Clinical features and management of a severe paradoxical reaction associated with combined treatment of Buruli ulcer and HIV co-infection

In West and Central Africa Buruli ulcer (BU) and HIV co-infection is increasingly recognised and management of these two diseases combined is an emerging challenge for which there is little published information. In this case we present a severe paradoxical reaction occurring after commencing antibiotic treatment for BU combined with antiretroviral therapy for HIV, and describe its clinical features and management. This includes to our knowledge the first reported use of prednisolone in Africa to manage a severe paradoxical reaction related to BU treatment

Differential Diagnosis of Skin Ulcers in a Mycobacterium ulcerans Endemic Area: Data from a Prospective Study in Cameroon

Clinical diagnosis of Buruli ulcer (BU) due to Mycobacterium ulcerans can be challenging. We aimed to specify the differential diagnosis of skin lesions in a BU endemic area

Impact of Human Immunodeficiency Virus on the Severity of Buruli Ulcer Disease: Results of a Retrospective Study in Cameroon

International audienceBACKGROUND:Buruli ulcer is the third most common mycobacterial disease after tuberculosis and leprosy and is particularly frequent in rural West and Central Africa. However, the impact of HIV infection on BU severity and prevalence remains unclear.METHODS:This was a retrospective study of data collected at the Akonolinga District Hospital, Cameroon, from January 1, 2002 to March 27, 2013. Human immunodeficiency virus prevalence among BU patients was compared with regional HIV prevalence. Baseline characteristics of BU patients were compared between HIV-negative and HIV-positive patients and according to CD4 cell count strata in the latter group. Buruli ulcer time-to-healing was assessed in different CD4 count strata, and factors associated with BU main lesion size at baseline were identified.RESULTS:Human immunodeficiency virus prevalence among BU patients was significantly higher than the regional estimated prevalence in each group (children, 4.00% vs 0.68% [P < .001]; men, 17.0% vs 4.7% [P < .001]; women, 36.0% vs 8.0% [P < .001]). Individuals who were HIV positive had a more severe form of BU, with an increased severity in those with a higher level of immunosuppression. Low CD4 cell count was significantly associated with a larger main lesion size (β-coefficient, -0.50; P = .015; 95% confidence interval [CI], -0.91-0.10). Buruli ulcer time-to-healing was more than double in patients with a CD4 cell count below 500 cell/mm(3) (hazard ratio, 2.39; P = .001; 95% CI, 1.44-3.98).CONCLUSION:Patients who are HIV positive are at higher risk for BU. Human immunodeficiency virus-induced immunosuppression seems to have an impact on BU clinical presentation and disease evolution

Numbers and percentages according to BU likelihood, crude odd ratios, adjusted odds ratios and points attributed in Buruli score of items associated with BU probability.

<p>Numbers and percentages according to BU likelihood, crude odd ratios, adjusted odds ratios and points attributed in Buruli score of items associated with BU probability.</p

Algorithm based on Buruli score applied to the patients included in the study.

<p>Algorithm based on Buruli score applied to the patients included in the study.</p

Differential Diagnosis of Skin Ulcers in a <i>Mycobacterium ulcerans</i> Endemic Area: Data from a Prospective Study in Cameroon

<div><p>Background</p><p>Clinical diagnosis of Buruli ulcer (BU) due to <i>Mycobacterium ulcerans</i> can be challenging. We aimed to specify the differential diagnosis of skin lesions in a BU endemic area.</p><p>Method</p><p>We conducted a prospective diagnostic study in Akonolinga, Cameroon. Patients presenting with a skin ulcer suspect of BU were included. <i>M</i>. <i>ulcerans</i> was detected using swabs for Ziehl-Neelsen staining, PCR and culture. Skin punch biopsies were taken and reviewed by two histopathologists. Photographs of the lesions were taken and independently reviewed by two dermatologists. Final diagnosis was based on consensus, combining the results of laboratory tests and expert opinion.</p><p>Results/ Discussion</p><p>Between October 2011 and December 2013, 327 patients with ulcerative lesions were included. Median age was 37 years (0 to 87), 65% were males, and 19% HIV-positive. BU was considered the final diagnosis for 27% of the lesions, 85% of which had at least one positive laboratory test. Differential diagnoses were vascular lesions (22%), bacterial infections (21%), post-traumatic (8%), fistulated osteomyelitis (6%), neoplasia (5%), inflammatory lesions (3%), hemopathies and other systemic diseases (2%) and others (2%). The proportion of BU was similar between HIV-positive and HIV-negative patients (27.0% vs. 26.5%; p = 0.940). Half of children below 15 years of age were diagnosed with BU, compared to 26.8% and 13.9% among individuals 15 to 44 years of age and above, respectively (chi2 p<0.001). Children had more superficial bacterial infections (24.3%) and osteomyelitis (11.4%).</p><p>Conclusion</p><p>We described differential diagnosis of skin lesions in a BU endemic area, stratifying results by age and HIV-status.</p></div

Estimated probability of Buruli ulcer according to pattern of laboratory test results in latent class model (1 = positive result, 0 = negative result; test order ZN CPC, PCR, culture, ZN Akonolinga.

<p>Dashed line: 70% probability of Buruli ulcer (predefined treatment threshold).</p

ROC curve of multivariable prediction model (A) and Buruli score (B).

<p>ROC curve of multivariable prediction model (A) and Buruli score (B).</p

Univariate analysis of variables associated with BU likelihood, Akonolinga, Cameroon.

<p>Univariate analysis of variables associated with BU likelihood, Akonolinga, Cameroon.</p