eMedicine Specialties > Dermatology > Mycobacterial Infections

Mycobacterium Marinum Infection of the Skin

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

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.

Differential Diagnoses

Other Problems to Be Considered

Infection with atypical mycobacteria (eg, Mycobacterium kansasii, Mycobacterium chelonae, Mycobacterium avium-intracellulare)⁵
Botryomycosis (Staphylococcus aureus)
Deep fungal infection (eg, with Cryptococcus neoformans, Histoplasma capsulatum, Coccidioides immitis, or Blastomyces dermatitis)
Dematiaceous fungi (chromomycosis or phaeohyphomycosis)
Infection with Francisella tularensis 
Rheumatoid arthritis⁶
Erythema elevatum diutinum

Workup

Laboratory Studies

• Culture is the criterion standard method of identification. Cultures are specific but not sensitive. Cultures may be positive in only 70-80% of cases.⁷
• Cultures at 25-32°C (77-89.6°F) may grow nonmotile acid-fast bacilli in 7-21 days. The organisms are photochromogens (Runyon group 1), producing yellow pigment only when exposed to light. No niacin or nitrate production occurs; urease is produced, but the organism is a weak producer of catalase at 25°C (77°F).⁸
• If culture results are negative but the history and clinical findings are consistent with M marinum infection, then treatment should still be strongly considered; additionally, performing a biopsy on the lesion may help identify the organisms.

Imaging Studies

• Consider obtaining imaging studies (plain radiography, CT scanning, or MRI) if tenosynovitis, osteomyelitis, or deep infection is suspected.⁹
• MRI may show exuberant tenosynovitis; however, unlike with purulent tenosynovitis, the underlying muscles and bony structures are rarely involved.

Other Tests

• Polymerase chain reaction (PCR) studies of tissue may help distinguish the exact Mycobacterium species involved.¹⁰ Errors of identification, specifically speciation, have been reported when using PCR.^11,12
• Mycobacteriophages are viruses that infect Mycobacterium. They are currently commercially available but are still being refined as a tool to rapidly identify the specific species in mycobacterial infections. They are also being developed as a future modality for diagnosis and treatment of these infections.¹³

Procedures

• Biopsy samples from cutaneous lesions or from intra-articular tissue should be obtained for histopathologic analysis. Acid-fast preparations, such as Ziehl-Neelsen and Fite stains, reveal acid-fast bacilli.
• Surgical drainage of skin lesions often is unnecessary; however, if a deeper infection is diagnosed, drainage may be indicated.

Histologic Findings

• The histopathologic findings vary depending on the duration of the lesion sampled and on the degree of granuloma formation.
• Early lesions show a nonspecific mixed inflammatory infiltrate, but acid-fast stains typically reveal bacilli. Established lesions display characteristic tuberculoid granulomas, often containing a stellate abscess.
• Abscess formation can vary from absent to marked.
• Granulomas can vary from poorly formed, consisting of epithelioid histiocytes and lymphocytes with few multinucleated giant cells, to fully formed granulomas with numerous multinucleated giant cells, although caseation is rare.¹⁴
• A lichenoid and granulomatous infiltrate has also been reported with M marinum infection.⁵
• The epidermis frequently demonstrates papillomatosis, hyperkeratosis, and an acute inflammatory infiltrate, with or without ulceration. 

Treatment

Medical Care

• Treatment is usually medical in nature, using bacteriocidal agents. The duration of therapy is empiric, with the recommendations to continue therapy for 4-6 weeks following clinical resolution of the lesions. Treatment of some infections may last as long as 25 months or longer.¹⁵
• Effective antimicrobials include tetracyclines, fluoroquinolones, macrolides, sulfonamides, and others.
• Drug resistance varies and has been reported with all classes of antibiotic treatment listed above. Combination therapy is used for cases with documented antimicrobial resistance or those not responding to single-agent therapy.¹⁵
• Spontaneous resolution has been reported. Treatment with radiation, cryotherapy, and heat probes has been reported.
• See Medication for further discussion of single- and combination-agent therapies.

