title: Excision of pre-ulcerative forms of Buruli ulcer disease: a curative treatment?
abstract: BACKGROUND
  Previous investigations have revealed that Mycobacterium ulcerans is extensively distributed spatially throughout ulcerative lesions, including in the margins of excised tissue. In contrast, bacilli in pre-ulcerative lesions are assumed to be concentrated in the center of the lesion. In order to assess the extent to which the surgical excision of pre-ulcerative lesions is capable of removing all infected tissue, we subjected the excision margins of pre-ulcerative lesions to laboratory analysis.
  
  
  METHODS
  Eleven patients with laboratory-confirmed pre-ulcerative lesions were included in the study. The diameter of the lesion and excised tissue and the "surgical distance" between the border of the lesion and excision margin were measured. The entire excision margin was cut into segments and subjected to IS2404 PCR.
  
  
  RESULTS
  The results from the PCR analysis on the samples of excision margins were highly significantly associated with the surgical distance (p < 0.001). The margin samples of nodules were significantly more often PCR positive than the plaques (p = 0.025). The size of the lesion and the size of the excised tissue did not significantly influence the PCR results. Statistically, a surgical distance of more than 9 mm was found to reduce the risk of remaining infected tissue to less than 10%, that of 13 mm to reduce the risk to less than 5%, and that of 25 mm to reduce the risk to nearly 0%.
  
  
  CONCLUSIONS
  The results of this study show that in preulcerative Buruli ulcer disease, bacilli may extend beyond the actual size of the lesion and that there is a strong correlation between the presence of M. ulcerans in the margin samples and the surgical distance. Excision with a surgical distance of 25 mm avoided the risk of remaining mycobacteria in this study. However, no recurrences occurred in the patients with M. ulcerans-positive excision margins. The need of postoperative antimycobacterial treatment in these patients remains to be determined.
authors.affiliation: Department of Infectious Diseases and Tropical Medicine (DITM), Ludwig-Maximilian University Munich, Leopoldstrasse 5, 80802, Munich, Germany. herbinger@lrz.uni-muenchen.de
authors.forename: K-H
authors.initials: KH
authors.lastname: Herbinger
authors.forename: D
authors.initials: D
authors.lastname: Brieske
authors.forename: J
authors.initials: J
authors.lastname: Nitschke
authors.forename: V
authors.initials: V
authors.lastname: Siegmund
authors.forename: W
authors.initials: W
authors.lastname: Thompson
authors.forename: E
authors.initials: E
authors.lastname: Klutse
authors.forename: N Y
authors.initials: NY
authors.lastname: Awua-Boateng
authors.forename: E
authors.initials: E
authors.lastname: Bruhl
authors.forename: L
authors.initials: L
authors.lastname: Kunaa
authors.forename: M
authors.initials: M
authors.lastname: Schunk
authors.forename: O
authors.initials: O
authors.lastname: Adjei
authors.forename: T
authors.initials: T
authors.lastname: Löscher
authors.forename: G
authors.initials: G
authors.lastname: Bretzel
mesh_terms: D000293:Adolescent; D000328:Adult; D054312:Buruli Ulcer / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D004251:DNA Transposable Elements; D004269:DNA, Bacterial / Q000235:genetics; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019911:Mycobacterium ulcerans / Q000235:genetics / Q000302:isolation & purification*; D016133:Polymerase Chain Reaction / Q000379:methods; D012867:Skin / Q000382:microbiology* / Q000473:pathology; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D004251:DNA Transposable Elements; D004269:DNA, Bacterial