients in 1897 by Sir Albert Cook, the first European physician in Uganda, which ‘Senior Lecturer Correspondence: Dr. A. J. Radford. School of Medicine, Flinders University of South Australia South Australia 5042 Accepted for publication: 3 October, 1974
may have been the same disease4 and 81 cases were seen in Zaire (then the Belgian Congo) between 1942 and 1949.5 The disease occurs with highest incidence along parts of the River Nile in Uganda, from where two-thirds of the 1500 recorded reports have been made.4, Papua New Guinea has the third highest incidence.6 Cases have also been seen in Indonesia’, Malaysia*, Nigeria’ and Mexico.“ There have been several comprehensive reviews of the subject written Nomenclature
In the twenty-five years since the disease was first described it has been given more than a dozen eponyms. The propinquity of the early patients to Bairnsdale gave the disease its first cluster eponym, the “Bairnsdale ulcer”.’, 2, It is most commonly known as “Buruli ulcer” or “Buruli Disease” after the area of Uganda from where the greatest number of reports have been made.4. 3 2 9 3 5 It has also been called “Searls’ ulcer” after one of the two general practitioners who first reported cases.I6 It has
1975
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recently been suggested that all eponyms be discarded and the term Mvcobacteriun? ukerans, which was given to the organism by the early Australian workers in this field, be used to describe the disease.14, 5 2 Thus, in this paper the disease is described as “infections with Mycohacterium ulcerans”, by reference to the part of the body involved. Distribution
In Australia, the disease is most frequently reported from around Cairns in northern Queensland. Earlier it was most commonly reported from the Bairnsdale area of Victoria where the disease still occurs sporadically (see map). More than half the Australian case reports have been from Queensland where at least three small foci have o ~ c u r r e d .1~7 -. The Northern Territory had a small focus on Croker Island.21 Sporadic occurrences have also been reported
in Victoria, Northern Territory, Queensland and New South Wales. The history of the single patient from Sydney suggested that his infection may have been acquired in Papua New Guinea?’ Reservoir of Infection and Route oj Transmission “Clustering” of cases without evidence of direct contact spread was noted in the first report.2 Such clustering is typically related to rivers and lakes in most endemic areas, but this has not been a marked feature of Australian reports, indeed. three cases were reported from Croker Island, north of Darwin.” (These three cases, together with the single case from nearby Daru Island in the Western District of P a p ~ a appear ~ ~ , to be the only reports from small island situations). Understanding of the epidemiology of the disease remains incomplete. The usual route of transmission of the organism to man has not
TABLE Distribution of Australian reports by State, age and sex Number of cases reported
State
Comments
.
~
3 3 5 10
Victoria
2, 13, 26 16, 15, 45 10 70
__ -_ _ _
New South Wales
1
40
*
‘several” 1
Queensland
“8-1 0” 8 6
21 43. 4 53. 61 9, 15. 18. 57, 70 13. 6. 19. 35, 59, 66
__
Northern Territory TOTAL (incl.
4
12 from Victoria)
8 13. 16, 18 =
-__
References
I . MacCallum et al.. 1948’ 2. Fenner and Leach, 195236 3. Francis, 1957’’ 4. Alsop, 1972’
Had been in New Guinea periodically up to 5 months before ulcer appeared.
5. Forbes et al., 195422
“Around 6. Rockhampton”. 7. 4 clustered from one 8. area “just north of 9. Brisbane”. Cairns (2), LO. Nambour (3), Maryborough, Sarina “around Cairns”.
__ ___
_ ..
Several crossreferences occur in the Victorian reports. Total =- at least 12. Most at Bairnsdale but sporadic cases at Colac and Yallourn.
Cilento, 19423 Lane. 196419 Abrahams and Tonge, 196420 Abrahams, 1Y73I7 Glynn, 197218
3 from Croker Island. 11. Quinn and Crotty, 196321
at least 39, excluding “several around Rockhampton”.
*Data unavailable for several cases.