Surgical Care

• Surgical drainage of most skin lesions often is unnecessary.
• Infection of deep structures such as the tendon sheaths, joint space, or bone should be managed with the help of a surgeon. Debridement of necrotic tissues of the synovium, tendon sheaths, and/or bone may be needed to control infection in spite of appropriate systemic antibiotic therapy. Amputations are rarely necessary.¹⁶

Consultations

• A variety of specialists may be involved in the diagnosis and treatment, such as dermatologists, rheumatologists, and infectious disease physicians.

Medication

• The mainstay of therapy for infection by M marinum is antimicrobials, including antibiotics and antimycobacterials.
• The organism is sensitive to rifampin plus ethambutol, tetracyclines (minocycline [MCN],¹⁷ doxycycline [DCN]), trimethoprim-sulfamethoxazole (TMP-SMZ), clarithromycin,¹⁸ and fluoroquinolones (ciprofloxacin, ofloxacin, sparfloxacin).
• Antimicrobials are administered singly or in combination.¹⁵ Successful combinations include:
  • TMP-SMZ and MCN or DCN
  • MCN, levofloxacin, and clarithromycin
  • DCN and clarithromycin or ciprofloxacin
  • DCN, clarithromycin, and ethambutol
  • Clarithromycin and ciprofloxacin or ethambutol
  • Ciprofloxacin and rifampin
  • Ciprofloxacin and clarithromycin (increased risk of QT prolongation)
  • Ciprofloxacin and ethambutol
• Combination antimycobacterial agents include the following:
  • Rifampin and ethambutol: This combination is regarded as highly effective therapy, especially for severe disease or in patients with impaired immune systems.
  • Streptomycin, ethambutol, and isoniazid
  • Clarithromycin, alone or in combination: This agent has shown the most efficacy of the macrolide antibiotics. One case report discusses the use of azithromycin in combination with ethambutol. Erythromycin has not demonstrated efficacy for treating M marinum infections.
• Combining rifabutin or rifampin with macrolide antibiotics is not recommended because of the decreased efficacy of the macrolide and the increased levels of rifabutin or rifampin.
• Most strains of M marinum have been found to be resistant to medications typically used for Mycobacterium tuberculosis, including isoniazid, streptomycin, pyrazinamide, and para-aminosalicylic acid.¹³ In contrast, ethambutol is effective in combination with antimycobacterial or antibiotics, but not as a single agent. 
• The duration of therapy is empiric; multiple sources recommend extended therapy for 4-6 weeks following clinical resolution of lesions.¹⁵

Antimicrobial agents

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Therapy must be taken regularly and continued for a sufficient period.

Rifampin (Rifadin, Rimactane)

Found to be effective as monotherapy and is successful when given in combination with another antimicrobial. Inhibits DNA-dependent bacterial RNA but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed from conversion to negative results from sputum culture.

Dosing

Adult

600 mg PO qd

Pediatric

10-20 mg/kg PO/IV; not to exceed 600 mg/d

Interactions

Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Has produced liver dysfunction; urine and other secretions turn reddish; obtain CBC counts and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur

Ethambutol (Myambutol)

Only effective when combined with another antimicrobial agent, preferably rifampin. Diffuses into actively growing mycobacterial cells (eg, tubercle bacilli). Impairs cell metabolism by inhibiting synthesis of one or more metabolites, which, in turn, causes cell death. No cross-resistance demonstrated. Mycobacterial resistance is common with previous therapy.

Dosing

Adult

25 mg/kg/d PO; not to exceed 2500 mg/d

Pediatric

<13 years: Not recommended
>13 years: Administer as in adults

Interactions

Aluminum salts may delay and reduce absorption (give several hours before or after ethambutol dose)

Contraindications

Documented hypersensitivity; optic neuritis (unless clinically indicated)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Reduce dose in impaired renal function; may have adverse visual effects, which may be reversible if promptly discontinued (physical examination should include ophthalmoscopy, finger perimetry, and color discrimination testing); elevated serum uric acid levels occur; precipitation of acute gout has been reported

Minocycline (Dynacin, Minocin) or Doxycycline (Doryx, Vibramycin)

Effective monotherapy; however, strains of M marinum resistant to doxycycline but sensitive to minocycline have been reported. Also treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma species.

