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Buruli UlcerBuruli_PathNCT02153034

Pathogenesis and Management of M. Ulcerans Disease, Buruli Ulcer

An observational study of Buruli Ulcer and Mycobacterium Ulcerans Disease, run by Kwame Nkrumah University of Science and Technology at 3 sites in Ghana.

Unknown status

Status not confirmed. The sponsor has not verified this record for over two years, so it may be out of date.

Official record
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Trial summary

Buruli ulcer is a neglected tropical disease caused by infection with Mycobacterium ulcerans (Mu) in rural parts of West Africa. It causes large skin ulcers mainly in children aged 5 to 15 years. Access to treatment is limited and many cases present late. Read more about this study

Who is it for?
Ages 5 years and olderHealthy volunteers can take part
Conditions the study is for
Buruli Ulcer, Mycobacterium Ulcerans Disease
How many people
400 participants
Where
3 sitesGhana
Study dates
May 2013to Jan 2018
Phase
Observational
Are there results?
None posted in the registry

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 5 years and older
  • All sexes
  • Healthy volunteers accepted
  • Child, Adult, Older adult

Study population: Patients with confirmed Buruli ulcer and healthy contacts of patients with Buruli ulcer

Who may be able to join

  • All patients 5 years old or more diagnosed as having Buruli ulcer.
  • Age-matched household contacts of patients that present with Buruli ulcer and healthy volunteers living in Buruli ulcer non-endemic communities

Who cannot join

  • Patients aged less than 5 years and those
  • Unwilling to give informed consent

Trial locations and contacts

3 sites in 1 country.

Ghana3 sites
  • Agogo Presbyterian Hospital

    Agogo, Asante Akim North District

  • Nkawie Government Hospital

    Nkawie, Atwima Nwabiangya District

  • Tepa Government Hospital

    Tepa, Ahafo Ano North District

Other trials in Ghana

About this study

Official title: A Study of the Pathogenesis and Management of M. Ulcerans Disease, Buruli Ulcer

Buruli ulcer is a neglected tropical disease caused by infection with Mycobacterium ulcerans (Mu) in rural parts of West Africa. It causes large skin ulcers mainly in children aged 5 to 15 years. Access to treatment is limited and many cases present late. There have been major advances in understanding the mechanism of disease together with improved diagnosis and management. The aim of the proposed studies is to identify markers predictive of a rapid response to antibiotic treatment and to investigate the pathogenesis of paradoxical reactions and oedematous lesions in Mu disease.

Infection with Mu results in a nodule under the skin which enlarges and breaks down to form an ulcer. This is because Mu produces a toxin that spreads outwards and damages subcutaneous tissue. In recent years it has been found that antibiotic treatment for 8 weeks with daily tablets and intramuscular injections heals ulcers. This is unpleasant and it would be better if the treatment could be shortened. Our previous studies suggest this may be possible. Therefore a wide range of tests will be investigated in order to identify markers for people in whom the infection is at an early stage with low numbers of Mu bacteria and low levels of toxin in the skin. During antibiotic treatment the rate of healing will be measured to find out which markers are the most reliable.

Read more

In some patients new areas of inflammation develop despite treatment and this is called a paradoxical reaction. The immune response to Mu will be investigated serially during antibiotic treatment to investigate the cause of paradoxical reactions.

About 15% of patients have oedematous disease, the most severe form of Buruli ulcer. We will study the amount of Mu toxin produced by the strain of Mu cultured from patients with this form of the disease.

Hypothesis

  • Buruli ulcer patients that heal rapidly/slowly or develop paradoxical reactions with treatment will have associated predictive viability or serum biomarkers.
  • Buruli ulcer patients with oedematous disease are associated with larger amounts of mycolactone and viable organisms
Read the detailed description

Procedures

Infected Participants

After collection of demographic data using standard World Health Organisation forms (BU01) together with a careful history to establish when early lesions (nodules, plaques and ulcers) were first observed, the type and dimensions of lesions will be documented together with digital photographs and tracings onto acetate sheets. For oedematous lesions only digital photographs will be obtained. Patients will be reviewed at 2 weekly intervals during standard antibiotic treatment (rifampicin 10mg/kg and streptomycin 15mg/kg) with further recordings of clinical data as is done for all routine patients. These measurements will enable calculation of rate of healing and healing time in relation to lesion size and type. Patients will be monitored for paradoxical reactions that occur after the start of treatment in about 8% of patients. These procedures are routinely provided as part of routine care of Buruli ulcer patients.

