Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Ure Eke and John Berth-Jones
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Fish tank granuloma is an infection of the skin caused by Mycobacterium marinum, causing plaques and nodules, commonly on the upper extremities, which may spread in a sporotrichoid fashion after an incubation period of 2 to 6 weeks. The most common sources of infection are tropical fish aquariums, and swimming pools. The infection is commonly limited to the skin, but tenosynovitis, osteomyelitis, and arthritis have been reported with deeper infections. Rarely, disseminated infection may occur, especially in the immunocompromised. There are reports of the development of cutaneous M. marinum infection whilst on infliximab and adalimumab although paradoxically, infliximab has been found to be a useful adjunctive therapy in the management of M. marinum infection.
No controlled trials have been conducted, probably owing to the paucity of cases. Successful treatment is reported with antibiotics given singly or in combination. The mean duration of treatment in various reports ranges from 6 to 20 weeks. No statistical difference in efficacy between treatments has been demonstrated. Lesions can often be effectively treated by simple excision, but occasionally this seems to result in a prolonged infection. Heat treatment of the infected area may have an adjunctive role. Although spontaneous resolution may occur within three years, treatment is required for rapid recovery from infection and the prevention of dissemination. The second-line treatments described below have been so designated as there is relatively little published information about them. The third-line treatments are probably best regarded as adjunctive.
Histology
Culture
Polymerase chain reaction to detect mycobacterial DNA
Genotyping and gene sequencing for molecular characterization and rapid detection of M. marinum
Histology shows non-caseating granulomas, but a complete absence of epithelioid cells and multinucleate giant cells is not unusual in acute lesions. Suppurative, tuberculoid and palisading patterns of granulomas have been described. Dermal small vessel proliferation with mixed inflammation may be a good indicator of cutaneous atypical mycobacterial infections. Ziehl–Nielsen staining is positive for acid-fast bacilli in 30% of biopsies. Culture of the biopsy specimen at 30–33°C yields pigmented colonies of M. marinum. PCR can provide rapid and sensitive detection of mycobacterial DNA in formalin-fixed, paraffin-embedded specimens. In vitro sensitivity studies have not been uniformly predictive of clinical response to the antibiotics. Although they do not have a routine role in directing initial treatment, they may be useful in resistant cases.
Epidemiological, clinical, and therapeutic pattern of Mycobacterium marinum infection: a retrospective series of 35 cases from southern France.
Eberst E, Dereure O, Guillot B, Trento C, Terru D, van de Perre P, Godreuil S. J Am Acad Dermatol 2012; 66: e15–16.
In this retrospective series, the treatment of 35 consecutive cases of M. marinum was reviewed. Thirty-four of 35 (97%) had complete clearance of skin lesions with one course of oral antimicrobial therapy given over a period of four to 24 weeks (median 12.4 weeks). Single antibiotic therapy was given successfully in 25 patients. Fourteen of these received minocycline 200 mg od, five patients received doxycycline 200 mg od and six patients received clarithromycin 500 mg od. Nine patients had dual antibiotic therapy using a combination of clarithromycin with doxycycline, minocycline, rifampicin or ofloxacin.
Sixty-three cases of Mycobacterium marinum infection. Clinical features, treatment and antibiotic susceptibility of causative isolates.
Aubry A, Chosidow O, Caumes E, Robert J, Cambau E. Arch Intern Med 2002; 162: 1746–5.
All patients were treated with antibiotics and 48% underwent surgery. Clarithromycin, doxycycline, and rifampicin were the most commonly prescribed antibiotics. Forty patients had drug combinations, commonly clarithromycin and rifampicin or tetracyclines, tetracyclines and rifampicin or ethambutol.
Soft tissue infections caused by marine bacterial pathogens: epidemiology, diagnosis, and management.
Finkelstein R, Oren I. Curr Infect Dis Rep 2011; 13: 470–7.
The authors support the use of dual antibiotic therapy to reduce the risk of resistance whilst advocating monotherapy for limited superficial infection. Suggested recommended treatment regimens include rifampicin with ethambutol, clarithromycin with ethambutol, clarithromycin with minocycline, and clarithromycin or minocycline monotherapy. They suggest that antibiotics should be given for 3 or 4 months and treatment should be continued for 1 to 2 months after resolution of lesions to reduce the chance of relapse.
