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• W2054042898 abstract "In November 2009, a previously healthy 16-year-old girl was referred to our department with a persistent skin lesion on her left leg. She had sustained a laceration at the same site in May 2008 when she scraped herself on barnacles whilst kayaking in the local Maribyrnong River. The laceration was slow to heal and gradually transformed into a nodular lesion over the following three months. A curettage in November 2008 failed to achieve clinical resolution and cultures revealed no causative organism. An attempt to excise the lesion in February 2009 was also unsuccessful; histology of the excised material showed granulomatous inflammation. Examination revealed a 13 mm diameter nodular, erythematous, non-tender lesion on her left lower leg (Figure 1). There was no regional lymphadenopathy and other physical examination was unremarkable. A biopsy of the lesion was sent for mycobacterial PCR testing. Sequencing of the PCR product revealed close homology with published sequences of Mycobacterium marinum. A QuantiFERON-TB Gold assay was positive. The patient was started on ethambutol and clarithromycin, which resulted in significant improvement within 6 weeks and near complete resolution of the lesion after 4 months. M. marinum is a non-tuberculous mycobacterium found in fresh as well as salt-water, which causes disease in fish and other water-dwelling animals. Humans typically develop infection – often referred to as ‘fish tank granuloma’ – following an aquatic injury, such as abrasions caused by contact with shellfish or coral. At-risk groups therefore include fishermen, fish fanciers, and water sports enthusiasts. M. marinum infections are rare; the incidence was recently estimated to be less than 1 case per 100 000 inhabitants per year.1Aubry A. Chosidow O. Caumes E. Robert J. Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates.Arch Intern Med. 2002; 162: 1746-1752Crossref PubMed Scopus (300) Google Scholar The hands and arms are the most commonly affected sites, followed by the lower limbs. Infections are typically limited to the skin and soft tissue, but invasive disease, including tenosynovitis, septic arthritis, osteomyelitis, and disseminated infection have been described.2Lahey T. Invasive Mycobacterium marinum infections.Emerg Infect Dis. 2003; 9: 1496-1498Crossref PubMed Scopus (41) Google Scholar, 3Lewis F.M. Marsh B.J. von Reyn C.F. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention.Clin Infect Dis. 2003; 37: 390-397Crossref PubMed Scopus (154) Google Scholar The skin lesions are typically nodular, but can be sporotrichoid, ulcerative or pustular in appearance or resemble an abscess. Regional lymphadenitis may be present, while systemic symptoms are rare.1Aubry A. Chosidow O. Caumes E. Robert J. Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates.Arch Intern Med. 2002; 162: 1746-1752Crossref PubMed Scopus (300) Google Scholar, 3Lewis F.M. Marsh B.J. von Reyn C.F. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention.Clin Infect Dis. 2003; 37: 390-397Crossref PubMed Scopus (154) Google Scholar, 4Chow S.P. Ip F.K. Lau J.H. Collins R.J. Luk K.D. So Y.C. Pun W.K. Mycobacterium marinum infection of the hand and wrist. Results of conservative treatment in twenty-four cases.J Bone Joint Surg Am. 1987; 69: 1161-1168PubMed Google Scholar The diagnosis of M. marinum infection is often significantly delayed, partly due to the rarity of this condition. In more than a third of cases the incubation period exceeds one month, and consequently the patient may not recall what was often a relatively minor injury.1Aubry A. Chosidow O. Caumes E. Robert J. Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates.Arch Intern Med. 2002; 162: 1746-1752Crossref PubMed Scopus (300) Google Scholar, 2Lahey T. Invasive Mycobacterium marinum infections.Emerg Infect Dis. 2003; 9: 1496-1498Crossref PubMed Scopus (41) Google Scholar In addition, the organism grows very slowly and therefore escapes detection in routine short-term bacterial cultures. M. marinum infection is generally diagnosed on the basis of histology, typically showing granulomatous inflammation with or without the presence of acid-fast bacilli, and growth of the organism in specific mycobacterial culture. As illustrated by our case, PCR enables a more rapid diagnosis and can aid in identifying the causative organism when attempts to culture the bacteria are unsuccessful. The tuberculin skin test is positive in the majority of patients.3Lewis F.M. Marsh B.J. von Reyn C.F. