Surgical Management of Mycobacterium Ulcerans: Experience From an Endemic Region
Sarah Lonie, MBBS, B Med Sci1, Rachael Leung, MBBS1, Parisa Naser, MBBS1, Peter G. Kelley, MBBS, FRACP2, David J Hunter-Smith, MBBS, FRACS, Plast1,3, Warren M. Rozen, MBBS, FRACS, Plast1,3
1Department of Plastic & Reconstructive Surgery, Peninsula Health, Frankston, Victoria, Australia, 2Department of Infectious Diseases, Peninsula Health, Frankston, Victoria, Australia, 3Peninsula Clinical School, Central Clinical School at Monash University, The Alfred Centre, Melbourne, Victoria, Australia
Background: The incidence of Mycobacterium ulcerans (MU) infection is increasing in Victoria, particularly in the Frankston and Mornington Peninsula regions. The infection commonly presents as a necrotic ulcer with surrounding subcutaneous necrosis and oedema. Traditional treatment has been wide excision and grafting or flap reconstruction, however this is often complicated by high recurrence rates. Contemporary management consists of antibiotic therapy and in selected cases, debridement of ulcers and/or reconstruction depending on the defect.
Methods: A retrospective clinical audit of medical records of patients who underwent surgical management of MU at Frankston Hospital was undertaken to assess the role of surgical intervention in this population.
Results: Between 2013 and 2018, 113 patients were identified, of which 44 (38.9%) required surgical intervention. Significantly less cases were managed surgically in 2018 (38.9%) compared to 2013 (85.7%), p<0.01. Intervention was most commonly excision and closure (37.2%), followed by immediate split skin graft (18.6%), multiple debridements (16.3%), debridement and delayed split skin graft (14.0%), free flap (7.0%), local flap (4.7%) and full thickness skin graft (2.3%). In the 19 surgical cases requiring reconstruction, the most common complication was graft failure (31.6%). In general, these patients had a shorter duration of antibiotics (25.8 compared to 36.8 days) compared to those with no complications.
Conclusion: The incidence of MU infection is increasing whilst surgical management is decreasing at Frankston Hospital. Surgery and particularly reconstruction is indicated for larger defects such as those resulting from paradoxical reactions and lesions that persist post antibiotic treatment.
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