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164 ____._I___
-_
RADF OK11
been identified. Australians were aniong the first to speculate that inoculation of the organism might occur through an insect vector as distinct from direct trauma, and also that soil or vegetation might be the natural habitat of the organism. 21 One patient from Queensland claimed that her ulcer had appeared following a “pineapple prick”.” Much effort has been put into testing this hypothesis. Bassett and Cahi1124 failed to isolate any mycobacteria similar to M. ulcerans from the riverine environment of the most endemic area of Papua and workers in Africa have obtained numerous cultures of mycobacteria from the soil and g r a w s of endemic areas, a few of which have some characteristics similar to those of M . ulcerans.13,2 5 Citing the parallel distribution of certain grasses with the incidence of disease, they have postulated that such habitats may be the natural reservoir of the organism but the findings of Australian laboratory workers have suggested that N . ulceranr may not be a saprophyte (see below). Neither has an animal reservoir been discovered. Recently Buckle26postulated that insectivorous bats, which are common around Bairnsdale and over much of New Guinea, may be the principal reservoir of M . ulcerans and that the bed-bug (Cimex), which is shared by both bats and man, may be the principal vector. Such a hypothesis, however, fails to explain the very patchy distribution of the disease in areas where human settlement is widespread and the bats are ubiquitous. Herpetofauna have recently been proposed as a possible natural reservoir following the successful estabblishment of infection in several species.27 Direct transmission of disease has occurred between laboratory animals (see below) and there are two reports of its probable occurrence in man.”” Nevertheless, it does not seem to be the usual mode of transmission. On one occasion in Queensland, father and daughter presented simultaneously. l 7 The occurrence of the disease in more than one member of a family either simultaneously or, more commonly, at different times is reported in areas of high incidence in Africa and New Guinea. As the natural reservoir and route of transmission have not been identified, the incubation 3 3
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period for the disease has not been accurately delineated. Animal experiments report figures varying from one week to well over a year according to size of the inoculating dose and previous BCG experience.’. 29 Retrospective estimates relating the appearance of disease from the date of entry of patients into known endemic areas suggest that 6-12 weeks is the usual period but it may be as short as two weeks.23 Age, Sex and Race Characteristics The most common age incidence reported for infections with Mycobacteriwn ulcerans is in 5-8 year olds. In Australia, however. the mean age of 29 patients was 28 ’ 6 years (range: 1-70), with one third of patients being 40 years or older and only four being under the age of 10 years. Although presentation has been most common in the second decade of life, the mean age of occurrence is considerably higher than that reported from all other countries with the exception of a small series from I n d o n e ~ i a .In~ no other series is the age distribution so scattered. Figure 1 illustrates the distribution by age of cases in Australia compared with those of Papua New Guinea. The male : female ratio in Australia is 1 . 3 : 1 and this is comparable to that found elsewhere. Four cases (10%) are known to have occurred in Aborigines who comprise approximately 1% of the total Australian population and about 3% of the population of the Northern Territory and Queensland. Outside Australia only five cases have been documented in Caucasians,
? f l L.
Austmlion (29cOSe5) Popuon&NewGuineon ( 112 coses)
mi I - I
Figure 1
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four in Africa30 Guinea.6
165
MYCOBACTER1I;M ULCERANS
__
33.