Samples

The additional samples required from patients for the study are an extra volume of blood (7ml) and 3 swabs taken on occasions (at baseline, week 4, 8, 12 and 16) only when the patient has a lesion at these time points. Swabs/fine needle aspirates are required to determine if organisms detected by polymerase chain reaction (PCR) are still viable, one for M. ulcerans culture, one for measurement of mycolactone concentration, and one for combined 16S ribosomal ribonucleic acid (rRNA) reverse transcriptase / insertion sequence IS2404 Real-Time qPCR assay (1).

For patients that develop paradoxical lesions during therapy an additional blood sample and 3 swabs/fine needle aspirates will be obtained at the time of the reaction for viability markers (M. ulcerans culture, combined 16S rRNA reverse transcriptase / IS2404 Real-Time quantitative polymerase chain reaction (qPCR) assay and mycolactone detection).

For oedematous lesions, one swab/fine needle aspirates will be obtained for mycolactone detection and quantification from lesions that are ulcerated. A 3 mm punch biopsy will be performed under local anaesthetic on non-ulcerated lesions for the same purpose only when the patient is 15 years old or above.

Established practice for routine diagnosis of M. ulcerans infection is to take fine needle aspirates from non-ulcerated lesions for acid-fast bacillus (AFB) detection, culture and PCR for IS2404. This specimen is not large enough for mycolactone quantification, an important part of the investigation into the pathogenesis of oedematous disease which often presents without ulceration. Swabs are used in the diagnosis of ulcers.

Controls For the household contacts of patients in endemic villages and healthy controls in non-endemic villages a 7ml blood sample will be obtained to investigate protein biomarkers by Luminex assay, T cell subsets by flow cytometry and immune responses using Enzyme Linked Immunosorbent Assay(ELISA) in a whole blood assay for comparative studies. No tissue biopsies will be taken.

Definition of paradoxical reaction Paradoxical reaction will be defined as an increase in inflammatory changes with increase in lesion size of greater than 100%, after initial improvement and decrease in size; and/or the appearance of new lesions following or during antimycobacterial treatment.

Investigations Detection of rapid responders: Biomarkers, tissue mycolactone concentration and immune response will be measured at baseline. The rate of healing will be estimated by documenting the initial size of the lesion and the time to complete healing as previously (2).

Detection of Mu: Swabs homogenates will be inoculated onto Lowenstein Jensen slopes for culture and microscopy will be carried out on Ziehl-Neelsen stained smears for AFB. PCR for IS2404 will be carried out as described previously (3).

Biomarkers:

Serum samples will be subjected to multi-analyte profiling using Luminex multianalyte profiling to identify markers of oedematous disease, paradoxical reactions and rapid responders.

We will also use mass spectrometry-based proteomics to generate additional serum/tissue biomarkers taking a three-stage approach. First we will use sample fractionation and mass spectrometry (matrix-assisted laser desorption/ionisation/time of flight/mass spectrometry) to determine the degree of variability of proteomic composition in samples from subjects to be treated with antibiotics. This first screening will allow the identification and removal of subjects showing a partial response and subsequent analysis of those showing the most disparate responses. Stage 2 comprises a deep liquid chromatography mass spectrometry (LC/MS/MS)-based quantitative analysis of pooled samples (3 pools generated randomly from each response cohort) from each of the identified response groups. Molecules that show significant changes will be considered as candidate biomarkers of drug response. In Stage 3 immunoassays (ELISA) will be developed in order to test the validity of each novel biomarker in its ability separately or in combination with existing biomarkers to predict drug response.

Immune response: Whole blood samples will be incubated with Mu antigens overnight at 37 degrees celsius and the supernate will be stored for cytokine assays using ELISA as in our previous studies (4).

Antigen stimulated T cell populations will also be studied by flow cytometry to assess the proportion of Interferon(IFN) gamma, Tumor necrosis factor (TNF) and interleukin-2 (IL2) secreting T cells in patients compared to controls.

