Delays in Patient Presentation and Diagnosis for Buruli Ulcer (Mycobacterium ulcerans Infection) in Victoria, Australia, 2011–2017

Abstract

Uncertainty regarding transmission pathways and control measures makes prompt presentation and diagnosis for Buruli ulcer critical. To examine presentation and diagnosis delays in Victoria, Australia, we conducted a retrospective study of 703 cases notified between 2011 and 2017, classified as residing in an endemic (Mornington Peninsula; Bellarine Peninsula; South-east Bayside and Frankston) or non-endemic area. Overall median presentation delay was 30 days (IQR 14–60 days), with no significant change over the study period (p = 0.11). There were significant differences in median presentation delay between areas of residence (p = 0.02), but no significant change over the study period within any area. Overall median diagnosis delay was 10 days (IQR 0–40 days), with no significant change over the study period (p = 0.13). There were significant differences in median diagnosis delay between areas (p < 0.001), but a significant decrease over time only on the Mornington Peninsula (p < 0.001). On multivariable analysis, being aged <15 or >65 years; having non-ulcerative disease; and residing in the Bellarine Peninsula or South-East Bayside (compared to non-endemic areas) were significantly associated with shorter presentation delay. Residing in the Bellarine or Mornington Peninsula and being notified later in the study period were significantly associated with shorter diagnosis delay. To reduce presentation and diagnosis delays, awareness of Buruli ulcer must be raised with the public and medical professionals, particularly those based outside established endemic areas.

Complicated Mycobacterium ulcerans infection in a child in the Northern Territory

“…2 Early clinical suspicion ensures appropriate samples are collected, including fresh tissue for microbiological and PCR investigations, as well as formalin-fixed for histopathology, although unfortunately diagnostic delays persist in non-endemic areas. 3 Optimal specimen collection includes two cotton swabs from beneath the undermined edges of the ulcer, or punch biopsies from edges of the lesion. 4 Due to significant necrosis from the production of mycolactone, lesions are often polymicrobial.…”

“…Diagnosis requires confirmation of M. ulcerans via PCR or culture, or necrotising granulomatous inflammation with AFB on histopathology 2 . Early clinical suspicion ensures appropriate samples are collected, including fresh tissue for microbiological and PCR investigations, as well as formalin‐fixed for histopathology, although unfortunately diagnostic delays persist in non‐endemic areas 3 . Optimal specimen collection includes two cotton swabs from beneath the undermined edges of the ulcer, or punch biopsies from edges of the lesion 4 …”

Mycobacterium ulceransnot detected by PCR on human skin in Buruli ulcer endemic areas of south eastern Australia

“…The paradox of a summer-transmitted disease appearing in winter is explained by a long incubation period with a median of 4.5 months plus additional time taken to establish the diagnosis after a lesion first appears [16][17][18].…”

“…We have also reported that although new BU cases are most often diagnosed in Victoria in winter and spring, peak transmission occurs in summer and autumn [10]. The paradox of a summer-transmitted disease appearing in winter is explained by a long incubation period with a median of 4.5 months plus additional time taken to establish the diagnosis after a lesion first appears [16-18].…”

Cell-mediated and serology-based tests for Mycobacterium ulcerans disease: A systematic review and meta-analysis

“…All these tests require trained staff with access to well-equipped laboratory facilities [9]. Furthermore, there are difficulties in the accurate diagnosis of BU in endemic localities with the current diagnostic tools [12], resulting in diagnosis delay that inevitably leads to severe forms of BU and long hospitalisation [12,13]. There is a call to develop an easy to use, reliable and rapid test for BU diagnosis and surveillance in "high-risk communities" to aid timely and effective treatment [12].…”