eMedicine Specialties > Infectious Diseases > Mycobacterial Infections
Mycobacterium Marinum
Updated: Jan 16, 2009
Introduction
Background
Mycobacterium marinum is an atypical Mycobacterium species found in cold or warm, fresh or salted water. M marinum infection occurs following skin and soft-tissue injuries that are exposed to an aquatic environment or marine animals. The infection usually presents as a localized granuloma but can evolve into an ascending lymphangitis that resembles sporotrichosis or can spread to deeper tissues. M marinum is a pathogen classified in Runyon group 1 and is a photochromogen, meaning it produces pigment when cultured and exposed to light. Culture growth occurs over 7-14 days and is optimal at 32°C.
For additional information on cutaneous M marinum infection, see the eMedicine article Mycobacterium Marinum Infection of the Skin.
Pathophysiology
M marinum is water-borne atypical Mycobacterium species that commonly infects fish and amphibians. It was first recognized to cause human disease in 1951. M marinum infection commonly develops as a complication of skin and soft-tissue injuries exposed to aquatic equipment such as fish lines and fishhooks, among others. Domestic exposures involved in infection commonly involve fish tank manipulations. M marinum infection was once called swimming pool granuloma, but that term is now rather obsolete because of the widespread use of chlorination in swimming pools. Chlorinated swimming pools are not considered an exposure risk.
M marinum grows best at 32°C; therefore, cooler extremities, particularly hands, are affected more often than central areas. This feature is also important for optimal growth in the microbiology laboratory. M marinum can disseminate in severely immunosuppressed individuals (eg, transplant recipients).
Frequency
United States
M marinum infections are rare but well described in the literature. The estimated annual incidence is 0.27 cases per 100,000 adult patients. The infection is typically limited to the skin, mostly involving limbs, but spread to deeper structures has been reported. This can result in clinical entities such as tenosynovitis, septic arthritis, and osteomyelitis. Dissemination is extremely rare and has been reported mainly in severely immunocompromised individuals.
M marinum is ubiquitous and is found in both salt and fresh waters. At least 150 fish and frog species, aquatic mammals (eg, dolphins), eels, oysters, African toads, and royal pythons are known to acquire natural M marinum infection. In Africa, M marinum has been isolated from healthy human skin and soil. Individuals who fish or work with aquariums are at an increased risk of exposure. To the authors’ knowledge, nosocomial M marinum infection has never been reported.
International
The international incidence and prevalence of M marinum infection are unknown owing to a lack of surveillance. One French study found the incidence of M marinum infection to be 0.04 per 100,000 inhabitants per year.
Mortality/Morbidity
- M marinum infection responds slowly to appropriate antibiotic therapy. Infected patients may require treatment for 2 weeks or up to 18 months.
- M marinum infection may result in persistent ulceration, draining sinuses, or septic arthritis. Aggressive M marinum infection may cause extensive osteomyelitis, resulting in amputation of the involved digit.
- Disseminated M marinum infection has been reported in significantly immunosuppressed individuals. Reports describe dissemination to the bone marrow and visceral involvement; however, the reports do not include deaths directly related to M marinum infection.
Race
M marinum infection has no known racial predilection.
Sex
M marinum infection has no known sexual predilection. Infection in men is typically linked to occupational exposures.
Age
M marinum infection has no known age predilection.
Clinical
History
- M marinum infection often follows abrasions to an extremity occurring in nonchlorinated water. Fishermen, oyster workers, swimmers, and aquarium workers are predisposed to infection.
- M marinum has an incubation period of approximately 2-3 weeks
- A mildly tender papule or nodule initially appears at the site of trauma, slowly enlarges, and then suppurates or ulcerates.
- The localized lesion can grow slowly over several months.
- Localized pain and induration are common.
- Further nodular lesions may develop along the lymphatic channels, resulting in ascending nodular lymphangitis.
- Regional lymphadenitis and systemic symptoms are uncommon.
- Contiguous spread to deeper structures (eg, tendons, joints, or even bones) occurs in up to one third of individuals with M marinum infection.
Physical
- In individuals with M marinum infection, a papule or bluish nodule develops at the inoculation site. Suppuration or ulceration appears at a later stage.
