Clinical epidemiology of laboratory-confirmed Buruli ulcer in Benin: a cohort study.

BACKGROUND: Buruli ulcer, caused by Mycobacterium ulcerans, was identified as a neglected emerging infectious disease by WHO in 1998. Although Buruli ulcer is the third most common mycobacterial disease worldwide, understanding of the disease is incomplete. We analysed a large cohort of laboratory-confirmed cases of Buruli ulcer from Pobè, Benin, to provide a comprehensive description of the clinical presentation of the disease, its variation with age and sex, and its effect on the occurrence of permanent functional sequelae. METHODS: Between Jan 1, 2005, and Dec 31, 2011, we prospectively collected clinical and laboratory data from all patients with Buruli ulcer diagnosed at the Centre de Dépistage et de Traitement de l'Ulcère de Buruli in Pobè, Benin. We followed up patients to assess the frequency of permanent functional sequelae. All analyses were done on cases that were laboratory confirmed. FINDINGS: 1227 cases of laboratory-confirmed Buruli ulcer were included in the analysis. Typically, patients with Buruli ulcer were children (median age at diagnosis 12 years) presenting with a unique (1172 [96%]) large (≥15 cm, 444 [36%]) ulcerative (805 [66%]) lesion of the lower limb (733 [60%]). Atypical clinical presentation of Buruli ulcer included Buruli ulcer osteomyelitis with no identifiable present or past Buruli ulcer skin lesions, which was recorded in at least 14 patients. The sex ratio of Buruli ulcer widely varied with age, with male patients accounting for 57% (n=427) of patients aged 15 years and younger, but only 33% (n=158) of those older than 15 years (odds ratio [OR] 2·59, 95% CI 2·04-3·30). Clinical presentation of Buruli ulcer was significantly dependent on age and sex. 54 (9%) male patients had Buruli ulcer osteomyelitis, whereas only 28 (4%) of female patients did (OR 2·21, 95% CI 1·39-3·59). 1 year after treatment, 229 (22% of 1043 with follow-up information) patients presented with permanent functional sequelae. Presentation with oedema, osteomyelitis, or large (≥15 cm in diameter), or multifocal lesions was significantly associated with occurrence of permanent functional sequelae (OR 7·64, 95% CI 5·29-11·31) and operationally defines severe Buruli ulcer. INTERPRETATION: Our findings have important clinical implications for daily practice, including enhanced surveillance for early detection of osteomyelitis in boys; systematic search for M ulcerans in osteomyelitis cases of non-specific aspect in areas endemic for Buruli ulcer; and specific disability prevention for patients presenting with osteomyelitis, oedema, or multifocal or large lesions. Our findings also suggest a crucial underestimation of the burden of Buruli ulcer in Africa and raise key questions about the contribution of environmental and physiopathological factors to the recorded heterogeneity of the clinical presentation of Buruli ulcer. FUNDING: Agence Nationale de la Recherche (ANR), Fondation Raoul Follereau, Fondation pour la Recherche Médicale (FRM), and Institut des Maladies Génétiques (IMAGINE).

A cutaneous ulcer resulting from Mycobacterium ulcerans--Leishmania braziliensis coinfection in South America.

Buruli ulcer is a tropical skin disease caused by Mycobacterium ulcerans. Its mode of transmission is not yet clearly understood. We report here a cutaneous ulcer in a European traveler in South America resulting from a coinfection detected specifically for Mycobacterium ulcerans and Leishmania braziliensis DNA with real-time polymerase chain reaction. This observation of a unique cutaneous ulcer raises the issue about possible modes of transmission of those two pathogens by the same vector.

Oral treatment for Mycobacterium ulcerans infection: results from a pilot study in Benin.

Mycobacterium ulcerans infection is responsible for severe skin lesions in sub-Saharan Africa. We enrolled 30 Beninese patients with Buruli ulcers in a pilot study to evaluate efficacy of an oral chemotherapy using rifampicin plus clarithromycin during an 8-week period. The treatment was well tolerated, and all patients were healed by 12 months after initiation of therapy without relapse.

Seasonal and regional dynamics of M. ulcerans transmission in environmental context: deciphering the role of water bugs as hosts and vectors.

