Abstract
Buruli ulcer (BU), one of the skin-related neglected tropical diseases (skin NTDs), is a necrotizing and disabling cutaneous disease caused by subcutaneous infection with Mycobacterium ulcerans. Leading on from the World Health Organization’s (WHO) establishment of a global BU initiative in 1998, >67,000 cases of BU have been reported from over 32 countries, mostly from West Africa and Australia. While treatment is currently in the transition period from rifampicin plus streptomycin (injection) to an all-oral regimen, it cannot hope to eradicate this opportunistic environmental pathogen. M. ulcerans is genetically very similar to related pathogenic organisms M. marinum, M. leprae and M. tuberculosis. However, M. ulcerans carries a unique megaplasmid, pMUM001, encoding the biosynthetic machinery responsible for production of a lipid-like exotoxin virulence factor, mycolactone. This diffusible compound causes the substantial divergence in BU’s pathogenic aetiology from other mycobacterial infections. Hence, mycolactone is cytotoxic and immunosuppressive and causes vascular dysfunction in infected skin. A major recent advance in our understanding of BU pathogenesis has been agreement on the mycolactone’s mechanism of action in host cells, targeting the Sec61 translocon during a major step in secretory and membrane protein biogenesis. While vaccine development for all mycobacteria has been challenging, mycolactone production likely presents a particular challenge in the development of a BU vaccine. The live-attenuated vaccine BCG is known to provide only partial and transient protection in humans but provides a convenient baseline in mouse preclinical studies where it can delay, but not prevent, disease progression. No experimental vaccine strategy has yet conferred greater protection than BCG. However, there is now the prospect of developing a vaccine against mycolactone itself, which may provide hope for the future.