Mycolactone detection: Lipids will be extracted from homogenised skin biopsies and swabs//fine needle aspirates and the biological activity of mycolactone will be measured by a cytotoxicity assay as described previously using human embryonic lung fibroblasts as target cells. The presence of mycolactone in tissue samples will be confirmed and quantified by mass spectrometry as previously described (5). Mycolactone production by the strain of Mu isolated from oedematous lesions will be quantified in vitro and the tissue concentration of mycolactone in oedematous lesions will be measured.

Sample size and justification There will be 450 participants in this study. Our previous studies showed a mean difference in TNF alpha at baseline between fast and slow responders to be 15pg/ml and a standard deviation of 33pg/ml. The standardized mean difference computed as d=15/33 was 0.45. The sample size required to detect this difference with a two-sided significance of 5% and with 80% power would be 100 participants in each group (that 200 patients). We expect an attrition rate of 20% bringing the sample size to 250 patients. There will be control group of 200 healthy volunteers

Statistical analysis For the purpose of this study a "rapid responder or fast responder" is defined as a patient with a time to healing of less than 12 weeks or rate of healing of greater than 4mm/week and " slow responder or slow healer" is defined as a patient with time to healing of 12 or more weeks or rate of healing of less than 3 mm/week

Data generated by multianalyte profiling will be analyzed by multivariate analysis, including principal component analysis (PCA) and partial least-squares (PLS)-related methods, using the SIMCA 13 software (Umetrics, Sweden) . Univariate analyses will be performed to further characterize candidate biomarkers. Here, differences between controls and disease patients will be analyzed using the non-parametric Wilcoxon rank sum (Mann-Whitney) test. Paired samples for BUD patients at week 0 and week 12 will be compared using the Wilcoxon signed rank test. Univariate analysis and multiple testing adjustments will be performed using R software (version 2.13.2, R Development Core Team, R Foundation for Statistical Computing, Vienna, Austria) and package QVALUE. GraphPad Prism software will be used for graphical representation.

Keywords
Buruli ulcer, Mycobacterium ulcerans disease, M. ulcerans disease
Medical subject headings
Buruli Ulcer

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

Study groups in NCT02153034
Study groupRoleWhat they receive
Buruli ulcer patients, no interventionBuruli ulcer patients administered standard standard care by the attending physician
Healthy contacts, no interventionHealthy volunteers who will be contacts of patients recruited or non-endemic controls. No intervention will be administered

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Measurement of serum/plasma proteins in diseased and healthy subjects

    Measured: Assessed for diseased participants at baseline, 8, 12, 16 weeks and only at baseline for healthy subjects

Secondary outcomes (1)
  1. Viable M. ulcerans and bacterial load measurement in tissue of diseased subjects

    Measured: Assessed at baseline, 4, 8, 12, 16 only if lesions are not healed

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted2 Jun 2014 (estimated)
  2. Study startMay 2013
  3. Primary completion15 Dec 2016
  4. Study completionJan 2018 (estimated)

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Observational
Observational model
Case-control
Time perspective
Prospective
Enrolment
400 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT02153034
Sponsor's protocol ID
MR/J01477X/1
Acronym
Buruli_Path
Status last verified
Mar 2017
First submitted
28 May 2014
Last updated
23 Mar 2017
Results posted
No
Data monitoring committee
No

Publications

  • Frimpong M, Agbavor B, Duah MS, Loglo A, Sarpong FN, Boakye-Appiah J, Abass KM, Dongyele M, Amofa G, Tuah W, Frempong M, Amoako YA, Wansbrough-Jones M, Phillips RO. Paradoxical reactions in Buruli ulcer after initiation of antibiotic therapy: Relationship to bacterial load. PLoS Negl Trop Dis. 2019 Aug 26;13(8):e0007689. doi: 10.1371/journal.pntd.0007689. eCollection 2019 Aug.

    PubMed 31449522

Questions about this trial

What is this clinical trial studying?

An observational study of Buruli Ulcer and Mycobacterium Ulcerans Disease, run by Kwame Nkrumah University of Science and Technology at 3 sites in Ghana.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 2 inclusion and 2 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: status not confirmed, as of the sponsor's last update on 23 Mar 2017. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 3 sites in Ghana. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

Results are not available in the source record.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Measurement of serum/plasma proteins in diseased and healthy subjects (time frame: Assessed for diseased participants at baseline, 8, 12, 16 weeks and only at baseline for healthy subjects). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT02153034, which also lists 1 linked publication.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 23 Mar 2017.

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