Mycobacterium Marinum Infection of the Skin

Mycobacterium Marinum Infection of the Skin

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Mycobacterium marinum is an atypical Mycobacterium found in salt water and fresh water. M marinum is the most common atypical Mycobacterium to cause infection in humans. Infection occurs following inoculation of a skin abrasion or puncture and manifests as a localized granuloma or sporotrichotic lymphangitis (see the image below).

Diagnosis and treatment are often delayed because of a lack of suspicion for mycobacterial involvement, ie, versus more common bacterial pathogens. Due to the increased use of immunosuppressants for transplant recipients and tumor necrosis factor (TNF) inhibitors for a variety of conditions, infections with mycobacteria other than tuberculosis (MOTT) are increasing.

M marinum is a slow-growing species that resides in both freshwater and saltwater environments, with optimal growth at 30-32°C. It is carried by many fish species and can result in human infection via inoculation of the skin by a fish bite, exposure of an open wound to contaminated water, contact with an aquarium, or contact with marine animals such as fish or turtles. [1] Exposure to M marinum via swimming pools is rare because most pools are chlorinated. [2]

The pathogen is classified as a photochromagen in Runyon group 1, which means that it produces yellow pigment when cultured and exposed to light. Culture growth occurs over 7-21 days and is optimal at 25-32°C (77-89.6°F) given the organism is adapted to infect ectotherms, such as fish. When endotherms, such as humans, are infected the infection favors the cooler extremities more than central sites. Systemic infection, usually of an immunocompromised host, has been reported. This indicates that the organism is capable of adapting to grow in conditions closer to 37°C. [3]

After inoculation into the host tissues via an abrasion or other wound, the mycobacteria are phagocytosed by macrophages. Inside the macrophage, they are able to interrupt the formation of the phagolysosome, which would normally kill the organisms. The mycobacteria, however, are able escape the lysosome and can move intracellularly and extracellularly via actin-based motility. This may contribute to cell-to-cell spread.

Tumor necrosis factor (TNF) is important for the immune response against mycobacteria. Studies have demonstrated that in the absence of TNF, macrophages engulf but do not destroy the mycobacteria. Instead, the mycobacteria survive and grow, finally killing the macrophage. [4] The importance of TNF is also supported by a number of reports of infection occurring in patients treated with TNF inhibitors, and these medications should be stopped during the course of antibiotic therapy. If not, the lesions may rapidly extend. [5, 6, 7]

Studies have revealed two pathophysiologically and genetically (ie, via amplified restriction-based polymorphism analysis) distinct populations of M marinum. One group can infect humans and causes acutely lethal disease in fish, while a second group cannot infect humans and causes chronic progressive disease in fish.

Utility of M marinum as an immunotherapy agent to elicit an antituberculosis response is currently being explored. [8] There is specific scientific interest in M marinum because of its genetic relatedness to Mycobacterium tuberculosis and because experimental infection of M marinum in fish mimics tuberculosis pathogenesis. [7]

United States

Infections caused by M marinum are uncommon but well described in the literature. The estimated annual incidence is 0.05-0.27 case per 100,000 adult patients. [9, 7] Of the more than 160 cases described, most are case reports of cutaneous infection; some report concomitant osteomyelitis, tenosynovitis, arthritis, and/or disseminated infection. Nosocomial infection has never been described.

International

Infection occurs worldwide, most commonly in individuals with occupational and recreational exposure to nonchlorinated fresh water or salt water. [10]

No racial predilection is apparent for M marinum skin infection.

No sexual predilection has been noted for M marinum skin infection.

M marinum infection has been reported in persons of every age group; however, it appears to be rare in the pediatric population. [11, 12]

Once identified and appropriately treated, M marinum infection can typically be successfully eradicated, usually with no major sequelae. M marinum skin infection typically remains localized and does not cause significant morbidity in patients who are immunocompetent. Cases reported in patients who are severely immunocompromised document disseminated infection via lymphatics and can involve the bone marrow and viscera, with rare reports of death secondary to the infection. [1]

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Kent ML, Watral V, Wu M, Bermudez LE. In vivo and in vitro growth of Mycobacterium marinum at homoeothermic temperatures. FEMS Microbiol Lett. 2006 Apr. 257(1):69-75. [Medline].

Clay H, Volkman HE, Ramakrishnan L. Tumor necrosis factor signaling mediates resistance to mycobacteria by inhibiting bacterial growth and macrophage death. Immunity. 2008 Aug 15. 29(2):283-94. [Medline].

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Levesque BG, Sandborn WJ. Mycobacterium marinum infection in the setting of antitumor necrosis factor alpha therapy for Crohn’s disease. Inflamm Bowel Dis. 2011 Jun. 17(6):1443-4. [Medline].