BACKGROUND: Buruli ulcer, the third mycobacterial disease after tuberculosis and leprosy, is caused by the environmental mycobacterium M. ulcerans. Various modes of transmission have been suspected for this disease, with no general consensus acceptance for any of them up to now. Since laboratory models demonstrated the ability of water bugs to transmit M. ulcerans, a particular attention is focused on the transmission of the bacilli by water bugs as hosts and vectors. However, it is only through detailed knowledge of the biodiversity and ecology of water bugs that the importance of this mode of transmission can be fully assessed. It is the objective of the work here to decipher the role of water bugs in M. ulcerans ecology and transmission, based on large-scale field studies. METHODOLOGY/PRINCIPAL FINDINGS: The distribution of M. ulcerans-hosting water bugs was monitored on previously unprecedented time and space scales: a total of 7,407 water bugs, belonging to large number of different families, were collected over one year, in Buruli ulcer endemic and non endemic areas in central Cameroon. This study demonstrated the presence of M. ulcerans in insect saliva. In addition, the field results provided a full picture of the ecology of transmission in terms of biodiversity and detailed specification of seasonal and regional dynamics, with large temporal heterogeneity in the insect tissue colonization rate and detection of M. ulcerans only in water bug tissues collected in Buruli ulcer endemic areas. CONCLUSION/SIGNIFICANCE: The large-scale detection of bacilli in saliva of biting water bugs gives enhanced weight to their role in M. ulcerans transmission. On practical grounds, beyond the ecological interest, the results concerning seasonal and regional dynamics can provide an efficient tool in the hands of sanitary authorities to monitor environmental risks associated with Buruli ulcer.

Use of fine-needle aspiration for diagnosis of Mycobacterium ulcerans infection.

Noninvasive methods for the bacteriological diagnosis of early-stage Mycobacterium ulcerans infection are not available. It was recently shown that fine-needle aspiration (FNA) could be used for diagnosing M. ulcerans infection in ulcerative lesions. We report that FNA is an appropriate sampling method for diagnosing M. ulcerans infection in nonulcerative lesions.

Disruption of the GPI protein-encoding gene IFF4 of Candida albicans results in decreased adherence and virulence.

Candida albicans is the most important cause of systemic fungal infection in immunocompromised humans. Candidiasis is often initiated by the adherence and the colonization of inert surfaces such as peripheral venous catheters, central catheters, prosthetic cardiac valves, and other prostheses. We have studied the early stage of adherence and have shown that the disruption of C. albicans IFF4 gene encoding a GPI-anchor protein, led to a decrease of adherence of the germ tubes to plastic. Here, we demonstrated the role of the IFF4 gene in adherence to silicone catheter, as well as in virulence using a murine model of disseminated candidiasis. The iff4 Delta null mutant showed both a decrease of adherence to silicone catheter and a reduction of virulence. This work presents evidence for the importance of the IFF4 gene in host-fungal interaction.

Evaluation of an immunomagnetic separation method to capture Candida yeasts cells in blood.

BACKGROUND: Candida species have become the fourth most-frequent cause of nosocomial bloodstream infections in immunocompromised patients. Therefore, rapid identification of pathogenic fungi to species level has been considered critical for treatment. Conventional diagnostic procedures such as blood culture or biochemical tests are lacking both sensitivity and species specificity, so development of rapid diagnostic is essential. RESULTS: An immunomagnetic method involving anti-Candida monoclonal antibodies was developed to capture and concentrate in human blood four different species of Candida cells responsible for invasive yeast infections. In comparison with an automated blood culture, processing time of immunomagnetic separation is shorter, saving at least 24 hours to obtain colonies before identification. CONCLUSION: Thus, this easy to use method provides a promising basis for concentrating all Candida species in blood to improve sensitivity before identification.

Clinical aspects and prognostic factors of leptospirosis in adults. Retrospective study in France.