- An ascending nodular lymphangitis develops in 25-50% of infected patients. This entity is also seen in other infectious etiologies, especially sporotrichosis, New World cutaneous leishmaniasis, nocardiosis, ulceroglandular form of tularemia, infections with other nontuberculous mycobacteria (eg, Mycobacterium chelonae, Mycobacterium fortuitum, Mycobacterium kansasii), various fungal infections (blastomycosis, histoplasmosis, cryptococcosis, coccidioidomycosis) and several pyogenic bacteria (Staphylococcus aureus, Streptococcus pyogenes, Burkholderia pseudomallei, Bacillus anthracis ).
- An upper extremity is affected in nearly 90% of persons with M marinum infection, mostly on the hands.
- Deeper involvement, with tenosynovitis, septic arthritis, and osteomyelitis of the underlying bone, may be evident on examination.
- Most patients with M marinum infection have a tuberculin skin test result between 5-9 mm of induration.
- M marinum infection may present similarly to interstitial granuloma annulare.1
Causes
Infection is caused by inoculation with M marinum. Individuals at an increased risk for infection include the following:
- Fishermen and fish-processing workers
- Saltwater aquarium maintenance personnel
- Home aquarium owners
- Immunocompromised individuals
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| References |
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References
Barr KL, Lowe L, Su LD. Mycobacterium marinum infection simulating interstitial granuloma annulare: a report of two cases. Am J Dermatopathol. Apr 2003;25(2):148-51. [Medline].
Awais A, Tam CS, Kontoyiannis D, et al. Rapid resolution of Mycobacterium marinum chronic skin infection during lenalidomide therapy for chronic lymphocytic leukemia. Clin Infect Dis. Apr 1 2008;46(7):e69-71. [Medline].
Kishihara Y, Nakashima K, Nukina H, et al. [Two cases of acquired immunodeficiency syndrome with disseminated non-tuberculous mycobacterial infection]. Kansenshogaku Zasshi. Dec 1993;67(12):1223-7. [Medline].
Rallis E, Koumantaki-Mathioudaki E, Frangoulis E, Chatziolou E, Katsambas A. Severe sporotrichoid fish tank granuloma following infliximab therapy. Am J Clin Dermatol. 2007;8(6):385-8. [Medline].
Adhikesavan LG, Harrington TM. Local and disseminated infections caused by Mycobacterium marinum: an unusual cause of subcutaneous nodules. J Clin Rheumatol. Jun 2008;14(3):156-60. [Medline].
Aubry A, Chosidow O, Caumes E, et al. Sixty-three cases of Mycobacterium marinum infection: clinical features, treatment, and antibiotic susceptibility of causative isolates. Arch Intern Med. Aug 12-26 2002;162(15):1746-52. [Medline].
Barton A, Bernstein RM, Struthers JK, et al. Mycobacterium marinum infection causing septic arthritis and osteomyelitis. Br J Rheumatol. Nov 1997;36(11):1207-9. [Medline].
Bartralot R, Garcia-Patos V, Sitjas D, et al. Clinical patterns of cutaneous nontuberculous mycobacterial infections. Br J Dermatol. Apr 2005;152(4):727-34. [Medline].
Bråbäck M, Riesbeck K, Forsgren A. Susceptibilities of Mycobacterium marinum to gatifloxacin, gemifloxacin, levofloxacin, linezolid, moxifloxacin, telithromycin, and quinupristin-dalfopristin (Synercid) compared to its susceptibilities to reference macrolides and quinolones. Antimicrob Agents Chemother. Apr 2002;46(4):1114-6. [Medline].
Edelstein H. Mycobacterium marinum skin infections. Report of 31 cases and review of the literature. Arch Intern Med. Jun 27 1994;154(12):1359-64. [Medline].
El-Etr SH, Subbian S, Cirillo SL, et al. Identification of two Mycobacterium marinum loci that affect interactions with macrophages. Infect Immun. Dec 2004;72(12):6902-13. [Medline].
Ena P, Sechi LA, Saccabusi S, et al. Rapid identification of cutaneous infections by nontubercular mycobacteria by polymerase chain reaction-restriction analysis length polymorphism of the hsp65 gene. Int J Dermatol. Aug 2001;40(8):495-9. [Medline].
Enzensberger R, Hunfeld KP, Elshorst-Schmidt T, et al. Disseminated cutaneous Mycobacterium marinum infection in a patient with non-Hodgkin's lymphoma. Infection. Dec 2002;30(6):393-5. [Medline].
Farooqui MA, Berenson C, Lohr JW. Mycobacterium marinum infection in a renal transplant recipient. Transplantation. Jun 15 1999;67(11):1495-6. [Medline].
