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Namisha Thapa1, DO Not All Granulomas Come from Fish Tanks: A Chronic Non- Healing Hand Wound After Swimming Namisha Thapa1, DO; Luke Strnad2,3, MD 1 Department of Medicine, 2 Division of Infectious Disease, Oregon Health & Science University, 3 Epidemiology Programs, OHSU-Portland State University School of Public Health Learning Objective Understand the complexity of diagnosis and treatment of Mycobacterium marinum infection Introduction Case Presentation “Aquarium granuloma”, “swimming pool granuloma”, A 27-year-old man presented with 2-year history of or “fish-tank granuloma” is caused by the non- non-healing left fifth digit hand wound. It initially tuberculous mycobacterium (NTM), M. marinum. started as erythema with fluctuance that began Usually chronic, indolent, non-healing wound, it after a cut from broken glass and subsequently requires meticulous history gathering, high clinical worsened after swimming in a river. suspicion, and often skin biopsy to make the diagnosis. Clinical Timeline 3/2016 10/2016 12/2016 3/2017 4/2017 6/2017 8/2017 5/2018 10/201810/2018 Dermatology Third I&D. OHSU ED visit. Cut L small Exploratory Dermatology ID follow-up. ED visit for Telephone visit. Punch Culture showed Seen by plastic finger with surgery done follow-up. Some medication hand wound; encounter: no biopsy done, pan-sensitive surgery for broken glass. for possible Suspected non-adherence. I&D done. symptom negative AFB M. marinum punch biopsy. Swam in foreign object.* foreign body Improved wound, Discharged improvement, stain and (1/2). Started 6- AFB positive. Georgia river Wound and referred not open. Plan to home on 1 wk persistent culture. wks Doxycycline, ID started one week culture to surgery f/u in 2 months to of antibiotics pain/drainage Treated with but patient Doxycycline, later negative for determine therapy hydrocortisone stopped early due Ethambutol, AFB duration *pathology: squamous epithelium and granulation tissue with for dermatitis to improvement Bactrim extensive acute and chronic inflammation with areas of necrosis May 2018 Physical Exam May 2018 Labs & Imaging Discussion: M. marinum Normal CBC, CMP, and CRP Prefers cooler temperature both in vivo and vitro, Wound culture: + M. marinum thus prefers extremities. It is difficult to culture Hand MRI: soft tissue wound with depending on lab’s incubation temperature. underlying cellulitis without evidence of Diagnosis sometimes made with granulomas on path abscess, osteomyelitis or septic arthritis Though NTM (non-tuberculous mycobacterium), can have false positive QuantiFERON Good cure rate with appropriate therapy (6 weeks to 12 months) - no controlled trials Superficial skin infections sometimes treated with monotherapy but generally combination therapy with 2 or more of the following antibiotics indicated: macrolides, tetracyclines, sulfonamides, ethambutol Erythematous, tender lesion on L hand Take Home Points from mid to distal fifth digit with overlying M. marinum often goes undiagnosed for many years necrotic scab and minimal serous drainage Negative AFB culture cannot be used to rule it out References Early diagnosis and treatment is crucial, as it can 1. Sette CS, Wachholz PA, Masuda PY, da Costa Figueira RBF, de Oliveira Mattar FR, Ura DG. Mycobacterium marinum infection: a case report. The Journal of Venomous Caseating granuloma on pathology Animals and Toxins Including Tropical Diseases. 2015;21:7. doi:10.1186/s40409-015-0008-9. 2. Aubry A, Chosidow O, Caumes E, Robert J, Cambau E. Sixty-three Cases of Mycobacterium marinum InfectionClinical Features, Treatment, and Antibiotic Susceptibility cause severe deeper infections in rare cases of Causative Isolates. Arch Intern Med. 2002;162(15):1746–1752. doi:10.1001/archinte.162.15.1746..
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