A healthy male teenager presented with a 2-month history of eruptions on the dorsum of his left hand, which showed diffuse painful erythema and a 2-cm ulcer. Results of blood tests were normal but for slightly elevated C-reactive protein levels (0.46 mg/dL). Culture results from the ulcer were negative for any general bacteria. Computed tomography showed neither gas production nor abscess formation. Histologic examination of the erythematous lesion revealed diffuse necrosis, and Ziehl-Neelsen (Z-N) staining showed many acid-fast bacilli in the subcutis. We diagnosed cutaneous mycobacterial infection.
Despite treatment with oral clarithromycin, 800 mg/d, and levofloxacin, 500 mg/d, the lesion expanded. Therefore rifampicin, 450 mg/d, was added to the treatment regimen 7 days after the initiation of therapy. We performed debridement on day 8 (Figure, A). Although almost all the skin on the dorsum of his hand was debrided, the erythema further expanded. We performed a second debridement on day 25 and additionally excised the erythematous lesion toward the wrist, including the area labeled 8 in Figure, B, and debrided necrotic tissue. The lesion rapidly improved after the second debridement, although some finger extensor tendons gradually became necrotic, and reconstruction of tendons was needed. The patient showed no recurrence at 1-year follow-up.
A, Clinical presentation just before first debridement: diffuse erythema and swelling on the dorsum of the left hand and necrotic skin ulcer on the lateral edge of the hand were observed; biopsies were performed at sites from 1 through 6 around the ulcer. B, Clinical presentation before second debridement: biopsies from the erythematous lesions were performed at sites 7 and 8. C, Clinical presentation before second debridement; biopsies from the erythematous lesions were performed at sites 9 and 10. D, Clinical presentation before second debridement: biopsies from the erythematous lesions were performed at sites 11 through 13. E, Histological findings from site 8: significant necrosis without granulomatous reaction was observed (hematoxylin-eosin, original magnification ×100). F, Histologic findings from site 10 showed granulomatous reactions without necrosis (hematoxylin-eosin, original magnification ×100). G, Results of polymerase chain reaction (PCR) analysis for IS2404 using pu4f and pu7r primers. Samples 1, 2, 4, 5, 6, and 11 tested positive for IS2404. Gene markers 1 through 13 represent biopsy samples taken from sites 1 through 13, respectively; gene marker N, normal control; gene marker D, 100-bp DNA marker.
At 4 weeks, growth of a yellow-white colony in Ogawa egg medium was observed. Analysis using DNA-DNA hybridization (Kyokuto, Japan) demonstrated Mycobacterium marinum bacteria. Polymerase chain reaction (PCR) analysis targeting insertion sequence IS24041,2 and pathogenic plasmid MUM001 gene sequences3 revealed Buruli ulcer caused by Mycobacterium ulcerans subspecies shinshuense, a rare mycobacterium phenotypically close to M ulcerans that produces a toxin resembling mycolactone.3,4 We note that M ulcerans subspecies shinshuense can also affect tendons and muscles, as in our case and at least 1 other case.5 Recommendations concerning the duration of antibiotic treatment and timing of surgical intervention for Buruli ulcer have been offered in preliminary guidelines issued by the World Health Organization, but there is no reliable evidence to determine the extent of surgical excision.
Using a 3-mm punch, we performed multiple biopsies from 13 erythematous sites on our patient’s hand and wrist (Figure, A-D) before first debridement at points 1 through 6 (Figure, A) and before second debridement at points 7 through 13 (Figure, B-D). We retrospectively examined the relationship among clinical presentations, histologic findings (hematoxylin-eosin [H-E] and Z-N stainings), and results of PCR analysis for IS2404 (Figure, G) to demonstrate the features of sites that needed debridement (Table). From the clinical course, we determined that all sites of first debridement (samples 1-6) and the area around sample 8 of the second debridement needed surgical resection. We performed the second debridement to address severe postoperative functional limitations and inflammation found on visual inspection, and significant improvement was achieved, even though other erythematous lesions were not surgically removed.
The histologic findings from H-E staining could be roughly categorized into 2 patterns: necrosis without granuloma formation (Figure, E) and granuloma formation without necrosis (Figure, F). The sites that needed resection were not related to the results of Z-N staining or PCR analysis for IS2404 but instead to the histologic features of cutaneous necrosis without granuloma formation. We speculate that skin erythematous lesions with histologic granuloma formation can possibly be spared from surgical excision, and erythematous lesions with persistent histologic necrosis should be excised.
The mapping biopsy procedure to determine an adequate surgical margin has been performed in cases of malignant neoplasm such as extramammary Paget disease.6 We propose that if administration of recommended antibiotics for an adequate duration proves ineffective, the preoperative mapping biopsy procedure might be used to determine the extent of surgical excision in Buruli ulcer and to avoid unnecessary resection if pathologic services are available.
Corresponding Author: Noriki Fujimoto, MD, PhD, Department of Dermatology, Shiga University of Medical Science, Setatsukinowa, Otsu, Shiga 520-2192, Japan (firstname.lastname@example.org).
Published Online: April 9, 2014. doi:10.1001/jamadermatol.2013.7497.
Conflict of Interest Disclosures: None reported.
Additional Contributions: The authors would like to thank Kazue Nakanaga, PhD, Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan, for her help in detecting the mycobacterium, and Narihito Kodama, MD, Department of Orthopedic Surgery, Shiga University of Medical Science, Shiga, Japan, for his help in surgical treatment.
Takahashi T, Fujimoto N, Nakanishi G, Ishii N, Tanaka T. Mapping Biopsy Procedure on Management of Severe Buruli Ulcer Due to Mycobacterium ulcerans, Subspecies shinshuense. JAMA Dermatol. 2014;150(6):669-671. doi:10.1001/jamadermatol.2013.7497