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Background  Buruli ulcer (BU) is a skin disease caused by  Mycobacterium ulcerans , with endemicity predominantly in sub-Saharan Africa and south-eastern Australia. The mode of transmission and the environmental reservoir(s) of the bacterium and remain elusive. Real-time PCR investigations have detected  M. ulcerans  DNA in a variety of Australian environmental samples, including the faeces of native possums with and without clinical evidence of infection. This report seeks to expand on previously published findings by the authors' investigative group with regards to clinical and subclinical disease in selected wild possum species in BU-endemic areas of Victoria, Australia.    Methodology/Principal Findings  Twenty-seven clinical cases of  M. ulcerans  infection in free-ranging possums from southeastern Australia were identified retrospectively and prospectively between 1998–2011. Common ringtail possums ( Pseudocheirus peregrinus ), a common brushtail possum ( Trichosurus vulpecula ) and a mountain brushtail possum ( Trichosurus cunninghami ) were included in the clinically affected cohort. Most clinically apparent cases were adults with solitary or multiple ulcerative cutaneous lesions, generally confined to the face, limbs and/or tail. The disease was minor and self-limiting in the case of both  Trichosurus  spp. possums. In contrast, many of the common ringtail possums had cutaneous disease involving disparate anatomical sites, and in four cases there was evidence of systemic disease at post mortem examination. Where tested using real-time PCR targeted at IS 2404 , animals typically had significant levels of  M. ulcerans  DNA throughout the gut and/or faeces. A further 12 possums without cutaneous lesions were found to have PCR-positive gut contents and/or faeces (subclinical cases), and in one of these the organism was cultured from liver tissue. Comparisons were made between clinically and subclinically affected possums, and 61 PCR-negative, non-affected individuals, with regards to disease category and the categorical variables of species (common ringtail possums  v  others) and sex. Animals with clinical lesions were significantly more likely to be male common ringtail possums.    Conclusions/Significance  There is significant disease burden in common ringtail possums (especially males) in some areas of Victoria endemic for  M. ulcerans  disease. The natural history of the disease generally remains unknown, however it appears that some mildly affected common brushtail and mountain brushtail possums can spontaneously overcome the infection, whereas some severely affected animals, especially common ringtail possums, may become systemically, and potentially fatally affected. Subclinical gut carriage of  M. ulcerans  DNA in possums is quite common and in some common brushtail and mountain brushtail possums this is transient. Further work is required to determine whether  M. ulcerans  infection poses a potential threat to possum populations, and whether these animals are acting as environmental reservoirs in certain geographical areas.

Clinical, Microbiological and Pathological Findings of Mycobacterium ulcerans Infection in Three Australian Possum Species