Forsgren A. Antibiotic susceptibility of Mycobacterium marinum. Scand J Infect Dis. 1993;25(6):779-82. [Medline].
Galdiero M, Finamore E, Galdiero E, et al. A case of granulomatous skin lesions caused by Mycobacterium marinum in the Campania region. New Microbiol. Jan 2005;28(1):89-92. [Medline].
Griffith DE, Aksamit T, Brown-Elliott BA, et al. An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases. Am J Respir Crit Care Med. Feb 15 2007;175(4):367-416. [Medline].
Harth M, Ralph ED, Faraawi R. Septic arthritis due to Mycobacterium marinum. J Rheumatol. May 1994;21(5):957-60. [Medline].
Hartmark-Hill JR, Kanodia AK, Frey KA. 53-year-old man with a swollen finger. Mayo Clin Proc. Feb 2008;83(2):217-20. [Medline].
Horowitz EA, Sanders WE. Other Mycobacterium Species. In: Mandell G, Bennett J, Dolin R, eds. Principles and Practice of Infectious Diseases. 4th ed. New York, NY: Churchill Livingstone; 1995:2264-73.
Iijima S, Saito J, Otsuka F. Mycobacterium marinum skin infection successfully treated with levofloxacin. Arch Dermatol. Aug 1997;133(8):947-9. [Medline].
Johnston JM, Izumi AK. Cutaneous Mycobacterium marinum infection ("swimming pool granuloma"). Clin Dermatol. Jul-Sep 1987;5(3):68-75. [Medline].
Kostman JR, DiNubile MJ. Nodular lymphangitis: a distinctive but often unrecognized syndrome. Ann Intern Med. Jun 1 1993;118(11):883-8. [Medline].
Lewis FM, Marsh BJ, von Reyn CF. Fish tank exposure and cutaneous infections due to Mycobacterium marinum: tuberculin skin testing, treatment, and prevention. Clin Infect Dis. Aug 1 2003;37(3):390-7. [Medline].
Petrini B. Mycobacterium marinum: ubiquitous agent of waterborne granulomatous skin infections. Eur J Clin Microbiol Infect Dis. Oct 2006;25(10):609-13. [Medline].
Ramakrishnan L. Images in clinical medicine. Mycobacterium marinum infection of the hand. N Engl J Med. Aug 28 1997;337(9):612. [Medline].
Rhomberg PR, Jones RN. In vitro activity of 11 antimicrobial agents, including gatifloxacin and GAR936, tested against clinical isolates of Mycobacterium marinum. Diagn Microbiol Infect Dis. Feb 2002;42(2):145-7. [Medline].
Roddy K, Kao G, Dawn M, et al. The arthritic fisherman. Am J Med. Apr 2008;121(4):287-9. [Medline].
Ryan JM, Bryant GD. Fish tank granuloma--a frequently misdiagnosed infection of the upper limb. J Accid Emerg Med. Nov 1997;14(6):398-400. [Medline].
Saadatmand B, Poulton JK, Kauffman CL. Mycobacterium marinum with associated bursitis. J Cutan Med Surg. Apr 1999;3(4):218-20. [Medline].
Shih JY, Hsueh PR, Chang YL, et al. Osteomyelitis and tenosynovitis due to Mycobacterium marinum in a fish dealer. J Formos Med Assoc. Nov 1997;96(11):913-6. [Medline].
Sokol DK, Azzarelli B, Smith RR, et al. Primary intravascular lymphomatosis associated with Mycobacterium marinum. J Neuroimaging. Jan 1998;8(1):47-9. [Medline].
Tan HH, Chan RK. Atypical mycobacterium infection with sporotrichoid spread in a patient with human immunodeficiency virus. Ann Acad Med Singapore. Nov 1999;28(6):846-8. [Medline].
Vazquez JA, Sobel JD. A case of disseminated Mycobacterium marinum infection in an immunocompetent patient. Eur J Clin Microbiol Infect Dis. Oct 1992;11(10):908-11. [Medline].
Weitzul S, Eichhorn PJ, Pandya AG. Nontuberculous mycobacterial infections of the skin. Dermatol Clin. Apr 2000;18(2):359-77, xi-xii. [Medline].
Wendt JR, Lamm RC, Altman DI, et al. An unusually aggressive Mycobacterium marinum hand infection. J Hand Surg [Am]. Sep 1986;11(5):753-5. [Medline].
Further Reading
Keywords
Mycobacterium marinum infection, M marinum infection, fish tank granuloma, swimming pool granuloma, fish fancier's finger
