Distribution of Buruli ulcer lesions over body surface area in a large case series in Ghana: uncovering clues for mode of transmission

Abstract

We studied hospital records of 750 consecutive Buruli ulcer patients in a highly endemic area in Amansie West, Ghana. Although more Buruli ulcer lesions were found on the right side of the body, comparison of lesions on arms and legs showed a bilaterally symmetrical distribution. Upper and lower extremities were affected equally by Buruli ulcers, if correction was made for differences in body surface area. Patients from outside the Amansie West district presented significantly more often with ulcerated lesions, which were more often located on a joint, than patients who lived in Amansie West, suggesting that longer travel distance might have caused delay. Our observations of a bilaterally symmetrical distribution of lesions on extremities and equal upper and lower extremity involvement are compatible with a mode of transmission that involves passive exposure of exposed body parts. An asymmetrical distribution of lesions was found in an earlier study, suggesting transmission by vegetation near the ground, through activities like farming or play. Perhaps, transmission in or near water, e.g. by bites of infected aquatic insects, might favour the pattern of distribution of lesions that we found.

Mycobacterium ulcerans Disease (Buruli Ulcer): Potential Reservoirs and Vectors

“…Many different reports from Africa and a study in Australia have consistently shown that the majority of lesions is located on the lower limbs [21,32,34,[54][55][56] and a focus on joints has been described in adults [21,55,56]. Furthermore, the anatomical site of the lesions was shown to vary with both age and gender.…”

“…Furthermore, the anatomical site of the lesions was shown to vary with both age and gender. While children tend to have a more dispersed distribution of lesions over the body, lesions seem to become increasingly confined to the limbs in adults [32,45,54,57], presumably because children cover their trunks less often compared to adults. The gender difference varies between studies and is thought to be influenced by behavioral factors and environmental contact patterns.…”

Epidemiology and disease burden of Buruli ulcer: a review

“…71 These differences in the distribution of lesions among children and adults were reconfirmed in other studies. 89,90,93 While some studies have reported that among females, arms were more 71 and the trunk less 90 frequently affected as compared with males, other data indicate a similar distribution of lesion sites in both sexes. 93 Variations in the affected anatomical sites by age and sex may be due to differences in domestic or agricultural activities (eg, females fetching water and working in the fields with their bare hands; males farming, carrying out work using hoes and other tools) or different behaviors (males and children more commonly exposing their upper trunk than females).…”

“…71 Several studies have reconfirmed this observation reporting that male patients were more prevalent in the younger age groups than females, but less prevalent in adults. 8,72,92,93 …”

“…In the majority of the patients, lesions occur on the lower limbs, followed by the upper limbs, the trunk, and the neck/ head. 8,72,90,93,110 In the refugee population in Kinyara, the site of the lesion varied with both sex and age. Among children below 5 years of age, the lesions were distributed over all parts of the body, while with increasing age, lesions on the head and trunk were less common and largely confined to the limbs.…”