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Please use this identifier to cite or link to this item: http://hdl.handle.net/123456789/11899

Title: A Severe Case of Buruli Ulcer Disease with Pleural Effusions
Authors: Phillips, Richard O.
Sarfo, Fred S.
Thompson, William
Paintsil, Albert
Abass, Mohammed K.
et. al
Issue Date: 19-Jun-2014
Publisher: PLOS Neglected Tropical Diseases
Citation: PLoS Negl Trop Dis 8(6): e2868. doi:10.1371/journal.pntd.0002868
Abstract: Patient GO is an 8-year-old student from Drobonso, a Buruli ulcer–endemic community in the Sekyere Afram Plains of the Ashanti region of Ghana. She presented with a month’s history of a painless nodule on the anterior chest which started increasing in size rapidly over the course of two weeks. After applying herbal preparations on the lesion and observing no improvement in symptoms, she sought medical attention through which a course of oral amoxycillin was prescribed for a week. However, her lesion continued to enlarge with involvement of her anterior and posterior chest walls and ulcerations over the left anterior cervical triangle and midsternal region. Upon the recommendation of a former patient from the same endemic region, she came to the Buruli ulcer clinic at the Agogo Presbyterian Hospital on the 24th of February 2011. On examination, the patient looked fairly stable and was afebrile (36.9uC), not pale, and anicteric with no regional lymphadenopathy. Her chest was clinically clear with a respiratory rate of 14 cycles/min. The most significant finding was an extensive oedematous lesion involving the chest and neck regions with two deep ulcerations (Figure 1). She weighed 31 kg at diagnosis (95th centile in weight for age). Swab samples obtained from the ulcer were positive by PCR for IS2404, acid-alcoholfast bacilli, and Mycobacterium ulcerans culture on Lowenstein-Jensen culture slopes. Patient was admitted, and antibiotic combination therapy comprising daily intramuscular injection of 15 mg/ kg of streptomycin and 10 mg/kg of oral rifampin was started together with wound care and nutritional support. Two weeks into treatment, she was noted to have become breathless with the accompaniment of fever and chills but with no associated cough. Clinical examinations revealed the presence of pleural effusions bilaterally and pyrexia of 37.9uC. Full blood counts revealed her white cell count had increased from 10.3 x 103 /L on admission to 20.8 x 103/L. An HIV antibody test was negative, and the performance of a chest X-ray confirmed the presence of bilateral pleural effusions (Figure 2). Diagnostic pleural aspirate showed the effusion to be an exudate with an elevated protein concentration of 82.5 g/l, pH = 7.5, and predominantly neutrophils on cytopathology but no isolates on aerobic and anaerobic cultures. PCR on pleural aspirate was positive for M. ulcerans but was negative for tuberculosis—a differential diagnosis. An aspirate of the effusion was tested for the presence of mycolactone using UPLC-mass spectrometry, as described elsewhere [1], but the intact mycolactone A/B was not detected. The left pleural effusion was drained with the aid of a chest tube and by needle aspiration of the right pleural effusion. She was put on 30 mg of oral prednisone twice daily for 2 weeks with resolution of the effusion within 2 weeks of its appearance. However, the effusion on the right side recurred (Figure 2D) and was managed successfully by needle thoracocentesis. Upon completion of antimycobacterial antibiotic therapy for 8 weeks, surgery was performed, comprising excision and skin grafting. The lesion healed gradually over 48 weeks but resulted in a hypertrophic scar over the manubrio-sternum. Parental informed consent was obtained.
Description: An article published by PLOS Neglected Tropical Diseases and available at doi:10.1371/journal.pntd.0002868
URI: http://hdl.handle.net/123456789/11899
Appears in Collections:College of Health Sciences

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