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Mycobacterium Marinum Remains an Unrecognized Cause of Indolent Skin Infections

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Mycobacterium Marinum Remains an Unrecognized Cause of Indolent Skin Infections CASE REPORT Mycobacterium marinum Remains an Unrecognized Cause of Indolent Skin Infections Julie Steinbrink, MD; Molara Alexis, MD; Daniella Angulo-Thompson, MD; Mayur Ramesh, MD; George Alangaden, MD; Marisa H. Miceli, MD water. Fishing, aquarium cleaning, and aquatic recre- PRACTICE POINTS ational activities are risk factors for infection.1,2 Diagnosis • Mycobacterium marinum infection should be sus- often is delayed and is made several weeks or even pected in patients with skin/soft tissue infections months after initial symptoms appear.3 Due to the pro- that fail to respond or progress despite treatment tracted clinical course, patients may not recall the initial with antibiotics active against streptococci and exposure, contributingcopy to the delay in diagnosis and ini- staphylococci. tiation of appropriate treatment. It is not uncommon for • Inquiring about environmental exposure prior to the patients with M marinum infection to be initially treated onset of the symptoms is key to elaborate a differ- with antibiotics or antifungal drugs. ential diagnosis list. We present a review of 5 patients who were diagnosed • Biopsy for pathology evaluation and acid-fast bacilli withnot M marinum infection at our institution between smear and culture are key to establish the diagnosis January 2003 and March 2013. of M marinum infection. Methods DoThis study was conducted at Henry Ford Hospital, a We identified 5 patients who had cutaneous lesions with cultures 900-bed tertiary care center in Detroit, Michigan. that yielded Mycobacterium marinum. It was discovered that all Patients who had cultures positive for M marinum 5 patients had a home aquarium, and infection was preceded by between January 2003 and March 2013 were identi- trauma to the hand. However, the association between the devel- fied using the institution’s laboratory database. Medical opment of the infection and exposure of the trauma site to the records were reviewed, and relevant demographic, epi- aquarium was not initially established until repeated questioning was performed. Skin biopsies or incision and drainage were performed demiologic, and clinical data, including initial clinical for all patients, and the diagnosis CUTISwas established by culture of the presentation, alternative diagnoses, time between ini- specimens. The mean time from initial presentation to diagnosis and tial presentation and definitive diagnosis, and specific initiation of appropriate treatment was 91 days (range, 21–245 days). treatment, were recorded. Prolonged therapy for 2 to 6 months was necessary for resolution of the infection. Results Cutis. 2017;100:331-336. We identified 5 patients who were diagnosed with culture-confirmed M marinum skin infections during the study period: 3 men and 2 women aged 43 to n environmental pathogen, Mycobacterium 72 years (Table 1). Two patients had diabetes mellitus and marinum can cause cutaneous infection when trau- 1 had hepatitis C virus. None had classic immunosup- A matized skin is exposed to fresh, brackish, or salt pression. On repeated questioning after the diagnosis Drs. Steinbrink and Miceli are from the Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Dr. Miceli also is from the Division of Infectious Diseases. Drs. Alexis, Angulo-Thompson, Ramesh, and Alangaden are from the Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan. Drs. Alexis, Ramesh, and Alangaden also are from the Infectious Diseases Section. The authors report no conflict of interest. Correspondence: Marisa H. Miceli, MD, Division of Infectious Diseases, University of Michigan Medical School, 1500 E Medical Center Dr, University Hospital F4005, Ann Arbor, MI 48109-5378 ([email protected]). WWW.CUTIS.COM VOL. 100 NO. 5 I NOVEMBER 2017 331 Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. M MARINUM SKIN INFECTION 332 I CUTIS TABLE 1. Clinical Characteristics, Diagnosis, and Management of Patients With Mycobacterium marinum Infection ® Characteristic Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient age, y/sex 43/F 64/M 68/M 57/F 72/M Comorbidities DM, HTN None copyHTN, GERD, OA HCV, HTN DM, HTN, BPH, gout Clinical presentation Edema, erythema, and pain Tender erythematous Erythematous tender Purulent material in the nail bed Pain and erythema of the right in the left middle finger; nodule on the left forearm nodules on the left of left thumb; despite treatment thumb; erythema progressed despite treatment with and thumb hand and forearm with antibiotics, she developed to the axilla; nodular lesions antibiotics, the infection