The incubation period is thought to vary between 2 weeks and 3 years with an average of 2-3 months. During the initial indolent course non-specific systemic features are common.
The first recognized stage of Buruli Ulcer disease is the development of a firm subcutaneous nodule, with a central punctum, often only visible on pinching the skin. As the nodule is non-tender presentations at this stage are rare.
The active second stage is characterized by formation of an ulcer with an undermined skin edge. This ulcer may be located anywhere on the body, most commonly the arms and legs and is often widespread at first presentation. Osteomyelitis may complicate the course of the disease.
Well organised host delayed-type hypersensitivity response results in the formation of granulomus, characteristic of the third stage.
Further to this fibrosis and scarring leads to contracture deformities and functional impairment.
Investigations
Experienced clinicians, such as those at the Reconstructive Plastic Surgery units in Accra and Kumase can make a confident diagnosis based on history alone. Recently RPSB Centre Accra has had the benefit of Polymerase Chain Reaction (PCR) equipment to confirm the clinical diagnosis. PCR allows detection of specific mycobacterium ulcerans sequences from swabs taken of ulcer exudate. Bacteria can also be identified following culture on Lowenstein-Jensen medium at 320C and Ziehl-Neelsen staining.
Treatment
WHO issued provisional guidelines on the use of antibiotics in the management of Buruli in 20043. An antibiotic combination of rifampicin and streptomycin has been found to be most effective and around 30-50% of early lesions will respond to medical therapy alone5. A recent study in the Lancet suggests that lesions less than six months old and smaller than 10cm in diameter can respond to medical therapy alone7. 7 Current best management of active lesions is with a combination of surgical resection and antibiotic therapy.
Burnt out disease, ie, where the ulcer has sloughed and healed by secondary intention, forms large scars and contractures if these are located over joints. Complete excision of active ulceration with a margin of 2- 4 cm and subsequent skin grafting is performed in Korle Bu with good result. When the lesions are present on the face it leaves a large defect to reconstruct and the use of free tissue transfer is one option, as seen in the case of MD.
Surgery is the treatment choice for correction of contracture deformities in patients presenting late with “burnt out” stage 3 disease.
Excision of lesions and direct closure or skin graft are performed in disease that is detected at early stages. Scar and contracture release using excision and grafting or Z-plasty techniques are common surgeries in Korle Bu as patients tend to present later on in the disease course. Unfortunately amputation is still necessary in advanced and aggressive disease.
Physiotherapy plays an important role in rehabilitation of patients with contracture and amputation.