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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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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 ...