Buruli ulcer

PST 520 – Skin Disorders and Rehabilitation

Miss Adebayo O.E.

Buruli Ulcer

• Buruli ulcer is a necrotizing and disabling cutaneous disease caused by Mycobacterium ulcerans

• It is the third commonest mycobacterial disease, after tuberculosis and leprosy.

• It causes extensive destruction of tissues leaving large ulcers on the body

• It is characterized by necrosis of subcutaneous tissue, leading to chronic, painless, and progressive ulcers.

• Without proper treatment, it may result in severe and permanent disability

• It mostly affects children less than 15 years of age

• it is distributed mainly in West Africa, but cases are also found in other parts of the world. There is limited awareness about the disease and it is one of the skin-related neglected tropical diseases

• It majorly occurs in the poor remote area

Pathogenesis

• M. ulcerans bacteria synthesises myolactone (a polypeptide derived Macrolide)

• Actions of myolactone leads to cytotoxicity, immunosuppression, and analgesic effects, which correspond well to the characteristic features of the disease , i.e. extensive deep ulceration with thick yellowish necrotic tissue and undermining, paucity of local inflammatory response, and no or limited pain

Mode of transmission

• The mode of transmission is not well understood

• Cases appear to be concentrated areas with proximity to slow moving or stagnant bodies of water (ponds, swamps, marshes, backwaters, dams, artificial lakes). Therefore, it is currently thought that the disease is transmitted from these environments to humans

• Insects bites near rivers, swimming in or wading through a river are also postulated risk factors

Buruli ulcer

• The lesion is usually painless unless there is secondary infection

Classification

• Category I: a single lesion <5cm in diameter

• Category II: a single lesion between 5cm and 15cm indiameter

• Category III: a single lesion >15cm in diameter, multiple lesions, lesions at critical sites (e.g. eye, breast, genitalia), and osteomyelitis.

Classification

• Category I lesions may completely heal with antibiotics treatment;

• some category II lesions may completely heal with antibiotics.

• Category III lesions require both antibiotics and surgery (some small lesions located at critical sites may heal with antibiotics alone

Clinical Features

• Necrotic skin ulcer with undermined edges

• The ulcers are slowly progressive and usually painless and mostly without systemic manifestations

• It often starts as a painless, often itchy, nodule or papule in the skin which is often ignored by the patient

• Early Buruli lesions may initially appear as a mobile subcutaneous nodule, a papule, or a raised plaque.

• If left untreated, it often leads to massive skin ulcer with debilitating complications, which includes contracture deformities, amputation, losss of organs such as the eye, breast and genitalia

• There could also be resultant sepsis, tetanus, heamrrhage, bone infections

Differential diagnosis

• Necrotizing fasciitis

• Venous ulcer

• Diabetic ulcer

• sickle-cell disease-related ulcers.

• Cutaneous tuberculosis

• Leprosy

• Malignant ulcer

Management

• Antibiotic therapy

• Surgery – all forms of buruli ulcer respond well to antibiotic treatment. However, although large lesions may be slow to heal and require surgery (debridement, skin grafting and scar revision)

• Wound care and management

• Pain relief

Complications

• Joint stiffness: the following can result in joint stiffness• Oedema or pain – movement will be restricted

• Incorrect bandaging – tight bandaging will restrict movement

• Extensive scars near or across joints

• Deformities – fixed joint deformities

• Contractures

• Functional limitation

Physiotherapy management

• Physiotherapy management starts with a complete and thorough assessment

• The range of motion, adhesion and scars should be assessed

• Limitation of movement is assessed before treatment

• Physiotherapy management is important in the active phase and rehabilitation of the disease.

Physiotherapy management

• Management is aimed at preventing and minimizing• Disability • Contractures• Deformities • Joint stiffnessManagement is also aimed at preserving and improving function.

Physiotherapy Management

• Passive range of motion exercise

• Active exercises

• Positioning

• Scar/adhesion management

• Functional training/rehabilitation