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention.Clin Infect Dis. 2003; 37: 390-397Crossref PubMed Scopus (154) Google Scholar Commercial interferon-gamma release assays used for the diagnosis of latent tuberculosis, such as the QuantiFERON-TB Gold and the T-SPOT.TB assay, are further useful adjunctive tests.5Connell T. Tebruegge M. Ritz N. Curtis N. Interferon-gamma release assays for the diagnosis of tuberculosis.Pediatr Infect Dis J. 2009; 28: 758-759Crossref PubMed Scopus (19) Google Scholar These assays incorporate antigens that are also present in M. marinum and have recently been reported to be positive in the majority of patients with M. marinum infection.6Kobashi Y. Mouri K. Yagi S. Obase Y. Miyashita N. Okimoto N. et al.Clinical evaluation of the QuantiFERON-TB Gold test in patients with non-tuberculous mycobacterial disease.Int J Tuberc Lung Dis. 2009; 13: 1422-1426PubMed Google Scholar The mainstay of treatment is anti-mycobacterial therapy, which may need to be combined with surgical debridement, particularly if deeper structures are involved.1Aubry A. Chosidow O. Caumes E. Robert J. Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates.Arch Intern Med. 2002; 162: 1746-1752Crossref PubMed Scopus (300) Google Scholar, 4Chow S.P. Ip F.K. Lau J.H. Collins R.J. Luk K.D. So Y.C. Pun W.K. Mycobacterium marinum infection of the hand and wrist. Results of conservative treatment in twenty-four cases.J Bone Joint Surg Am. 1987; 69: 1161-1168PubMed Google Scholar Most clinical isolates of M. marinum are susceptible to a broad range of antibiotics, including rifampin, ethambutol, tetracyclines, clarithromycin, fluoroquinolones, and linezolid.1Aubry A. Chosidow O. Caumes E. Robert J. Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates.Arch Intern Med. 2002; 162: 1746-1752Crossref PubMed Scopus (300) Google Scholar, 7Braback M. Riesbeck K. Forsgren A. Susceptibilities of Mycobacterium marinum to gatifloxacin, gemifloxacin, levofloxacin, linezolid, moxifloxacin, telithromycin, and quinupristin–dalfopristin (Synercid) compared to its susceptibilities to reference macrolides and quinolones.Antimicrob Agents Chemother. 2002; 46: 1114-1116Crossref PubMed Scopus (45) Google Scholar Currently there are no published clinical trials in patients with M. marinum infections. Most experts recommend empiric treatment with a combination of two antibiotics, with later adjustment according to drug susceptibility if necessary.3Lewis F.M. Marsh B.J. von Reyn C.F. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention.Clin Infect Dis. 2003; 37: 390-397Crossref PubMed Scopus (154) Google Scholar The majority of patients respond well to antibiotics, although a prolonged treatment course over several months is required. However, refractory cases requiring multiple antibiotic courses and surgical interventions have been reported.1Aubry A. Chosidow O. Caumes E. Robert J. Cambau E. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates.Arch Intern Med. 2002; 162: 1746-1752Crossref PubMed Scopus (300) Google Scholar, 3Lewis F.M. Marsh B.J. von Reyn C.F. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention.Clin Infect Dis. 2003; 37: 390-397Crossref PubMed Scopus (154) Google Scholar, 4Chow S.P. Ip F.K. Lau J.H. Collins R.J. Luk K.D. So Y.C. Pun W.K. Mycobacterium marinum infection of the hand and wrist. Results of conservative treatment in twenty-four cases.J Bone Joint Surg Am. 1987; 69: 1161-1168PubMed Google Scholar This case highlights the importance of considering M. marinum infections in individuals with chronic skin lesions following aquatic trauma – even if there was no fish tank involved. MT is supported by a Fellowship from the European Society for Paediatric Infectious Diseases and an International Research Scholarship from the University of Melbourne. Consent: Patient and parental consent was obtained for publication of the case details and figures. Conflict of interest: All authors have no competing interests to declare." @default.
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