Infection with Mansonella perstans Nematodes in Buruli Ulcer Patients, Ghana

Richard O. Phillips

, Michael Frimpong, Fred S. Sarfo, Birte Kretschmer, Marcus Beissner, Alexander Debrah, Yaw Ampem-Amoako, Kabiru M. Abass, William Thompson, Mabel Sarpong Duah, Justice Abotsi, Ohene Adjei, Bernhard Fleischer, Gisela Bretzel, Mark Wansbrough-Jones, and Marc Jacobsen

Author affiliations: Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (R.O. Phillips, A. Debrah); Komfo Anokye Teaching Hospital, Kumasi (R.O. Phillips, F.S. Sarfo, Y. Ampem-Amoako, O. Adjei); Kumasi Collaborative Centre for Research, Kumasi (M. Frimpong, M. Sarpong Duah); Bernhard Nocht Institute of Tropical Medicine, Hamburg, Germany (B. Kretschmer, B. Fleischer); University Hospital, Ludwig-Maximilians-University of Munich, Munich, Germany (M. Beissner, G. Bretzel);Agogo Presbyterian Hospital, Agogo, Ghana (K.M. Abass, W. Thompson, J. Abotsi); St. George’s University of London, London, UK (M. Wansbrough-Jones); University Children’s Hospital, Dusseldorf, Germany (M. Jacobsen)

Abstract

During August 2010–December 2012, we conducted a study of patients in Ghana who had Buruli ulcer, caused by Mycobacterium ulcerans, and found that 23% were co-infected withMansonella perstans nematodes; 13% of controls also had M. perstans infection. M. perstansco-infection should be considered in the diagnosis and treatment of Buruli ulcer.

Buruli ulcer, caused by Mycobacterium ulcerans, is a neglected tropical disease common in rural parts of West Africa. Infection with M. ulcerans causes disfiguring skin ulcers, mainly in children. The disease is highly focal, and in Ghana, cases are reported mainly from the humid and tropical southern regions, including Ashanti and Greater Accra (1). Recent studies suggest that aquatic invertebrates serve as a reservoir for M. ulcerans, although complete transmission pathways remain unknown (2,3). Aquatic insects infected with M. ulcerans can establish infection in mice by biting (4), but it is not clear that this is the cause of human infection (5). In southeastern Australia, evidence has been found linking infected mosquitoes with human cases (6,7), but proof of transmission is lacking.

Residents of regions in which Buruli ulcer is endemic are frequently exposed to parasitic infections such as filariasis. In Ghana, lymphatic filariasis caused by Wuchereria bancroftinematodes is found in several regions to which Buruli ulcer is endemic, such as the Upper Denkyira District in the central region of Ghana, but its prevalence is unknown (8). The filarial nematode Mansonella perstans is endemic to countries in central and western Africa; its distribution overlaps that of other filarial nematodes W. bancrofti, Loa loa, and Onchocerca volvulus (9). Infective M. perstans larvae are transmitted through the bite of Culicoides midges (Diptera: Ceratopogonidae); the larvae develop over the course of months into adult worms that reside in serous cavities, particularly in the abdomen. M. perstans infection is not associated with a specific set of clinical signs and symptoms, but those attributed to this infection include acute swelling in the forearms, hands, and face that recedes in a few days and often recurs; itching with or without rash; arthralgia; and eosinophilia (9).

During an investigation into the immunopathogenesis of Buruli ulcer, we observed M. perstansnematodes in preparations of peripheral blood mononuclear cells from a patient. This finding led us to consider whether this organism was involved in the transmission or pathogenesis of M. ulcerans disease or if the finding was incidental. We then conducted a small case–control study to investigate the frequency of M. perstans co-infection in patients with M. ulcerans disease and the effect of this co-infection, if any, on patient response to antimicrobial drug therapy.

Dr Phillips is a senior lecturer at the Kwame Nkrumah University of Science and Technology. His research interest is the pathogenesis and management of M. ulceransdisease (Buruli ulcer).

Acknowledgments

We are grateful to the patients and contacts from the Asante Akim North District who agreed to be part of this study.

Funding for this work was provided by the European Community's Seventh Framework Programme under grant agreement no. 241500. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. R.O.P.’s research is funded under the United Kingdom Medical Research Council and the Department for International Development African Research Leader scheme reference MR/J01477X/1.

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Figures

Table

Table. Characteristics of patients with active Mycobacterium ulcerans infection, monoinfected or co-infected with Mansonella perstans, and of household contacts, Ghana, August 2010–December 2012

Suggested citation for this article: Phillips RO, Frimpong M, Sarfo FS, Kretschmer B, Beissner M, Debrah A, et al. Infection with Mansonella perstans nematodes in Buruli ulcer patients, Ghana. Emerg Infect Dis [Internet]. 2014 Jun [date cited]. http://dx.doi.org/10.3201/eid2006.131501

DOI: 10.3201/eid2006.131501

Medline reports that reference 8 "Hoerauf, Specht, Buttner, Pfarr, Mand, Fimmers, et al., 2008" was corrected in "Med Microbiol Immunol. 2008 Sep;197(3):335" (Note: Taylor, Mark J [added]).