Buruli Ulcer; signs, forms, nursing care and prevention

Introduction

It is a chronic infectious disease characterized by the development of subcutaneous nodule which undergoes ulceration with undefined edges and a lot of necrotic tissue. This infection leads to extensive destruction of the skin soft tissue with the formation of large ulcers. Early diagnosis and treatment are vital in preventing complications and disability.

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Incubation period: 2months - several years

Causative Agent: Mycobacterium Ulcerans

Mode of transmission; the mode of transmission has been rather elusive and mostly speculative. The probable methods of spread are;

• Inoculation by minor trauma.
• Biting insects.
• Through association with water bodies.

Please note that none of these has been proved to be actual mode of transmission.

In Ghana, cases have been reported in the following areas.

• Asante Akin north and Amansie west Districts of Ashanti region.
• Eastern region
• Central region
• Brong Ahafo region

The disease was first described by Albert Cook in the Buruli District of Uganda in 1897, from where it obtained its name.

Pathophysiology

When the organism (M.Ulcerans) gets into the body. They invade the skin and subcutaneous tissue producing indolent nodule. The bacteria produce a toxin called mycolactone that destroys skin and deep fascia. The mycolactone causes necrosis and ulcers may spread rapidly to become very large and disfiguring.

Signs and symptoms

1. Usually the lesion starts as small subcutaneous swelling which is palpable but not visible.
2. The lesion may itch.
3. Gradually, it increases in size until the skin is slightly raised.
4. The nodule is firm, painless and non-tender.
5. It becomes necrotic and eventually ulcerates.
6. After healing it leaves massive scar and various forms of deformity.

Diagnosis

• Histology of the nodule.
• Smear from necrotic tissue reveal many acid-fast bacilli.
• Skin slit test – Positive.

Pre-Ulcerative Forms

There are 3 main forms:

1. Nodule: It is a lesion that extends from the skin into the subcutaneous tissue which measure about 1.2cm in diameter. The lesion is usually painless but may be itchy with discoloured surrounding skin.
2. Plaque: This is a firm elevated, well demarcated lesion more than 2cm in diameter with reddened skin over the lesion.
3. Non-Ulcerative Oedema: Diffuse, painless with well-defined margins, few days before the swelling breaks into ulcer, it usually becomes larger and painful.

Treatment

1. Patients with Buruli Ulcer lesions should be treated with Streptomycin 15mg/Kg and Rifampicin 10mg/Kg for 8 weeks.
2. Surgery to remove nodule followed by skin grafting.
3. Wound care.
4. Prevention of disability.

Nursing care

• Care of ulcer.
• Well balanced diet with high protein.
• General nursing care of infectious disease.
• Surgical nursing care.
• Bed rest is very essential.

Control and Prevention

1. Currently BCG vaccination is the only intervention that may control the disease.
2. We have 3 levels of prevention

• Primary prevention: 
• observing good personal hygiene.
• Avoiding injury.
• Wearing of protective clothing.
• Avoid playing in stagnant and muddy waters

• Secondary prevention: Early reporting for prompt treatment before swelling breaks down into wound.
• Tertiary prevention: Affected individuals need rehabilitation due to deformity.

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