Nontuberculous mycobacterial infections of the skin: a retrospective study of 25 cases.
Dodiuk-Gad R, Dyachenko P, Ziv M, Shani-Adir A, Oren Y, Mendelovici S, et al. J Am Acad Dermatol 2007; 57: 413–20.
In this retrospective study, 16 patients were identified to have M. marinum cutaneous infection. The mean interval between clinical presentation and diagnosis was 7.1 months and one patient developed tenosynovitis prompting the authors to highlight the need for early treatment with clinical suggestion of M. marinum infection. Clarithromycin was their recommended drug of choice based on in vitro susceptibility and clinical response.
Atypical mycobacterial cutaneous infections in Hong Kong: 10 year retrospective study.
Ho MH, Ho CK, Chong LY. Hong Kong Med J 2006; 12: 21–6.
Seventeen cases of M. marinum were identified over a 10-year period. Thirteen responded to treatment with oral tetracycline alone (nine minocycline and four doxycycline). Two patients had antituberculous drugs initially but were subsequently switched to minocycline. One patient had a combination of isoniazid, rifampicin, ethambutol, and minocycline. The average duration of treatment was 20 weeks. The authors recommend minocycline 100 mg twice daily as the treatment of choice.
Cutaneous non-tuberculous mycobacterial infections: a clinical and histopathological study of 17 cases from Lebanon.
Abbas O, Marrouch N, Kattar MM, Zeynoun S, Kibbi AG, Rached RA, et al. J Eur Acad Dermatol Venereol 2011; 25: 33–42.
Ten out of 11 patients were successfully treated with either minocyline 100 mg bd (six patients) or clarithromycin 500 mg bd monotherapy (four patients). Patients were treated for an average of 4.8 months (range 3–8 months).
Treatment of Mycobacterium marinum cutaneous infections.
Rallis E, Koumantaki-Mathioudaki E. Expert Opin Pharmacother 2007; 8: 2965–78.
Review article. Surgical treatment may not be necessary or may even be contraindicated in some patients, and should be reserved for cases with isolated superficial lesions that are non-responsive to systemic therapy. Cryotherapy, electrodessication, photodynamic therapy, and local hyperthermic therapy have also been reported with some success.
Efficacy of oral minocycline and hyperthermic treatment in a case of atypical mycobacterial skin infection by Mycobacterium marinum.
Hisamichi K, Hiruma M, Yamazaki M, Matsushita A, Ogawa H. J Dermatol 2002; 29: 810–11.
Minocycline 200 mg daily and local hyperthermic treatment (a disposable chemical pocket warmer) was used every evening for five to six hours over 2.5 months. Although there have been four cases in Japan where patients have been treated with hyperthermic treatment alone, the authors advocate it to be used in conjunction with minocycline.
Possible role of anti-TNF monoclonal antibodies in the treatment of Mycobacterium marinum infection.
Garzoni C, Adler S, Boller C, Furrer H, Villiger PM. Rheumatology 2010; 49: 1991–3.
A patient with PCR-confirmed M. marinum synovial infection of the foot was given triple combination therapy of ethambutol, clarithromycin, and rifampicin for 4 months. Clinical improvement was noted with the subsequent addition of infliximab 5 mg/kg/month.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Minocycline 100–200 mg once daily for 6–12 weeks
Doxycycline 100 mg twice daily for 3 to 4 months
Clarithromycin 500 mg once or twice daily for 3 to 4 months
Rifampin 600 mg and ethambutol 1.2 g daily for 3 to 6 months
Co-trimoxazole 2–3 tablets twice daily for 6 weeks
Clarithromycin 250 mg twice daily and ethambutol 800 mg once daily for 2 to 6 months
Ciprofloxacin 500 mg + clarithromycin 250 mg twice daily for 4 months
Rifabutin 600 mg + clarithromycin 500 mg twice daily + ciprofloxacin 500 mg twice daily for 4 months
Azithromycin 500 mg three times a week for 2 months
Simple excision
Curettage and electrodesiccation
Incision and drainage
Heat therapy by gloves, hot water or heated armlet
Photodynamic therapy
Cryotherapy
Adjunctive anti-TNF-α inhibitors
