Presumptive Diagnosis of Buruli Ulcer Based on Clinical Presentation Oluniyi PE, *Oke AA, Komolafe IOO   Dept. Biological Sciences, Faculty of Natural Sciences, Redeemer’s University, Ede 232101.Osun State. *Presenting Author E-mail: okead@run.edu.ng Mobile : 08083985596/08106363873. INTRODUCTION Buruli ulcer (BU),caused by Mycobacterium ulcerans, is an infectious and chronic debilitating tropical disease of the skin, subcutaneous tissue and occasionally bone, that can lead to permanent disfigurement and disability1,2. BU is one of the 17 neglected tropical diseases and has been reported in at least 33 countries with tropical, subtropical and temperate climates. Between 5000–6000 cases are reported annually from 15 of the 33 countries, most of these cases occur in rural communities that settle near wetlands, rice-growing areas, slow flowing streams or lakes in sub-Saharan Africa where almost half of people who are affected are children under 15 years of age2. The exact mode of transmission of the BU agent is still unknown, however some carnivorous water bugs among others are thought to be responsible1,3. BU is now the third most common mycobacterial disease of humans after tuberculosis and leprosy . However, in some parts of Cote d’Ivoire, Ghana and Benin Republic, Buruli ulcer has overtaken tuberculosis and leprosy as the most common4 . A co-infection of leprosy and Buruli ulcer is possible but very rare5 while a co-infection with tuberculosis has, till date, not been reported 6 . BU was first reported in Nigeria in 1967 when four cases in the Benue river valley and around Bambus area in the then Adamawa Province were documented 7. Then in 1975, a case of BU involving a Caucasian family residing near a newly constructed dam on the campus of the University of Ibadan in south-west Nigeria was discovered 8 . Subsequent case search yielded 23 more cases within and around Ibadan metropolis. For two decades thereafter there was no follow-up search or research on BU in Nigeria. Meanwhile it had been reported in endemic proportions among several communities in many other countries on the West African coast. Between 1998 and 2000,samples sent from the Leprosy and Tuberculosis Hospital in Moniaya-Ogoja, Cross River State to the Institute of Tropical Medicine in Belgium were confirmed positive. On this premise, in 2006 a WHO team and health authorities in Nigeria conducted a 5-day active case search of the disease in five states in South-South and South-East regions where 37 suspected cases were examined and 14 (38%) of them were confirmed positive Buruli ulcer at the Institute of Tropical Medicine, Antwerp, Belgium using IS2404 PCR method 9 . Despite these reports BU still remains generally unnoticed ,unreported and untreated thus making the determination of the burden of disease difficult. This is due to the poor knowledge about the disease. Till date public awareness of BU is very low even among the health workers who are supposed to treat the disease. An appropriate diagnosis of the BU is very crucial in its control and except in the endemic areas where the disease is known the diagnosis of BU can be a challenge. Aim: This study was an attempt to presumptively identify cases of BU disease in the absence of a laboratory confirmation. A WHO-prepared colour atlas of Buruli ulcer images was mounted at the outpatient department (OPD) of 2 government-owned hospitals in Ogun State, south-west, Nigeria Hospitals, to serve as guide in the identification of similar lesions presenting to the hospitals. Direct comparisons of the images and the presenting lesions were made. Patients demographic details such as sex, age, origin, duration and distribution of the ulcers including the presence of pain or otherwise were also recorded. RESULTS A total of eighteen out-patients comprising 13(72.2%) females and 5(27.8%) males in two public hospitals, presenting with Buruli ulcer-like lesions were observed. 10(55.6%) and 8(44.4%) of them were from the tertiary and secondary health facilities respectively. 11 (61%) of the ulcers were located on the lower limb, 4(22%) on the breast and 4 (22%) on the upper limb; 14(77.8%) of the patients were above 40 years of age, 2(11.1%) were between 18 and 30years while only 2(11.1%) were below 15 years. 16(89%) of the patients could not remember how the ulcer started while 2(11%) of them said their lesions started with a scratch. All but 1 case were painless with undermined edges which are characteristic features consistent with BUD. Fig. 1 Pictorial WHO Images of Buruli Ulcer Fig. 2. Images from Patients with presumptive Buruli Ulcer in the two hospitals CONCLUSION Although it is believed that BU is more common in children below 15 years in sub-Saharan Africa2 the reverse is the case in this study where 89% of the patients were actually adults. Similarly most of the ulcers(61%) in this study were on the lower limbs as also documented by WHO 2,6 .The fact that we could not confirm these cases by PCR due to lack of materials does not diminish the significance of this study as BU has been confirmed in Oyo and Ogun States both in south-west, Nigeria previously. The detection of these ulcers in just two hospitals and within a period of three months is significant and suggestive of Buruli ulcer being probably more prevalent in Ogun State, Nigeria and even in the nation as a whole than aforethought. METHODS REFERENCES 1. Stinear, T., Johnson, P.D. (2008). First isolation of M. ulcerans from an aquatic environment. The end of a 60-year search? PLoS Negl Trop Dis, 2(3):216. 2. World Health Organization (2014). Buruli ulcer- A guide for field health workers. WHO 3. Ablordey et al.(2015). Whole Genome Comparisons Suggest Random Distribution of Mycobacterium ulcerans Genotypes in a Buruli Ulcer Endemic Region of Ghana. PLoS Negl Trop Dis, 9(3):ee0003681. 4. Asiedu, K. (2005). Report of the WHO Global Buruli Ulcer Initiative meeting held in Geneva, Switzerland from March 14 – 17, 2005. 5. Meyers, W.M., Connor, D.H. (1975). Mycobacterium ulcerans infections in patients. Leprosy Review, 46: 21-27. 6. Komolafe, O.O (2011). Buruli Ulcer. Redeemer’s University Quarterly seminar presentation held on 23rd November, 2011. 7. Gray, H.H., Kingma, S. (1967). Mycobacterial skin ulcers in Nigeria. J Trop Dis Hyg, 61:712-4. 8. Oluwasanmi, J.O., Itayemi, S.O., Alabi, G.O. (1975). Buruli (mycobacterial) ulcers in Caucasians in Nigeria. Brit J Plas Surg, 28: 111-113. 9. Chuckwuekezie, O., Ampadu, E., Sopoh, G. (2007). Buruli ulcer in Nigeria. 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