eMedicine Specialties > Infectious Diseases > Mycobacterial Infections

Mycobacterium Marinum

Alexandre Lacasse, MD, MSc, Fellow in Infectious Diseases, University of Tennessee at Memphis
Michael Gelfand, MD, FACP, Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis, University of Tennessee; Raphael J Kiel, MD, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Infectious Diseases Division, William Beaumont Hospital

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

Differential Diagnoses

Workup

Laboratory Studies

• M marinum is a nonmotile acid-fast bacillus (AFB) that grows in 2-3 weeks, with optimum growth on Lowenstein-Jensen medium at 30°C. Laboratory personnel should be notified in advance since AFB cultures are mostly carried at higher temperatures.
• M marinum is a photochromogen (Runyon group 1), producing a yellow pigment when exposed to light.
• M marinum produces urease and catalase (weakly) but does not produce niacin or nitrate.
• Polymerase chain reaction (PCR) amplification techniques using Mycobacterium genus-specific primers can be used to diagnose M marinum infection directly in the biopsy sample.

Imaging Studies

• First, obtain radiography of the affected area to evaluate for underlying osteomyelitis.
• Obtain either MRI or CT scanning of the affected area if tenosynovitis or deeper infection is suspected, including osteomyelitis if the screening radiography findings are unrevealing. This would also be indicated in patients with prosthetic material from a previous injury.

Procedures

• Surgical drainage of skin lesions is often unnecessary. Deeper-structure infection may require surgical debridement.

Histologic Findings

Younger lesions show epidermal hyperkeratosis, a mixed inflammatory response, or, possibly, frank suppuration. Older lesions may present as organized granuloma. Caseation is uncommon. The organisms are acid-fast and may have a transverse banding pattern.

Treatment

Medical Care

The mainstay of treatment in M marinum infection is antimicrobial therapy. The duration of therapy is not well defined, but treatment of skin and soft-tissue infections should be continued for 1-2 months after resolution of symptoms and lesions. Therefore, the treatment duration is typically 3-4 months, longer if deeper structures are involved. Some authors have suggested a minimum duration of 6 months. In some cases, a treatment duration of up to 2 years has been reported. Combination treatment with 2 active agents is preferred, although success has been obtained with single-agent approach. Spontaneous resolution of M marinum infection has been reported.

Surgical Care

Surgical drainage of skin lesions may be unnecessary. A French study revealed no clear benefit or change in outcome using a concomitant surgical approach. Deeper-structure infections may require surgery, although its definite role is not well established. Reports have suggested that antibiotic therapy alone is enough to cure most patients and that additional surgical debridement provides cure in remaining cases.

Consultations

An infectious disease specialist can establish the diagnosis and suggest management. A dermatologist can also provide expertise.

Medication

M marinum is resistant to the antituberculosis medications isoniazid, pyrazinamide, and para-aminosalicylic acid and shows intermediate sensitivity to streptomycin. Isolates are sensitive to rifampin, rifabutin, ethambutol, clarithromycin, and sulfonamides, including trimethoprim-sulfamethoxazole (TMP-SMX). Intermediate or complete sensitivity has been reported for both doxycycline and minocycline. Fluoroquinolones also show activity against M marinum. Routine susceptibility testing is not recommended and should be reserved for cases of treatment failure.

No comparative trials of treatment regimens for M marinum skin and soft-tissue infections have been performed. The recommended approach is to use combination of 2 active agents until 1-2 months after resolution of lesions or for a minimum of 6 months. Clarithromycin and ethambutol combination treatment is likely to provide optimal efficacy and tolerability. Rifampin should be added to the treatment regimen when osteomyelitis or other deeper-structure infections are present. Other combinations that have also been used include ethambutol/rifampin, clarithromycin/rifampin, cyclines/clarithromycin, and cyclines/rifampin.