and one in Papua New
Clinical Feature.\ The condition is first noticed as a blind “boil” or subcutaneous lump particularly on an exposed surface. This may itch, but is usually painless. A history of preceding trauma is occasionally given. After a variable period of weeks. the lump breaks down with the escape ofa gelatinous ooze revealing a shallow ulcer with a necrotic base. In some lesions the fluid is semi-purulent. Particularly in areas of extensive subcutaneous fat, such as the buttocks. considerable thickening and induration may occur prior to ulceration. The edges of such ulcers resemble and have the consistency of orange peel. The condition becomes indolent over a period of weeks or months. Ulcers tend to show five characteristics. They are painless. Asymmetrical undermining may extend many centimetres subcutaneously in any direction. The granulation tissue which develops is brownpink in colour. “blubbery” in nature and easily removed. Involvement of fatty tissue changes it from its normal moist, light yellow, vascular nature to a dry, avascular white substance similar to that of the fat of uncooked bacon rashers. The surrounding skin may become hyperpigmented. Satellite nodules and ulcers may develop. Lymph gland enlargement only occurs when secondary infection is superimposed, although the late Jean Tolhurst and colleagues found lymphadenitis in lesions induced in cattle in V i ~ t 0 r i a .Lesions j~ tend to be relatively painless unless secondary infection or extension below the deep fascia occurs or the lesion is of the oedematous type. Patients usually remain afebrile and without systemic upsets when secondary infection is absent. i.e. the lesions are “cold”. Distribution of Lesions Only in one case of this series did ulceration occur on the trunk and this was reported to follow trauma to the area.” Lesions have occurred on the left side twice as frequently as on the right, with the left leg being the site of predeliction (Fig. 2). It is interesting to
Figure 2
speculate whether the centrifugal distribution of lesions supports the hypothesis of direct inoculation of the organism at the most exposed sites or if it represents the sites where, due to lower temperature gradients, the organism can more easily establish itself, or both. Multiple lesions have been reported twice in Australia.’, 2 2 In Zaire they occur in u p to a quarter of cases.5 In some places 20% of lesions are reported to extend below the deep fascia.6 In this series it was only recorded three times and in only one of these was it breached prior to surgical interference. Elsewhere lesions have involved tendon, muscle, nerve tissue and bone. In Africa “metastatic” bone and joint lesions have been r e p ~ r t e d . ~ Local or distant osteomyelitis is characterised by marked osteolysis and the development of sequestra but no new bone formation. It is probable that in Australia patients tend to report earlier for treatment than in some other countries. Puthology The main features of acute lesions include necrosis, especially of fatty tissue, oedema, infiltration with lymphocytes, plasma cells and macrophages, and a variable increase in fibrous
166
RADFORD
tissue. Polymorphonuclear leucocytes are not present in large numbers except where pyogenic bacteria are also present. Acid-fast bacilli are characteristically clumped together in oval or round masses in avascular, necrotic areas and under the edges of ulcers. They may also be found in small groups or singly and may occasionally be seen inside macrophages. Occasional giant cells are sometimes reported but the characteristic caseating chronic inflammatory reaction of tuberculous lesions has not been seen except in experimentally induced lesions in cattle. 34 Calcium is occasionally deposited in fatty tissue. In early lesions a reactive phase characterised by epithelial and giant cell systems of the tuberculous type with minimal lesions and Sew acid-fast bacilli is reported from Africa.35 This type may normally regress spontaneously. Patients with such lesions give positive skin tests to material prepared from M . ulcerans colonies called “Burulin”. Spontaneous healing in one area of a lesion, or indeed a whole lesion, may occur and partial re-epithelialisation of undermined edges is not an uncommon feature. In other countries primary healing with extensive scarring, contraction and lymphoedema may occur in lesions of long standing. Bacteriology, Serology and Animal Experiments The initial description of the organism and its characteristics, in particular the hypothermic conditions (32-33°C) required for culture, and the macroscopic and microscopic pathology of the disease were originally described in Melbourne by MacCallum, Tolhurst, Buckle and Sissons.’ These workers also proposed the name Mycobacterium ulcerans for the organism.” Extensive serological, culture and sensitivity experiments were carried out by Fenner and Leach36, 3 8 , 39, 4 2 , 5 0 , 5 1, and Fisher3’ in the early 1950s. Using heat-killed bacteria and the direct complement fixation test, Fenner and Leach36by cross-absorption techniques showed that M . ulcerans was “antigenically distinct” from other mycobacteria tested and that it appeared to be more closely related to mammalian tubercule bacilli than to M . avium,
