Volume 29, Issue 1, Pages 1-8 (January 2011)

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Volume 29, Issue 1, Pages 1-8 (January 2011) Buruli Ulcer: Advances in Understanding Mycobacterium ulcerans Infection Douglas S. Walsh, MD, Françoise Portaels, PhD, Wayne M. Meyers, MD, PhD Dermatologic Clinics Volume 29, Issue 1, Pages 1-8 (January 2011) DOI: 10.1016/j.det.2010.09.006 Copyright © 2011 Terms and Conditions

Fig. 1 Plaque of BU on the right flank of a Ghanaian boy. The lesion has characteristic rolled borders and is remarkably stellate, a feature of some plaques. Dermatologic Clinics 2011 29, 1-8DOI: (10.1016/j.det.2010.09.006) Copyright © 2011 Terms and Conditions

Fig. 2 (A) Plaque of BU on the forearm of a Congolese boy invaded the deep tissues and bone, causing contiguous osteomyelitis. (B) Radiograph shows contiguous reactive osteitis and necrosis of the cortex of the radius, with formation of a large sequestrum (arrow). Dermatologic Clinics 2011 29, 1-8DOI: (10.1016/j.det.2010.09.006) Copyright © 2011 Terms and Conditions

Fig. 3 Distribution of BU by country, as of 2010. Relative endemicity is denoted as high (red), moderate (yellow), and low (green); asterisks denote countries with suspected cases. Imported BU is occasionally diagnosed in the United States, Canada, and Europe. Dermatologic Clinics 2011 29, 1-8DOI: (10.1016/j.det.2010.09.006) Copyright © 2011 Terms and Conditions

Fig. 4 Microscopic section of the undermined edge of a major BU. Note contiguous coagulation necrosis of the panniculus and fascia and vasculitis with thrombosis of a medium-sized vessel (arrow) (hematoxylin-eosin, original magnification ×40). A mild host inflammatory response is consistent with a toxin-mediated process. Dermatologic Clinics 2011 29, 1-8DOI: (10.1016/j.det.2010.09.006) Copyright © 2011 Terms and Conditions

Fig. 5 Microscopic section of early nodule of BU showing clumps of extracellular acid-fast bacilli (AFB, red) in the center of widespread necrosis (Ziehl-Neelsen stain, original magnification ×40). Necrosis extends far beyond the AFB, supporting the notion that M ulcerans produces a diffusible necrotizing toxin. Dermatologic Clinics 2011 29, 1-8DOI: (10.1016/j.det.2010.09.006) Copyright © 2011 Terms and Conditions

Fig. 6 Proposed classification and natural history of untreated clinical forms of active BU. Dermatologic Clinics 2011 29, 1-8DOI: (10.1016/j.det.2010.09.006) Copyright © 2011 Terms and Conditions