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Mycobacterium ulcerans causes indolent, necrotizing cutaneous lesions known as Buruli ulcers, an appellation given by Dodge and Lunn who described the first large epidemic, located in Buruli County (now called Nakasongola), Uganda.1 Today, M ulcerans infections are recognized to present a spectrum of clinical disease: nodules, plaques, severe edemas and massive ulcers in the skin, and osteomyelitis. Buruli ulcer, after tuberculosis and leprosy, is the third most common and perhaps least understood major mycobacterial infection. In contrast to tuberculosis and leprosy, Buruli ulcer is closely related to environmental factors.2

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In South America, known countries in which Buruli ulcer is endemic include French Guyana, Suriname, and Peru.3,4 While Mexico is the only North American country in which it is endemic, travelers to endemic areas occasionally present to European, American, and Canadian medical centers.5-8

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Since 1998, the World Health Organization (WHO) has recognized Buruli ulcer as a reemerging infectious disease in West and Central Africa with an important public health impact.9 In endemic countries, Buruli ulcer is a major public health and psychosocial problem because of potential disabling sequelae.10 The disease tends to afflict children 15 years old and under in those countries in which it is highly endemic.

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Epidemiology

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Endemic foci of Buruli ulcer are most common near rural permanent wetlands in warm geographic regions, especially in areas prone to seasonal flooding. Buruli ulcers have been reported from at least 27 countries, principally in the tropics.2 A few patients live in nontropical regions such as China,11 Japan,12 and southern Australia.13 The greatest number of reported patients live in West Africa (Benin, Burkina Faso, Côte d’Ivoire, Ghana, Guinea, Liberia, and Nigeria), with an estimated total annual incidence exceeding 7000 patients.2,14,15 Other known endemic countries include Angola, Cameroon, Democratic Republic of Congo, Equatorial Guinea, French Guiana, Gabon, Indonesia, Malaysia, Papua New Guinea, Peru, Suriname, Togo, and Uganda.16-19 The rapid reemergence of Buruli ulcer disease began in the early 1980s and is thought to be attributable to environmental factors such as deforestation, artificial topographic alterations (dams and irrigation systems), enlarging populations engaged in basic manual agriculture in wetlands, and possibly global climatic changes.20 In North America, 2 cases of Buruli ulcer were reported in central Mexico, the nearest location of the disease to the United States.21

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Individuals of all ages are affected, but children 15 years of age or younger constitute about 75% of all cases.22 Approximately 80% of the lesions are located on the limbs, with highest frequencies involving the lower extremities. The sexes are affected equally, and racial predilection is unknown.23 Anecdotal observations of children in families of multiple parentage have suggested a possible genetic predisposition. This possibility is supported by molecular studies.24 Seasonal changes in climate affect incidence in some foci.25,26 Focal prevalence within countries varies ...

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