Treatment failure is associated with deeper-structure involvement and is not related to drug therapy. Doxycycline and minocycline monotherapy should probably be used for more superficial soft-tissue infections, as treatment failure has been reported. Clarithromycin monotherapy has been used with some success. Azithromycin can be an alternative to clarithromycin in other nontuberculous mycobacterial infections, but its efficacy is unknown in M marinum infection.

A recent case report showed that lenalidomide, a thalidomide derivative used to treat chronic lymphocytic leukemia, rapidly resolved a chronic biopsy-proven M marinum skin infection refractory to conventional treatment. The mechanism is unknown but is likely related to the immunomodulation effect of lenalidomide.²

Antimycobacterials

Empiric antimycobacterial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Rifampin (Rifadin)

Inhibits bacterial RNA synthesis by binding to DNA-dependent RNA polymerase, blocking RNA transcription. Effective for treating tuberculosis and atypical mycobacterial infections and for eliminating meningococci carriage states. Also useful for prophylaxis of Haemophilus influenzae type b infection. Used in combination with other antibiotics for prophylaxis and to treat staphylococcal infections.

Dosing

Adult

10 mg/kg/d PO/IV usually as a single dose; not to exceed 600 mg/d

Pediatric

10-20 mg/kg/d PO/IV usually as a single dose; 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 1 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

Use with caution in patients with liver impairment; observe for hyperbilirubinemia; urine, feces, saliva, sweat, tears, and CSF may be discolored to red/orange; remove contact lenses while on treatment; obtain CBCs and baseline clinical chemistries prior to and throughout therapy; 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)

Suppresses mycobacteria multiplication by interfering with RNA synthesis. Bacteriostatic against tubercle bacilli.

Dosing

Adult

No previous antituberculous therapy: 15 mg/kg (7 mg/lb) PO qd as a single dose
Previous antituberculous therapy: 25 mg/kg (11 mg/lb) PO qd

Pediatric

Not generally used in children >6 y who are not able to take visual acuity and color perception tests reliably
<13 years: Not recommended
>13 years: Administer as in adults

Interactions

Decreased absorption with aluminum salts (administer several h before or after ethambutol dose)

Contraindications

Documented hypersensitivity; presence of optic neuritis (unless clinically indicated)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Major toxicity of ethambutol is retrobulbar neuritis and peripheral neuropathy; visual field constriction or impairment of acuity or color vision may develop, perform visual acuity and color perception testing q4-6wk while on therapy; reduce dose in impaired renal function

Antimicrobials

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Doxycycline (Vibramycin)

Used to treat infections caused by Rickettsia, Chlamydia, and Mycoplasma. Used for community-acquired pneumonia and other common infections due to susceptible organisms. Has activity against M marinum, M fortuitum, and M chelonae. Inhibits protein synthesis and thus bacterial growth by binding to 30S, and possibly 50S, ribosomal subunits of susceptible bacteria.

Dosing

Adult

100 mg PO/IV bid

Pediatric

<8 years: Not recommended
>8 years: 100-200 mg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d

Interactions

Bioavailability decreases minimally with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate

Contraindications

Documented hypersensitivity; children <8 y; severe hepatic dysfunction

Precautions

Pregnancy

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

Precautions

Use of tetracyclines during tooth development may cause permanent discoloration of the teeth, do not administer in last one-half of pregnancy through age 8 y; photosensitivity reactions are rare

Clarithromycin (Biaxin)

Effective against most strains on nontuberculous mycobacterium species, including M marinum, Mycobacterium avium-intracellulare, M fortuitum, M chelonae, and Mycobacterium abscessus. Exerts antibacterial action by binding to 50S ribosomal subunit, resulting in inhibition of protein synthesis.

Dosing

Adult

500 mg PO q12h

Pediatric

<6 months: Not established
>6 months: 15 mg/kg/d PO divided q12h

Interactions

Toxicity increases with coadministration of fluconazole and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; 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; concurrent use with pimozide

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 is not recommended with CrCl <25 mL/min; administer 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

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 1-2 h before or after taking fluoroquinolones

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

Adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Azithromycin (Zithromax)

Treats mild-to-moderate microbial infections.