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M . ranae or M . phlei. “The highest titres were obtained with homologous or closely related strains but cross-reactions with quite dissimilar strains were often strong.” Fenner and Leach found that BCG absorbed all the antibody to M . ulcerans strains from sera produced against them. Of the other bacteria only M. ulcerans and bovine strains did this completely. They could find no evidence to confirm Fisher’s36 suggestion, based on haemolytic titres using sensitised cells, that M . ulcerans resembled M . phlei more closely than other st rains. Fisher found an antibody against cells sensitised with human tubercule bacilli in the sera of rabbits immunised against M. ulcerans. He also found a similar antibody in the sera of six leprosy patients but not in the sera of nonleprous controls. MacCallum et a/.’ had noted some cases, including one child, with no evidence of tuberculosis but who gave positive Mantoux reactions. The literature reveals no consistent response to tuberculin skin-testing in this disease. Conversion has occurred with experimental lesions in cattle in Victoria to both human and avian tuberculin and to a specific antigen named “ulceranin”. Fenner38 was not able to distinguish between four strains of M . ulceruns using a standardised skin-test in guinea pigs which had been sensitised by intraperitoneal injections with a standard dose of M . u1ceran.s antigen. The reactions of the strains were consistent and distinct from those of M . avium, M. ranae, M . phlei, M . paratuberculosis and BCG. The reactions to mammalian PPD in animals sensitised to M. ukerans were very strong, as they were to an homologous preparation. The next strongest reaction was to avian PPD. Using M . ulcerans as a challenge, the strongest reactions were in animals sensitised to homologous and paratuberculous bacilli. In culture using Dubos’ medium, M . ulcerans showed characteristics which supported a closer relationship to mammalian mycobacteria than to other species.39 Colony morphology was indistinguishable from virulent mammalian tubercule bacilli although the M. ulcerans generation time was longer, even at temperatures
APRIL
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MYCORACTERIlJM ULCERAM
below 37°C. M. ulcerans colonies in alkaline suspension bound strongly with neutral red unlike avirulent and non-pathogenic mycobacteria. This distinguished M . ulcerans from M . balnei and confirmed the Scandinavian belief that these were separate species although both grow best at low temperature^.^' Mycobacterium ulcerans is unusual amongst mycobacteria in that it gives consistently negative results to most of the biochemical tests used to differentiate this genus. M . ulcerans, unlike any other mycobacterid tested to date, has recently been found to degrade the aminoacid hydr~xyproline.~’ In the first published in vivo experiments, Tolhur: and Buckle’, produced lesions in rats, mice and rabbits and later in cattle.34 Lesions could not be produced in guinea pigs, fowls or lizards although lesions have been induced recently in a wide range of herpeto-fauna in the western hemi~phere.’~Subcutaneous injections produced only localised lesions whilst intraperitoneal and intracerebral inocula produced widespread and sometimes fatal disease. The incubation period following subcutaneous injection of infected material varied from 7-20 months. MacCallum et al.’, found that foot-pad lesions could be produced in mice within a few days with heavy inocula (several million organisms per millilitre) but Fenner 4 2 was able to induce lesions after 150 days with inocula of only 5 - 10 organisms. Inocula of live material did not always produce lesions and it was postulated that the site of inoculation may be important in producing disease. Forbes -et al.” produced only local lesions with subcutaneous injections; disseminated infections occurring with intraperitoneal inoculations. Fenner4’ also studied the behaviour of the organism in developing chick embryos and was able to produce lesions in the livers of chicks which were incubated at 33°C but not at 37°C. Bolliger, Forbes and Kirkland43 reported the first apparently natural spread of the disease from experimentally infected possums to their non-infected cage members with incubation periods of up to six months. Similar animal experiments to those of MacCallum and colleagues were repeated by Forbes et aL2’ who 293
167
also found that the small possum, the phalanger (Trichosurus vulpecula). was a good experimental model. Sensitivity was originally tested to four drugs. Four M. ulcerans strains were insensitive to thiosemicarbazone and also to isoniazid, except in concentrations of 10 pg/ml. Three strains were partly sensitive to para-aminosalicylic acid (PAS) at concentrations of 10pg/ml and one strain was completely insensitive at this strength.39 Forbes, Wannon and Kirkland2’. found in vitro sensitivity of their strain to “sulphetrone” and PAS. They believed that local applications of PAS may have assisted the healing process of their case. Quinn and Crotty2’, found the organism from one of their patients strongly sensitive to streptomycin and cycloserine but only weakly sensitive to isoniazid and PAS. All Australian strains tested have been found to be sensitive to streptomycin, as they have been elsewhere. All strains tested by Fenner and Leach were “very sensitive” to con.~~ this centrations of 1 p g / d in ~ i t r o Despite in vitro sensitivity. well established lesions do not respond readily to streptomycin therapy. One case is said to have “responded” to systemic s t r e p t ~ m y c i n and ~ ~ this drug has been efficient in preventing mice foot-pad lesions from developing if given simultaneously with the infecting inocula. It has also been effective in healing “early lesions” in animals.34 Six out of eight recently tested Australian strains were sensitive to cycloserine, four out of five to ethambutol, three out of six to ethionamide and one out of four to rifampicin. The only strain tested against diamino-diphenylsulphone (“dapsone”) was found to be sensitive.45 Treatment
If the condition is recognised early enough, excision of the initial nodule and primary closure can be effected. Radical excision of the ulcer, extending into normal tissue, followed by skin grafting was originally recommended by Maclure to Searls and Alsop, and has remained the principal line of therapy in this country and elsewhere.’’ 1 8 , 2 3 Chemotherapy alone has been disappointing.