Dosing

Adult

100 mg PO bid

Pediatric

<8 years: Not recommended
>8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with doxycycline but is unusual with minocycline; reduce dose in renal impairment; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur.

Trimethoprim and sulfamethoxazole (Bactrim, Septra)

Several case reports have shown effectiveness of this drug. Reports indicate that it can help eradicate organisms unresponsive to either antituberculars or tetracyclines. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Dosing

Adult

160 mg TMP/800 mg SMZ PO q12h for 10-14 d

Pediatric

<2 months: Not recommended
>2 months: 15-20 mg TMP/kg/d PO in 3-4 divided doses for 14 d

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in pregnancy or breastfeeding; discontinue at first appearance of rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged intravenous infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, long-term alcoholism, elderly patients, anticonvulsant therapy, malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Clarithromycin (Biaxin)

Cases of organisms resistant to conventional antitubercular therapy have responded to clarithromycin but not erythromycin. Use of azithromycin has not been reported. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Has bactericidal activity against atypical Mycobacterium species (eg, M marinum).

Dosing

Adult

500 mg PO bid

Pediatric

15 mg/kg PO divided bid

Interactions

Toxicity increases with coadministration of fluconazole or pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, or HMG CoA-reductase inhibitors; serious cardiac arrhythmias may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents

Contraindications

Documented hypersensitivity; coadministration of pimozide or cisapride

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Coadministration with ranitidine or bismuth citrate not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies

Ciprofloxacin (Cipro)

Fluoroquinolones are effective alone or in combination with other medications to eradicate M marinum. Inhibits bacterial DNA synthesis and, consequently, growth.

Dosing

Adult

500 mg PO bid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Severe hypersensitivity reactions characterized by rash, fever, eosinophilia, jaundice, and hepatic necrosis with fatal outcome rarely occur; tendon ruptures requiring surgical repair or prolonged disability have been reported; crystalluria rarely occurs because human urine is usually acidic; alkalinity of urine should be avoided; may cause nervousness, agitation, insomnia, anxiety, nightmares, or paranoia; moderate-to-severe phototoxicity manifested as an exaggerated sunburn reaction can occur if directly exposed to sunlight; fatal reactions may occur when coadministered with theophylline

Levofloxacin (Levaquin)

For treatment of tuberculosis and some atypical mycobacterial infections in combination with rifampin and other antituberculosis agents.

Dosing

Adult

500-1000 mg PO qd or divided bid

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Interactions

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Follow-up

Further Inpatient Care

• Patients can be treated in an outpatient setting and should be seen frequently until they begin to respond to therapy, then less frequently until the infection is fully cured. Patients may benefit from seeing an infectious disease physician in an outpatient setting.

Deterrence/Prevention

• People who work near or in salt water should take precautions to avoid abrasions, trauma, or bites from fish and marine animals.
• People who work with aquariums should wear gloves if they are cleaning tanks or expect to encounter trauma to their hands or feet.
• If bites or abrasions occur, cleanse the skin, apply an antibacterial preparation, and dress with an appropriate bandage.

Complications

• Persistent ulceration
• Osteomyelitis, bony erosion
• Bursitis
• Tenosynovitis
• Arthritis
• Disseminated infection

Prognosis

• Once identified and appropriately treated, M marinum infection can typically be successfully eradicated, usually with no major sequelae.

Miscellaneous

Medicolegal Pitfalls

• Sporotrichosis is most commonly associated with nodular lymphangitis. For this reason, M marinum infection can often be misdiagnosed as sporotrichosis. Patients sometimes undergo long courses of antifungal treatments before further spreading of the Mycobacterium elicits a repeat biopsy and culture.
• Involved joints may be misdiagnosed as inflammatory arthritis, and the joint may be inappropriately injected with a corticosteroid. Corticosteroid injection can result in marked progression of the disease.¹⁹

References

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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

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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