Dosing

Adult

500 mg PO qd

Pediatric

<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Rifabutin (Mycobutin)

Indicated for the treatment of tuberculosis and several atypical mycobacterial infections. If GI upset occurs, administer dose bid with food.

Dosing

Adult

300-600 mg PO qd; alternatively, 10-20 mg/kg/d; not to exceed 600 mg/d

Pediatric

Not established; suggested dose is 5 mg/kg/d PO

Interactions

Steady-state zidovudine plasma levels may decrease after repeated rifabutin dosing but does not affect inhibition of HIV by zidovudine

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

Do not administer to patients with active tuberculosis; no evidence exists that rifabutin is effective in prophylaxis against Mycobacterium tuberculosis; may administer isoniazid and rifabutin concurrently in patients requiring prophylaxis against both M tuberculosis and M avium complex; perform hematologic studies periodically in patients receiving prophylaxis due to association with neutropenia and, more rarely, thrombocytopenia

Minocycline (Dynacin, Minocin)

Effective monotherapy. However, resistant strains of M marinum have been reported. 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; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; 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 prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupus-like syndromes may occur

Sulfamethoxazole and Trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

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

Dosing

Adult

160 mg TMP/800 mg SMZ (1 tab DS) PO q12h

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; 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; age <2 mo

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

Do not use during last trimester of pregnancy due to potential toxicity to newborn (eg, jaundice, hemolytic anemia, kernicterus)
Dosage adjustments (adult adjustments)
CrCl (mL/min) 80-50: Recommended IV dose q18h
CrCl 50-10: Recommended IV dose q24h
CrCl <10: Not recommended
HD: 4-5 mg/kg after HD
During peritoneal dialysis: 0.16-0.8 g q48h
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD deficient individuals; AIDS patients 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

Follow-up

Further Outpatient Care

• Patients with M marinum infection are treated in an outpatient setting.
• Follow-up visits with patients should be scheduled weekly until they begin to respond to therapy and then biweekly until the infection is fully cured.

Inpatient & Outpatient Medications

• Continue combination therapy or monotherapy 1-2 months after the infection resolves.

Transfer

• Transfer to other facilities is unnecessary.
• Refer patients with M marinum infection to an infectious diseases physician or a dermatologist in an outpatient clinical setting.

Deterrence/Prevention

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

Complications

• Persistent ulceration or suppuration
• Osteomyelitis
• Tenosynovitis
• Arthritis
• Disseminated infection
• Amputation of involved digit

Prognosis

• With treatment, M marinum infection carries an excellent prognosis. A study from France reported cure in 87% of cases. Treatment failure was significantly related to deeper-structure involvement and ulcerative skin lesions but not to acquired antimicrobial resistance.
• Clinical presentations and outcomes of M marinum infections in patients with HIV infection did not differ from those in patients without HIV infection.

Patient Education

• Patients with M marinum infection are not infectious and are cured with proper treatment.
• Educate people who work near salt water to cleanse their skin with an antibacterial preparation and to dress abrasions or bites with an appropriate bandage.

Miscellaneous

Medicolegal Pitfalls

• Failure to accurately identify M marinum as the causative agent: M marinum infection may be mistaken for sporotrichosis or other causes of nodular ascending lymphangitis.
• Failure to obtain appropriate biopsy samples and skin lesion cultures to determine appropriate therapy

Special Concerns

• M marinum infections in patients with AIDS may result in dissemination to the bone marrow, liver, spleen, and lung.³ This infection may be difficult to detect in this setting and may be confused with M tuberculosis.
• M marinum infections may disseminate in patients receiving infliximab therapy.⁴
• M marinum infections do not respond to conventional antituberculosis agents, such as isoniazid, pyrazinamide, para-aminosalicylic acid, and streptomycin.