168
RADFORD
A less radical surgical approach involving excision of only necrotic tissue and extensive curettage of all involved surfaces after laying the lesion open, combined with chemotherapy, has been described.6x4fiShattock was able to effect cure with curettage alone.7 If chemotherapy is used the most appropriate regime is streptomycin and dapsone, possibly combined with ethambutol and should be continued for at least two weeks after healing appears complete. Recent controlled trials in Africa have found both clofazimine and rifampicin i n e f f e ~ t i v e .4~8 ~ , Heliotherapy was used in one of the patients of the earliest series.2 Because of the unusual temperature requirements for culture, several Australian workers have advocated locally applied heat.16,’8’23The last two used a heat cradle as an adjunct to healing following surgery. Hyperthermia was first used in West Africa and Though this procedure has not been proven to be of definitive value it may have assisted healing in some cases.
NO.
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Addendum
An additional report was recently made of an infection in a 19 year old male from Brisbane. The organism was isolated by culture from an ulcer which developed following trauma to the wrist.53 References 1 2.
3 4. 5. 6
7. 8. 9.
10. 11
Fenner5’, 5 1 succeeded in making mice resistant to infections with M . ulcerans by immunising them with BCG. This resistance was complete against low dose inocula but less successful against higher doses. The data on the Australian cases does not allow an assessment of the number of cases who have received BCG immunisation prior to the development of lesions, though positive Mantoux reactions without any other evidence of tuberculosis were recorded on several occasions. In one case of these cases the patient was only two years old.’ On two occasions a definite negative skin reaction was noted. In an attempt to obtain cross-immunity, BCG immunisation was first carried out in an endemic area of Papua New Guinea in 19666 and in Uganda a year later.35 Some protection appears to have been afforded by this measure. Until more is known of the method of infection of this disease, no other preventive measure is available.
12
The helpful criticisms of Dr. G. Pringle and Dr. F. M. Shattock are acknowledged. My thanks are also due to
5,
Mr. J. Brady of the Audio-visual unit of the Liverpool School of Tropical Medicine who produced the map and figure, and to Miss C. Marsden for her secretarial assistance. I am grateful to Dr. E. W. Abrahams, Director of Tuberculosis Services. Queensland, for information regarding case reports from Queensland.
Prevention
Acknowledgements
VOL..
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17. 18.
19. 20. 21.
22 23. 24. 25
26. 27.
28. 29.
30.
31. 32.
