Differential diagnosis of ulcerative cutaneous lesions: the emergence of buruli ulcer in Western European countries

The Buruli ulcer (BU), secondary to the infection by Mycobacterium ulcerans, is considered by the World Health Organization (WHO) to be a neglected tropical disease. Despite being the third most common mycobacteriosis, reported in more than 30 countries, it is the one that raises the most epidemiological doubts. Clinically, it manifests itself as a painless and necrotizing lesion of the skin, subcutaneous tissue and bone. Typically, it occurs on lower limbs, having several possible clinical manifestations (nodules, papules, plaques, edema and/or ulcers). Fibrosis and contractures resulting from the healing process are the factors responsible for stigmatization and morbidity associated to BU. The WHO recommends treatment with double antibiotic therapy for a period of eight weeks, even in the presence of a suspected case without laboratorial confirmation. Despite the vast knowledge about the Buruli ulcer in endemic countries, in Western European countries such as Portugal this diagnosis may be overlooked. We present a clinical case to illustrate the importance of the diagnostic suspicion and timely treatment in the prognosis of BU patients.