Aucun titre de diapositive

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Clinical aspects of Buruli ulcer Physical
examination and positive diagnosis
Adapted from Pr Kanga J.M. course
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Definition of BU

• Skin mycobacterium infection caused by
  Mycobacterium ulcerans (an AFB)
• Occurring mainly as skin lesions (nodules,
  plaques and ulcers) than can be complicated by
  bone and joint involvement. Involvement of other
  organs like the eyes and pleural are exceptional
• Spreading in inter-tropical areas, in swampy
  soils or water body surroundings, forestry or
  surface mining zones

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Lesions in BU

• Skin lesions
• Papule
• Nodule
• Plaque
• Oedema
• Ulcer
• (Scar)

• Complications
• Osteomyelitis
• Arthritis
• Contractive joint
• Amputation
• Eye involvement
• Pleural involvement
• Multiple lesions

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Diagnosis of BU

• BU diagnosis is based on
• Clinical lesions mainly
• And epidemiological context
• Laboratory confirmation is obtained by
• Ziehl Neelsen staining for AFB
• Culture of M. ulcerans
• Histopathology
• PCR to identify M. ulcerans genes

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Diagnosis of BU

• BU diagnosis is done with 3 criteria
• Clinical aspect of lesions
• Epidemiological context
• Demonstration of AFB in a specimen of lesion
• In the field, if laboratory tests are not
  available, the 2 first critera (clinical and
  epidemiological) are sufficient to establish the
  diagnosis and start the treatment.

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Diagnostic steps

• 3 steps
• Questioning the patient
• Physical examination
• Laboratory confirmation

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The disease history

• Six (6) key questions
• Date on onset (since when?)
• Mode of occurrence (sudden onset? Fleetingness?
  Seasonal?)
• Symptoms fever?, pain? itching? scales?
  Adenopathy?
• Contact with BU case or history of BU in the
  family or vicinity?
• Environmental favouring factors?
• Received prior treatments?

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Questioning the patient

• Six key answers
• Date of onset? a papule or a nodule, a few weeks
  to three months ago
• Mode of evolution? Progressive, insidious, from
  a papule to nodule, plaque, (oedema) and ulcer
• Symptoms? no pain (before the over-infected
  ulcer stage), sometime a mild itching, no
  satellite lymph node (if the lesion is not
  over-infected)
• Contact with a BU case? YES, some BU cases in
  the family or in the same village or dwelling
• Environmental factors? YES, marshy soil, water
  body, water dam, rainy season, forestry or
  surface mining area
• Ineffectiveness of treatment with common
  antibiotics alone (penicillin, tetracyclin,
  sulfamide)

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Physical examination

• Requirements for skin examination
• Good lightning, preferably day light
• Naked patient (while preserving his privacy)
• Steps of the skin examination
• From distance (locating the lesions)
• Close exam (colour, height of nodule/plaque,
  undermined edges of ulcer)
• Palpation of lesions (papule, nodule, plaque and
  oedema)
• Search of associated signs
• General examination fever, adenopathy, anaemia,
  low blood pressure, oedema
• Full physical check up (mainly on bones and
  joints, nerves)

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Laboratory confirmation

• Search for AFB, direct microscopic exam or
  culture (specimen to be preserve cool 4º C)
• Papule, nodule, plaque
• oedema
• Ulcer

• Take specimens in the middle of the lesion after
  excision
• Swab several specimens from the undermined edges

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Other laboratory confirmation tests

• Histo pathological examination
• Take specimens as for bacilloscopy
• Preserve specimens in a formalin solution at 10

• Polymerase chain reaction (PCR)
• Take specimens as for bacilloscopy
• Keep specimens cool

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Skin lesions
Onset stage, pre-ulcerative
Papule
Raised skin lesion, firm, painless, palpable,
subcutaneous, adherent to the skin, Ø lt 1 cm,
itching
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Skin lesions
Onset stage, pre-ulcerative
Nodule
Raised skin lesion, firm, painless, palpable,
subcutaneous, adherent to the skin, Ø 1 à 2 cm,
itching, surrounded by oedema
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Skin lesions
Pre-ulcerative stage
Plaque
Large raised skin lesion, Ø gt 2 cm (up to palm
wide) , indurate, painless, with defined edges
separating from surrounding skin, violet-grey
like or clear compared to normal skin
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Skin lesions
Pre-ulcerative stage
Large plaque
Extended skin lesion, several cm2 (gt palm wide),
indurate, painless, slightly raised, with
precise limits separating from surrounding skin,
clear and reddish aspect
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Skin lesions
Pre-ulcerative stage
Oedema
Diffuse, extensive swelling, firm, non pitting,
ill-defined margins, painless, with colour
change over the affected skin - absence of other
cardinal inflammatory signs (dolor, calor, rubor)
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Skin lesions
Pre-ulcerative stage
Oedema
Extensive swelling, composed of several plaques
of different sizes, side by side or joined. When
palpating, one can find the limits of some plaques
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Skin lesions
Ulcerative stage
Ulcer
Loss of substance, not deep, limited size,
single, painless, with a necrotic yellow-like
floor, without satellite lymph node
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Skin lesions
Late stage, necrosis and ulcer
Ulcer
Deep and extensive loss of substance, variable
size, unique or multiple, painless or slightly
painful, undermined and indurate edges, coloured
in grey black, without satellite lymph nodes
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Complications
Osteomyelitis
Osteomyelitis with sequestration
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Complications
Osteomyelitis
Bone involvement with fistula to the skin
X-ray of osteomyelitis
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Complications
Arthritis
Oedema of the elbow without ulceration
X-ray showing a geode with bone sequestration
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Complications
Osteo-arthritis
Contiguous osteomyelitis by reaction
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Complications
Amputation and contractive joints
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Complications
Scarring, with sequel as atrophyand oedema
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Complications
Scar, striction and oedema
Striction
Lymph oedema
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Complications
Osteomyelitis and amputation
Extensive osteo-arthritis
X-ray of bone destruction
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Complications
Multiples sites
Multiple sites of BU on limbs leadingto
amputation of the right upper limb
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Complications
Lung involvement
X-ray pleurisy
Lung oedema with dyspnoea of decubitus
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Conclusion

• Early diagnosis of BU is crucial
• This enables to cure the patient with medical non
  invasive treatment (combined specific
  antibiotics) or to limit surgery to simple
  excision and suture of onset lesions (papule,
  nodule, plaque, oedema, small sized ulcer)

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Conclusion (contd)
In endemic area, easy diagnosis on clinical signs
For difficult cases, laboratory confirmation
isrequired