ALanp, D. G. (19721: The Baimsdale ulcer. Aust. N . Z . J SurR. 41. 317 MACCALL~.M. P.. TOLHCRST. J. C.. BCCKI-E.G and Sls\ol;s. H. A. (1948). A new mrcobacterial infection :n man. J. Poth. Bnct 60. 93. Cii.ENm. R (19421: Tropical Direores in Austrulosm. 2nd ed., Smith and Paterson, Brishane, 306. LUNZ,H. F., C O N ~ O D. R , H., WII.KS,N. E , BARNIEY. G. R . KAMUNVI, F, CLANcFu. J . K. and BE^, I. D. A (1965). Buruli (mycobacteriall ulceration Ln Uganda, E . Afr. rned. J. 12, (61, 275 JA X S S ~ NP. S . G.. Q L ~ R T I ~ K J X MT . .1.. S I E N I A W ~JK. Iand . GATTI,F. (1959) Necrotic tropical ulcers and mycobacterial causative agent\. Trop. jirogr. Med. 11,293 R 4 l ) f . o ~ A. ~ . J. (19740): Mvcnbucterrum uirrruns in Papua New Guinea. Pnpuo N Guinen mrd. J 17, (2). 145 SHATTOCK. F M. (1965): Mgcohacterial skin ulceration, E A,fr. mrd .I. 42, 548 PFTTIT,J H S.. MARrHETTF. N. J. and RhhS, R. J. W. (1966) M ~ c o hocterium uicrruns infection. Clinical and bactcriological study of thc first cases recognised in South-East Asia, Brit. J. Derm. 78, 187. GRAY.H. H., KINGMA,S. and KOK. S. H. (19671 Mycobacterial skin ulcers in Nigeria, Truns. m y . Soc. frop.. Med. H y g . 61. (3,712. LAVALLEAGUKAU. P.. MAR0UEZ-lTLRRlRARRIA. F. and MIIIDI.ERROOK. G (1953): Un case de infection humana por A4ycohocter~umulcerans en el hemisferio occidental, nora previa. Inr. J. Lepprorv 21, 469. RADFOUD. A J (1974h): Mycohnrterium ulreranr A review I . Epidemiology. P u p a N Glrrneu med J. 17, (2), 129. RAIIFORI), A J (1974~):Myrohncterium ulctmns. I 1 Clinical features. histopathologg. treatment and prevention. Papua N Gurneu med J 17, (2). 133. BARKER.D. J . P. (1973): Epidemiology of M.vcoburteriwn dreruns infection, Trans. roy. [email protected]. Med. Hpg. 67, (I). 43. JANTSENS. P. G. (1972): Skin ulcers caused by acid-fast bacilli, In Essuys on Tropical Dermutology, ed. J. Marshall, Excerpta Medica Monograph, Amsterdam, 264. EDITORIAL (1972): The Baimsdale ulcer, Med. J . Aust. 2, 858. F R A X YJ.~ ,K.(1957): Scarl‘s ulcer: Report of further ca5e of indolent cutaneom ulceration due to infection with Mycobocrerium ulcerun,. Alfred Horpitol Clin. Rep. (Melbourne) 1, 87. ABRAHAMS, E. W. (1973): Personal communication. G L Y ~ NP., 1. (19721: The use of surgery and local temperature elevafion In Mycohucrerium ulcerans infection. Aust. N Z.J Surp. 41, 312. LANE. D. (1964): Mycobacteriol ulcerans infections in Queensland. Med. J . Ausf. 1 , 124. ABRAHAYS, E. W. and TOUGE, J . 1. (1964): Mqcohncrerium ulcerunr in Queensland, .Wed. J . Aust. 1, 334. Q U I N NJ., V. and CROTTY, J M. (1963). Mycohucrerium u l c ~ r a ninfection ~ in the Northern Territory. Med. J. Aust. 2, 317. FORBES, B. R. V., WANSON.I. S. and KIRKLAND, W B. (1954): Indolent cutaneous ulceration due to infectton with Mrcohucterrum u/cerun.s. Med. J Aust. 1, 475. &ID, 1. S (1967). Mpcobacterium ulcerans infection: A report of 13 cases at the Port Moresby General Hospital, Papua, Med J . Aust. I, 472 BASSETT,H. and CAH~LL, M. (1966): Personal communication. BARKER, D. J. P.. CLANCEY, I. K., MORROW,R. H. and RAO. S . (1970): Transmission of Buruh disease. Brrr. med. J . 