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Aubry 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 Aug 12-26. 162(15):1746-52. [Medline].

Nor NM, Baseri MM. Skin and subcutaneous infections in south-east Asia. Curr Opin Infect Dis. 2015 Apr. 28 (2):133-8. [Medline].

Doedens RA, van der Sar AM, Bitter W, Scholvinck EH. Transmission of Mycobacterium marinum from fish to a very young child. Pediatr Infect Dis J. 2008 Jan. 27(1):81-3. [Medline].

di Meo N, Stinco G, Trevisini S, De Marchi S, Albano A, Trevisan G. Sporotrichoid Mycobacterium marinum infection in an elderly woman. Dermatol Online J. 2015 May 18. 21 (5):[Medline].

Appelgren P, Farnebo F, Dotevall L, Studahl M, Jonsson B, Petrini B. Late-onset posttraumatic skin and soft-tissue infections caused by rapid-growing mycobacteria in tsunami survivors. Clin Infect Dis. 2008 Jul 15. 47(2):e11-6. [Medline].

Bouricha M, Castan B, Duchene-Parisi E, Drancourt M. Mycobacterium marinum infection following contact with reptiles: vivarium granuloma. Int J Infect Dis. 2014 Apr. 21C:17-18. [Medline].

Ko DY, Song KH. Mycobacterium marinum infection occurring on the face. J Dermatol. 2013 Sep. 40(9):773-4. [Medline].

S Breza T Jr, Magro CM. Lichenoid and granulomatous dermatitis associated with atypical mycobacterium infections. J Cutan Pathol. 2006 Jul. 33(7):512-5. [Medline].

Lam A, Toma W, Schlesinger N. Mycobacterium marinum arthritis mimicking rheumatoid arthritis. J Rheumatol. 2006 Apr. 33(4):817-9. [Medline].

Janik JP, Bang RH, Palmer CH. Case reports: successful treatment of Mycobacterium marinum infection with minocycline after complication of disease by delayed diagnosis and systemic steroids. J Drugs Dermatol. 2005 Sep-Oct. 4(5):621-4. [Medline].

Gluckman SJ. Mycobacterium marinum. Clin Dermatol. 1995 May-Jun. 13(3):273-6. [Medline].

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Mahaisavariya P, Chaiprasert A, Manonukul J, Khemngern S, Tingtoy N. Detection and identification of Mycobacterium species by polymerase chain reaction (PCR) from paraffin-embedded tissue compare to AFB staining in pathological sections. J Med Assoc Thai. 2005 Jan. 88(1):108-13. [Medline].

Ho MH, Ho CK, Chong LY. Atypical mycobacterial cutaneous infections in Hong Kong: 10-year retrospective study. Hong Kong Med J. 2006/January. 12:21-6.

Nolte O, Haag H, Hafner B. A mutation in the 65,000 Dalton heat shock protein gene, commonly used for molecular identification of non-tuberculous mycobacteria, leads to the misidentification of Mycobacterium malmoense as Mycobacterium marinum. Mol Cell Probes. 2005 Aug. 19(4):275-7. [Medline].

Lai CC, Tan CK, Lin SH, Liu WL, Liao CH, Huang YT, et al. Diagnostic value of an enzyme-linked immunospot assay for interferon-? in cutaneous tuberculosis. Diagn Microbiol Infect Dis. 2011 May. 70(1):60-4. [Medline].

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Kirstin Altman, MD Assistant Professor of Dermatology, Texas A&M Health Science Center College of Medicine

Kirstin Altman, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Texas Dermatological Society

Disclosure: Nothing to disclose.

Tahmina Mahmood, MD Resident Physician, Department of Dermatology, Baylor Scott and White Healthcare System

Disclosure: Nothing to disclose.

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Joslyn S Kirby, MD Assistant Professor, Department of Dermatology, Milton S Hershey Penn State Medical Center

Joslyn S Kirby, MD is a member of the following medical societies: American Academy of Dermatology, Women’s Dermatologic Society, International Society for Cutaneous Lymphomas, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

S Alison Basak, MD, MA Resident Physician, Department of Dermatology, Penn State Hershey Medical Center

S Alison Basak, MD, MA is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Pennsylvania Medical Society, Women’s Dermatologic Society, Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Ellen J Kim, MD Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania

Ellen J Kim, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Dermatology Foundation, Medical Dermatology Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Saeed Jaffer, MD, MS Assistant Clinical Professor, University of California at Los Angeles School of Medicine; Consulting Staff, Boston Dermatology

Saeed Jaffer, MD, MS is a member of the following medical societies: American Academy of Dermatology and American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Mycobacterium Marinum Infection of the Skin

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