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Skin-Destroying Ulcer Appears in NSW as New Treatment Guidelines Emerge

Infectious disease specialists have revealed the skin- and flesh-destroying Bairnsdale ulcer has struck a man in NSW for the first time, as experts publish new recommendations for treating the tropical infection. //

Also known as the Buruli or Daintree ulcer, Bairnsdale ulcers are caused by Mycobacterium ulcerans infection, and result in the destruction of skin, soft tissue, and sometimes bone.

Associate Professor Paul Johnson, Deputy Director of the Infectious Diseases Department of Austin Health, in Melbourne, and colleagues have used the Medical Journal of Australia to caution GPs and other doctors to look out for the infection in NSW.

M. ulcerans infection was first described in Australia in coastal Victoria (Bairnsdale) in 1948 and since then has been found in central coastal Queensland and the Northern Territory.

Now, Assoc Prof Johnson and colleagues have identified the first known case believed to have originated in NSW.

“Australian primary care clinicians need to be aware that Bairnsdale ulcer may occur in NSW, to ensure early diagnosis and treatment to minimise disability,” he said.

The finding came as Australian plastic surgeons, GPs, laboratory scientists, pathologists, infectious disease physicians and public health experts collaborated to set down new consensus recommendations for the treatment and prevention of M. ulcerans infection.

Assoc Prof Johnson said the recommendations state that antibiotics and surgery are recommended for large ulcers, while smaller ulcers with clear margins can be treated with surgery alone.

The reason for outbreaks and mode of transmission are not yet known, but Assoc Prof Johnson said in endemic areas, direct exposure to the environment and to mosquitos are risk factors for contracting the infection.

“Wearing protective clothing and insect repellent appears protective,” he said.

“Future research should focus on what determines why a particular area becomes endemic.”

In the same issue of the MJA, Dr Daniel O’Brien, an infectious disease specialist at Barwon Health in Geelong, and colleagues said that treating the ulcers with surgery alone failed to eradicate the infection for one in four patients.

However after studying the treatment outcomes in a case series of 40 people in south-eastern Australia, they found that treating the initial ulcers with a combination of antibiotics for up to three months, as well as surgery, eradicated the infection in all patients.

“The combination of (the antibiotics) rifampicin and ciprofloxacin seems promising, and has the potential to provide an easily accessible, relatively well tolerated and inexpensive oral antibiotic treatment that can result in a significant reduction in ... morbidity and cost,” Dr O’Brien said.

In a related editorial, World Health Organisation tropical disease control officer Dr Kingsley Asiedu, and London-based infectious disease physician Dr Mark Wansbrough-Jones, said further research is needed into the treatment, diagnosis, and transmission of Buruli ulcer.

The disease is most common in Africa, they said, where patients cannot readily access or afford surgery.

“More work is needed to develop an ideal treatment strategy, in both developing countries and more sophisticated medical settings,” Dr Asiedu said.

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