2, 558. BUCKLE,G. (1972): Nates on Mycobarlerium ulcerunr, Aidst. N Z . J . Surg. 41, 320. MARTUS.L. C., STOTTMEIER, K. D. and MORROW, R. H. (1973). Experimental infection of herpetofauna with Mycohocterrwn ulceruns. Paper presented to Conference on Mycobonerium ulceruns. Middlesex Hospital London, July 5-6th. F c n ~ t J, . (1973): Personal communication. FENNER,F. (1950): The significance of incubation period in infectious diseases, Med. J Aust. 2, 813. VAN OYE E. and BALLION, M. (1950): Faudra-t-il tenir compte d‘une nouveile affection bacilles acido-resistants en Afrique? (Note preliminaire). (Is there any new disease due to acid-fast bacilli in Africa? Preliminam. note). . Ann. So?. belae. Med. rrop. 30, 619. JANSSENS. P. G.,PATTUN,S. R., BovEROurLE, M. T H , QCERTINMOST. J. and DF MCYSCK,A. (1963): Un ulcire necrotique tropical nriginaire du Bas-Katanga, Ann. SOC.belge. Wed. trap. 5, 129 FARBER.E. R. and TSANG,A. (1967): Mycobacterial (“Buruli”) ulcer in Peace Corps worker, Arch Surg. 95, 297. 2 %
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38 39. 40
41
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169
MYCOBACTERIUM ULCEKANS
ULLMANX. U (1973) Mycobacrerrum ulceram in B European Paper presented to Conference on .Mycohacteriem ulceram Middlesex Hospital, London, July 5 -6th. TOLHURIT, J C., BCCKIF,G. and W E L L l N t i r i l N , N. A. M. (1959) The experimental infection of calves with M . ulceruns. J. Hyg. (Lund.1 67, 47. UGWIIABLRULI GROCP (1969): BCG vaccination against Mycohocrrrium uleerans infection (Buruli ulcer), Lancet 1. 111. Fchhfn, F. and L t a m . R. H. (19521: Studies on Mvvcohacrerlum ulceranb. 1. Serological relationship usith other mycobacteria. Aurr. J. exp. Biol. med. Sci. 30, 1. FISHER,S. (1951)’ Antigenic relationships of erythrocyte absorbable reactions of some mycobacteria. Ausl. J . rxp. R i d med S i i 29, I FESNER. F (1952) Studies on Mvcohocrerrum ulceram 11. Cross reactivity in guinea pigs sensitized with Mi.cohotrrrium ulreronr, Ausr J F X ~ Bid . med. Sci. 30, 11. LLACH.R H. and FENSER.F. (1954). Studies on M ulcvrani and :+I. bolner. 111. Growth in the semi-synthetic culture media of Dubos and drug sensitivity in wfro and in vivo. Ausr. J . e.xp. B i d med. Sci. 32, 835 LINNIIS.F and N O R D ~ A ~ .N(1952): , A new rype of pathogenic mycobacterium. N o d Med 47, 681 GRAXGI.J. M. (1973). A possible key test for hfycubacierium ulcerans based o n an amino-acid utilisation test Paper presented to Conference on Mycohucrerium ulcerans. Middlesex Hospital. London. July 5-6th FEXNER, F. (1956): The pathogenic behaviour of Mqcohaclerrum ulccrans, and Mycoboelrrium halnei in the mouse and the developing chick embryo. Amer. Rev. Tuberc. 73, 650 BOI.I.IGER.A,. FORBES. 8. R V and KIRKIAND. W B. (1950): Transnimion oia recently isolated mycobacterium t o phalangers (Trrchosurw vulprculu), Ausr. J . Sci. 12, (4). 146
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46. 47.
48.
49. 50. 51
52.