not nodular lesions in a linear developed in a linear manner spread proximally to fashion from the wrist to the to the antecubital fossa despite the wrist forearm treatment with antibiotics Reported exposure/ Puncture injury of left finger No direct injury; reported Splinter injury to the Injury to left thumb while Nail clipping trauma at initial on a clothing tag activity included rose left thumb while cleaning the house presentation Dogardening and fish cutting shrubs tank cleaning Duration of symptoms 3.5 mo 4 mo 2.5 wk 6 wk 2 d before initial presentation Initial diagnosis: Cellulitis: CIP LEV AZIT Cellulitis: CEP TERB Fungal infection: ITRA Cellulitis: CLIN Cellulitis: CEP CLIN VAN treatment CEP VAN ITRA Workup BiopsyCUTIS Biopsy Biopsy Biopsy Incision and drainage Biopsy results Suppurative granulomatous Neutrophilic and Dermal abscess Noncaseating granulomatous N/A inflammation granulomatous inflammation inflammation Incubation period 26 d 40 d 18 d 5 wk (∙34 d) 11 d Time from presentation 245 d 91 d 21 d 23 d 76 d to therapy Treatment MINO DOXY + CLAR DOXY DOXY DOXY + CLAR + TMP-SMX TMP-SMX + ETH DOXY + AZIT + ETH DOXY + CLAR Duration of treatment 3 mo Unknown At least 2 mo 6 mo 4 mo (temporarily moved out of state) Outcome Resolution Lost to follow-up Resolution Resolution Resolution Ultimate source Aquarium Aquarium Aquarium Aquarium Aquarium of exposure Abbreviations: F, female; M, male; DM, diabetes mellitus; HTN, hypertension; GERD, gastroesophageal reflux disease; OA, osteoarthritis; HCV, hepatitis C virus; BPH, benign prostatic hyperplasia; CIP, ciprofloxacin; LEV, levofloxacin; AZIT, azithromycin; CEP, first-generation cephalosporin; TERB, terbinafine; ITRA, itraconazole; CLIN, clindamycin; VAN, vancomycin; N/A, not applicable; MINO, minocycline; DOXY, doxycycline; CLAR, clarithromycin; ETH, ethambutol; TMP-SMX, trimethoprim-sulfamethoxazole. WWW.CUTIS.COM Copyright Cutis 2017. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. M MARINUM SKIN INFECTION was established, all 5 patients reported that they kept a Three patients also received empiric antifungal therapy home aquarium, and all recalled mild trauma to the due to suspicion of sporotrichosis. hand prior to the onset of symptoms; however, none of Skin biopsies were performed on 4 patients, and inci- the patients initially linked the minor skin injury to the sion and drainage of purulent material was performed on subsequent infection. the fifth patient. Histopathologic examination revealed All 5 patients initially presented with erythema and granulomatous inflammation in 3 patients. Stains for swelling at the site of the injury, which evolved into acid-fast bacilli were positive in all 5 patients. Definitive inflammatory nodules that progressed proximally up to diagnosis of the organism was confirmed by growth of the arm despite empiric treatment with antibiotics active M marinum within 11 to 40 days from the tissue in against streptococci and staphylococci (Figures 1 and 2). 4 patients and purulent material in the fifth patient. Susceptibility testing was performed on only 1 of the 5 isolates and showed that the organism was susceptible to amikacin, clarithromycin, doxycycline, ethambutol, rifampin, and trimethoprim-sulfamethoxazole (TMP-SMX). The mean time from initial presentation to initia- tion of appropriate therapy for M marinum infection was 91 days (range, 21–245 days). Several different treat- ment regimens were used. All patients received either doxycycline or minocycline with or without a macrolide. Two also received other agents (TMP-SMX or etham- butol). Treatment duration varied from 2 to 6 months in 4 patients, and all 4 had complete resolution of the A lesions; 1 patientcopy was lost to follow-up. Comment Diagnosing the Infection—Diagnosis of M marinum infec- tion remains problematic. In the 5 patients included in thisnot study, the time between initial onset of symptoms and diagnosis of M marinum infection was delayed, as has been noted in other reports.4-7 Delays as long as 2 years before the diagnosis is made have been described.7 DoThe clinical presentation of cutaneous infection with M marinum varies, which may delay diagnosis. Nodular lymphangitis is classic, but papules, pustules, ulcers, inflammatory plaques, and single nodules also can occur.1,2 Lymphadenopathy may or may not be present.4,8,9 The dif- ferential diagnosis is broad and includes infection by other B nontuberculous mycobacteria such as Mycobacterium chelonae; Mycobacterium fortuitum; Nocardia species, CUTIS especially Nocardia brasiliensis; Francisella tularensis; Sporothrix schenckii; and Leishmania species. It is not sur- prising that 4 patients in our study were initially treated for a gram-positive bacterial infection and 3 were treated
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