Multimedia

Media file 1: Photograph of Mycobacterium marinum infection.

Media file 2: Photograph of Mycobacterium marinum infection.

References

1. 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].

2. 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].

3. 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].

4. 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].

5. 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].

6. 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].

7. 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].

8. 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].

9. 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].

10. 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].

11. 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].

12. 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].

13. 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].

14. Farooqui MA, Berenson C, Lohr JW. Mycobacterium marinum infection in a renal transplant recipient. Transplantation. Jun 15 1999;67(11):1495-6. [Medline].

15. Forsgren A. Antibiotic susceptibility of Mycobacterium marinum. Scand J Infect Dis. 1993;25(6):779-82. [Medline].

16. 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].

17. 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].

18. Harth M, Ralph ED, Faraawi R. Septic arthritis due to Mycobacterium marinum. J Rheumatol. May 1994;21(5):957-60. [Medline].

19. 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].

20. Horowitz EA, Sanders WE. Other Mycobacterium Species. In: Mandell G, Bennett J, Dolin R, eds. Principles and Practice of Infectious Diseases. 4^th ed. New York, NY: Churchill Livingstone; 1995:2264-73.

21. Iijima S, Saito J, Otsuka F. Mycobacterium marinum skin infection successfully treated with levofloxacin. Arch Dermatol. Aug 1997;133(8):947-9. [Medline].

22. Johnston JM, Izumi AK. Cutaneous Mycobacterium marinum infection ("swimming pool granuloma"). Clin Dermatol. Jul-Sep 1987;5(3):68-75. [Medline].

23. Kostman JR, DiNubile MJ. Nodular lymphangitis: a distinctive but often unrecognized syndrome. Ann Intern Med. Jun 1 1993;118(11):883-8. [Medline].

24. 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].

25. Petrini B. Mycobacterium marinum: ubiquitous agent of waterborne granulomatous skin infections. Eur J Clin Microbiol Infect Dis. Oct 2006;25(10):609-13. [Medline].

26. Ramakrishnan L. Images in clinical medicine. Mycobacterium marinum infection of the hand. N Engl J Med. Aug 28 1997;337(9):612. [Medline].

27. 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].

28. Roddy K, Kao G, Dawn M, et al. The arthritic fisherman. Am J Med. Apr 2008;121(4):287-9. [Medline].

29. 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].

30. Saadatmand B, Poulton JK, Kauffman CL. Mycobacterium marinum with associated bursitis. J Cutan Med Surg. Apr 1999;3(4):218-20. [Medline].

31. 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].

32. Sokol DK, Azzarelli B, Smith RR, et al. Primary intravascular lymphomatosis associated with Mycobacterium marinum. J Neuroimaging. Jan 1998;8(1):47-9. [Medline].

33. 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].

34. 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].

35. Weitzul S, Eichhorn PJ, Pandya AG. Nontuberculous mycobacterial infections of the skin. Dermatol Clin. Apr 2000;18(2):359-77, xi-xii. [Medline].

36. 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].

Keywords

Mycobacterium marinum infection, M marinum infection, fish tank granuloma, swimming pool granuloma, fish fancier's finger

Contributor Information and Disclosures

Author

Alexandre Lacasse, MD, MSc, Fellow in Infectious Diseases, University of Tennessee at Memphis
Alexandre Lacasse, MD, MSc is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Michael Gelfand, MD, FACP, Chief, Professor, Department of Internal Medicine, Division of Infectious Diseases, Methodist Healthcare of Memphis, University of Tennessee
Michael Gelfand, MD, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Southern Medical Association
Disclosure: Nothing to disclose.

Raphael J Kiel, MD, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Infectious Diseases Division, William Beaumont Hospital
Raphael J Kiel, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Geriatrics Society
Disclosure: Nothing to disclose.

Medical Editor

Klaus-Dieter Lessnau, MD, FCCP, Clinical Associate Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory; Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Aaron Glatt, MD, Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, New Island Hospital
Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

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