53
P E X N I N ~A~ TH.O11957) ~ . in Feldman and Karlson 11957) iU>mbactrriurn ulcerans infections Response to chcmotherapy In mice. Amrr. Reu. Tubrrc 75. 266. FFLOMAX, W. H and KARLSO%. A G (1957). Myrobocrer!wn ulcerans infections. Response lo chemotherapy in mice. A m u R r t . Tuherc 75. 266 Li 3s. H F and RFES, R J . W (19b41 ‘Treatment of Mycohacterial skin ulcers in Cganda with a riminophenazine derivative (8663). Lrincri 1.247 REVILL, W. D. L (1967): Treatment of Mjeohocrerum ulcerom infection. Paper presented to Conference on Mgcohorrermm ulcerons, Middlesex Hospital. London, July 5-6th. , R ~ ~ I LW. L .D. L., PIKE.M. C , MORKOW,R H. and A T ~ ~ J.G (19731 A controlled trial of trealment of ,Mycohacrerium ulcerons infection with Clofazimine, Lancer 2, 873. M ~ L ~ N EF. Y .and JOHNSON. B. A. (1950): Supplemcntdr). repolt of a ca.% of chronic ulceration of the foot due to a new pathogenic mycohelxe. Med. rrop. 30, :499. bacterium (MacCalluml, Ann. SOC. FFNNER.F. (1953): Two recently discovered mycobacter~awhich cause skin ulceration in man (M.ulcerans and M . habieii. VI. Internal. Cnngr. Microbiol., Rome. IV, 395 FIN~FR F.. (1957). Homologous and heterologous immunity in Infections of mice with Mycubacfrrium ulcerons and Wycohocterrum balm!, Amer. 1.Tuherc. 76, 79. RADFlinl>. A. J. (1973): The nomenclature of mycobacteriuni ulcerans infections, Trans. roy Soc. rrop Wed. Hyg. 67, ( 6 ) . 885. Ann Rep of the Health and Medical Services of the State of Queensland, 1973-74, p 79.
Aust N Z J Med (1975) 5, pp 169-170 __ _ _ I _ -
Comment CARCINOEMBRYONIC ANTIGEN (CEA): T E N YEARS‘ PERSPECTIVE
The case report by Professor Naim and his colleagues (December issue, page 531) reminds us again of the expectation that the immunology laboratory may yield diagnostic and therapeutic tools for the management of persons with cancer. The first such diagnostic test to become widely available has been the radioimmunoassay for carcinoembryonic antigen (GEA) in peripheral blood. CEA is a glycoprotein which was found in association with carcinoma of the colon as well as normal fetal gastrointestinal tissue ten years ago by Gold and Freedman’. While elevated levels of CEA in blood were first reported to be found exclusively in the blood of persons with carcinoma of the colon’, wider clinical testing showed that CEA was detectable in association with a variety of other cancers including stomach, pancreas, liver, breast and lungss. Several radioimmunoassays are now in use throughout the world for the detection of CEA in blood. The most widely available is that developed by Hansen6 which employs perchloric acid extraction of plasma to eliminate glycoproteins which crossreact with CEA, and zirconyl phosphate gel to precipitate the CEA-anti CEA complexes. The cut-off point for a “positive” test with this method, as well as with the Farr technique developed in Gold’s laborat o y 2 , is 2.5 ng/ml. The direct double antibody microradioimmunoassay developed at the Walter and Eliza Hall Institute is performed on whole serum without perchloric
acid extraction and gives a “positive” result at 5 ng/m13. The Todd assay which has been used extensively in clinical studies at the Chester Beatty Institute also is a direct assay, that is, perchloric acid extraction is not employed, and a “positive” result with this assay is 12.5 ng/ml or higher4. It is clear that the clinician should know the method which his laboratory employs as well as the arbitrary level chosen to designate an abnormal value. When CEA levels in serum or plasma are compared with the extent of spread of cancer, it is found that CEA elevation is infrequently detected when the cancer is at an early curable stage. A collaborative North American study’ which employed the Hansen technique for detection of CEA in persons with well documented carcinoma of colon showed “positive” tests in 18% of persons staged as Dukes A (localized to bowel wall) and 79% staged as Dukes C2 (widely metastatic). Similar results have been described by others ’. Persons with no clinically detectable cancer, but with inflammatory disease of the same organs in which CEAassociated cancers are found, may have elevated blood CEA levels. These diseases include ulcerative colitis’, pancreatitisg, hepatic cirrhosisg, chronic bronchitis and emphysema4, as well as chronic heavy smoking’“. It is apparent that interpretation by the physician of a positive test for CEA is made difficult for several reasons. Many of the non-cancerous diseases which are associated with an elevated level of CEA in blood are conditions which carry an associated increased risk to cancer, e.g. heavy
