eMedicine Specialties > Dermatology > Mycobacterial Infections

Mycobacterium Marinum Infection of the Skin

Author: Joslyn S Kirby, MD, Assistant Professor, Department of Dermatology, Milton S Hershey Penn State Medical Center
Coauthor(s): Ellen J Kim, MD, Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania; Saeed Jaffer, MD, MS, Assistant Clinical Professor, University of California at Los Angeles School of Medicine, Consulting Staff, Boston Dermatology
Contributor Information and Disclosures

Updated: Jul 13, 2009

Introduction

Background

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

Pathophysiology

M marinum infection occurs following trauma to an extremity that is in contact with an aquarium, salt water, or marine animals such as fish or turtles. Exposure to M marinum via swimming pools is rare because most pools are chlorinated.

The pathogen is classified in Runyon group 1 and is a photochromogen, which means 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) because the organism is adapted to infect ectotherms, such as fish. Endotherms, such as humans, also can be infected; the cooler extremities are affected more often than central sites. Systemic infection, usually in the context of an immunocompromised host, has been reported. This indicates that the organism is capable of adapting to grow in conditions closer to 37°C.1

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 kill the organisms. The mycobacteria then escape the lysosome and can move intracellularly and extracellularly via actin-based motility. This may contribute to cell-to-cell spread.

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.2

Studies have revealed 2 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.

Frequency

United States

Infections caused by M marinum are uncommon but well described in the literature. The estimated annual incidence is 0.27 cases per 100,000 adult patients. Of the approximately 160 cases described, most are case reports of cutaneous infection; however, some have 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 fresh or salt water.

Mortality/Morbidity

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 have resulted in disseminated infection involving the bone marrow and viscera and may result in death.

Race

No racial predilection is apparent for M marinum skin infection.

Sex

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

Age

M marinum infection has been reported in persons of every age group; however, it appears to be rare in the pediatric population.3

Clinical

History

  • Patients at risk include anglers (commercial, recreational), oyster workers, swimmers, aquarium workers, and individuals with aquariums in their homes. Infection has also been reported following natural disasters involving the ocean.4
  • Patients may present with a papule, nodule, or ulcer at the site of trauma and a history of exposure to nonchlorinated water 2-3 weeks earlier. Patients may give a history of a papule or nodule that subsequently ulcerated and/or (1) signs of the infection spreading up the finger or hand or (2) involvement of the local joint or tendons. Over a period of months, localized cutaneous disease can spread to soft tissues.
  • Localized pain and induration are common. Fever, lymphadenopathy, and systemic infection are rare, with the exception of in immunosuppressed patients.

Physical

  • An erythematous or bluish 0.5- to 3-cm papule or nodule develops at the inoculation site. Ulceration can occur later, and subsequent lesions may be present along the path of lymphatic drainage of the extremity. This occurs in 25-50% of patients and is termed sporotrichotic spread.
  • The upper extremity is the inoculation site in 90% of cases.
  • Lymphadenopathy may be present.
  • Patients may have deeper involvement, with tenosynovitis, bursitis, septic arthritis, and osteomyelitis of the underlying bone. Dissemination to the bone marrow and abdominal viscera is rare.
  • If diagnosis is delayed, the infections can mimic rheumatoid arthritis, gout, trauma-related tenosynovitis, foreign body, deep fungal infections, or malignancy.

Causes

The cause is infection with M marinum.

  • Exposure of traumatized skin to affected aqueous environments (fish tanks) is the leading predisposing factor.
  • Individuals who are consistently exposed to the organism are more likely to develop the infection.
  • Hosts who are immunocompromised are also at increased risk.

More on Mycobacterium Marinum Infection of the Skin

Overview: Mycobacterium Marinum Infection of the Skin
Differential Diagnoses & Workup: Mycobacterium Marinum Infection of the Skin
Treatment & Medication: Mycobacterium Marinum Infection of the Skin
Follow-up: Mycobacterium Marinum Infection of the Skin
References
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References

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Further Reading

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Keywords

mycobacterial skin infection, fish tank granuloma, tropical fish tank granuloma, M marinum, Mycobacterium, Mycobacterium marinum, mycobacteria other than tuberculosis, MOTT, nontuberculous mycobacteria, mycobacteria, acid-fast mycobacteria, saltwater infection, freshwater infection, marine infection, marine bacteria, water-borne bacteria, water-borne bacterial infection

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Contributor Information and Disclosures

Author

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, International Society for Cutaneous Lymphomas, Pennsylvania Academy of Dermatology, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Medical Editor

Terry L Barrett, MD, Clinical Professor of Dermatology and Pathology, University of Texas Southwestern School of Medicine; Director, ProPath Dermatopathology, Dallas, Texas
Terry L Barrett, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, College of American Pathologists, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

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, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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