BACKGROUND: Because early recognition and initiation of antibiotic therapy are important, clinicians should familiarize themselves with the clinical presentation of leptospirosis, and determine prognostic factors. PATIENTS AND METHODS: This study included all patients treated at Angers University Hospital between January 1995 and December 2005 for leptospirosis - both probable (cases combining epidemiologically suggestive features with compatible clinical, laboratory, and radiographic findings, with no other diagnosis envisioned) and confirmed (by finding microorganism on direct examination or culture of blood, urine or CSF, or by seroconversion or by a significant increase in the antibody titer between two samples). Severe leptospirosis was defined by hospitalization in the critical care department or need for renal dialysis. The statistical analysis used SPSS software version 12. RESULTS: Of 97 records reviewed, we retained 62 cases that met the criteria above, including 35 confirmed cases, 27 probable and 15 severe. The sex ratio was nine men for every woman. The patients' mean age was 45+/-18 years [12-77]. The principal clinical signs observed were: fever (n=59) with shivering (n=42), diffuse myalgia (n=41), headaches (n=38), jaundice (n=24), conjunctival suffusion (n=10), rash (n=11), herpes eruption (n=7), renal damage (n=33) that was sometimes severe (>500 micromol/L) (n=7), meningitis (n=12), meningoencephalitis (n=2), myocarditis or pericarditis (n=6), and atypical radiographic lung disease (n=16), sometimes with ARDS (n=6). Blood tests showed thrombocytopenia (platelets<140 G/L) in 65.5% of patients (n=40). Logistic regression modeling showed that two criteria remained independently predictive of development toward severe leptospirosis: clinical jaundice (p=0.005) and cardiac damage seen either clinically or on ECG (p<0.02). These factors can be identified easily at the first clinical examination and during evolution, and should help to reduce mortality by allowing earlier management of patients with suspected leptospirosis.

Impact of Mycobacterium ulcerans biofilm on transmissibility to ecological niches and Buruli ulcer pathogenesis.

The role of biofilms in the pathogenesis of mycobacterial diseases remains largely unknown. Mycobacterium ulcerans, the etiological agent of Buruli ulcer, a disfiguring disease in humans, adopts a biofilm-like structure in vitro and in vivo, displaying an abundant extracellular matrix (ECM) that harbors vesicles. The composition and structure of the ECM differs from that of the classical matrix found in other bacterial biofilms. More than 80 proteins are present within this extracellular compartment and appear to be involved in stress responses, respiration, and intermediary metabolism. In addition to a large amount of carbohydrates and lipids, ECM is the reservoir of the polyketide toxin mycolactone, the sole virulence factor of M. ulcerans identified to date, and purified vesicles extracted from ECM are highly cytotoxic. ECM confers to the mycobacterium increased resistance to antimicrobial agents, and enhances colonization of insect vectors and mammalian hosts. The results of this study support a model whereby biofilm changes confer selective advantages to M. ulcerans in colonizing various ecological niches successfully, with repercussions for Buruli ulcer pathogenesis.

Disruption of Candida albicans IFF4 gene involves modifications of the cell electrical surface properties.

During the past two decades, the prevalence of candidiasis has increased markedly and Candida albicans has now become one of the most important causes of nosocomial infections, especially after colonization of inert surfaces such as catheters or prostheses. In a previous report, we demonstrated the overexpression of 35 unidentified genes in response to adherence of C. albicans germ tubes to plastic. Therefore, a bioinformatic analysis was performed searching for genes encoding surface proteins potentially involved in adherence. Nineteen genes were thus selected, and one of them, CaIFF4, was further investigated. The deduced protein of this CaIFF4 gene revealed a glycosylphosphatidylinositol (GPI)-anchored site as well as the presence of a N-terminal signal peptide. Disruption of both alleles of CaIFF4 gene from C. albicans parent strain BWP17 was performed by PCR method. Then investigations of properties of null mutant for CaIFF4 gene showed a decrease of adherence of germ tubes to plastic in comparison to the parent strain BWP17. Besides, electrophoretic mobilities of germ tubes of CaIFF4 null mutant and of parental strain BWP17 were measured. Data were then analysed with soft particles analysis theory. Results point out a less important electrophoretic mobility of germ tubes of CaIFF4 null mutant in comparison to germ tubes of BWP17 parental strain.

DNA array analysis of Candida albicans gene expression in response to adherence to polystyrene.

Candidiasis is often initiated by the colonization of inert surfaces. In order to elucidate the mechanisms involved in this adherence process, DNA macroarrays were used to analyze the transcriptome of Candida albicans, the main causative agent of this mycoses, in a simple adherence model using germ tubes produced in polystyrene Petri dishes. Non-adherent germ tubes produced on glass surface were used as a control. Analysis of gene expression displayed 77 genes identified as statistically overexpressed in adherent germ tubes. Among these genes, some encoded enzymes participating in metabolism of lipids (such as LIP6), of proteins (such as SAP1) or of carbohydrates (like PGI1, PMI40 and PSA1. Some of these genes have already been reported as playing a role in pathogenesis of C. albicans. However, functions were unknown for a large part (45.5%) of the overexpressed genes which will be analyzed further in order to define their relationship with adherence.