Journal Article

Paradoxical Responses After Start of Antimicrobial Treatment in Mycobacterium ulcerans Infection

Abass, K. Mohammed, Bretzel, Gisela, Awuah, Peter C., Schouten, Jan P., Stienstra, Ymkje, Tuah, Wilson, Adjei, Ohene, van der Werf, Tjip S., Thompson, William A., Awuah-Boateng, Nana Yaa, Nienhuis, Willemien A.

2012

Overview

Background. Antimicrobial killing in mycobacterial infections may be accompanied by (transient) clinical deterioration, known as paradoxical reaction. To search for patterns reflecting such reactions in the treatment of Buruli ulcer (Mycobacterium ulcerans infection), the evolution of lesions of patients treated with antimicrobials was prospectively assessed. Methods. The lesion size of participants of the BURULICO antimicrobial trial (with lesions ≤ 10 cm crosssectional diameter) was assessed by careful palpation and recorded by serial acetate sheet tracings. Patients were treated with antimicrobials for 8 weeks. For the size analysis, participants whose treatment had failed, had skin grafting, or were coinfected with human immunodeficiency virus were excluded. For every time point, surface area was compared with the previous assessment. A generalized additive mixed model was used to study lesion evolution. Nonulcerative lesions were studied using digital images recording possible subsequent ulceration. Results. Of 151 participants, 134 were included in the lesion size analysis. Peak paradoxical response occurred at week 8; > 30% of participants showed an increase in lesion size as compared with the previous (week 6) assessment. Seventy-five of 90 (83%) of nonulcerative lesions ulcerated after start of treatment. Nine participants developed new lesions during or after treatment. All lesions subsequently healed. Conclusions. After start of antimicrobial treatment for Buruli ulcer, new or progressive ulceration is common before healing sets in. This paradoxical response, most prominent at the end of the 8-week antimicrobial treatment, should not be misinterpreted as failure to respond to treatment.

• Publisher: Oxford University Press
• Subject: Adolescent / Anti-Bacterial Agents - administration & dosage / Antibiotics / Antimicrobial agents / Antimicrobials / ARTICLES AND COMMENTARIES / Bacterial diseases / Bacterial infections / Biological and medical sciences / Buruli Ulcer - drug therapy / Buruli Ulcer - microbiology / Buruli Ulcer - pathology / Child / Clinical outcomes / Drug therapy / Experimentation / Female / Fungal infections / Gram-positive bacteria / Healing / HIV / Human bacterial diseases / Human immunodeficiency virus / Humans / Infections / Infectious diseases / Lesions / Male / Medical sciences / Mycobacterium / Mycobacterium ulcerans / Mycobacterium ulcerans - isolation & purification / Prospective Studies / Pulmonary tuberculosis / Skin - pathology / Surface areas / Tuberculosis and atypical mycobacterial infections / Ulcers / Young Adult