Sporotrichoid Spread Research Articles

Mycobacterium marinum hand infection masquerading as tinea manuum: a case report and literature review

Fish tank granuloma is a rare skin infection caused by Mycobacterium marinum. It occurs after exposure of skin abrasions to contaminated water or infected fish. The majority of M. marinum infections today are fish tank-related. The most common presentation is a solitary nodule, often with sporotrichoid spread. Other presentations do not occur often. The diagnosis is often delayed because of lack of suspicion, nonspecific histopathological findings, and frequently unsuccessful cultivation. Here we present the case of a 37-year-old male with M. marinum skin infection, presenting as erythematous scaling plaques. Because the initial results of laboratory and histopathological examinations were negative for a fungal infection or nontuberculous mycobacteria, the patient was treated empirically with several systemic antibiotics and antifungals without any success. Finally, the diagnosis of fish tank granuloma was confirmed 3 months after the initial presentation of the patient. After the introduction of treatment with rifampicin and clarithromycin, complete clinical remission was observed after 6 months of therapy.

Fish Tank Granuloma – a Case Report

Abstract Swimming-pool granuloma and fish tank granuloma refer to the infections caused by Mycobacterium marinum. After having been discovered in salt water fish in Philadelphia Aquarium and described in 1926, this skin infection was first reported in humans in 1951. It developed in people who had swum in contaminated swimming pools. M. marinum is a non-tuberculous, atypical mycobacterium, which is found on plants, soil and fish in freshwater and salt water worldwide. Humans become infected usually after trauma and contact with an aquatic environment. Infection is limited to the skin and usually occurs in healthy individuals, but in immunocompromised patients the infection may disseminate or spread to the subcutis and bone. The lesions usually appear as solitary nodules or plaques that may lead to suppurative ulcers after 2-3 weeks of incubation. Occasionally, there may be sporotrichoid spread along lymphatics. Its diagnosis is frequently delayed, probably because the infection is very rare and a history of aquatic exposure, which is present in the majority of cases, is often overlooked. Common misdiagnoses include fungal and parasitic infection, cellulitis, verrucous tuberculosis of the skin, gout, rheumatoid arthritis, a foreign body and a skin tumour. We present a case of a 39-year-old Caucasian male with a 12-month history of a single erythematous tender nodule on the right dorsal aspect of the right hand. Histopathological examination revealed longstanding suppurated granulomatous inflammation. The infection was not responsive to several courses of antibiotics until we introduced doxycycline capsules as monotherapy which led to complete remission after 5 months.

Mycobacterium marinum infection with sporotrichoid spread from fish tank exposure.

An immunocompetent 52-year-old man presented with lesions and inflammation on his left arm after lacerating his index finger while cleaning a fish tank ([Figure 1][1]). The lesions appeared at the laceration site two weeks after the injury and continued to progress for five months. He had no fever

Mismanagement of cat bite wound: lessons to learn.

Animal inflicted wounds, left untreated may result in chronic bacterial or fungal infection. Clinical features of these infections may overlap leading to a delay in diagnosis and treatment. We report a case of chronic non-healing cat bite wound treated with several antibiotics without improvement. Later patient developed the classical "sporotrichoid spread" and a presumptive diagnosis of sporotrichosis was made. Laboratory investigation for fungal culture and skin biopsy failed to identify the underlying pathogen. A trial of oral antifungal agent resulted in complete recovery of the lesions implicating fungus as the causative pathogen. Physicians should have a high index of suspicion for fungal infections when managing animal inflicted wounds.

The Infectious and Noninfectious Dermatological Consequences of Flooding: A Field Manual for the Responding Provider.

Meteorological data show that disastrous floods are increasingly frequent and more severe in recent years, perhaps due to climatic changes such as global warming. During and after a flood disaster, traumatic injuries, communicable diseases, chemical exposures, malnutrition, decreased access to care, and even mental health disorders dramatically increase, and many of these have dermatological manifestations. Numerous case reports document typical and atypical cutaneous infections, percutaneous trauma, immersion injuries, noninfectious contact exposures, exposure to wildlife, and exacerbation of underlying skin diseases after such disasters as the 2004 Asian tsunami, Hurricane Katrina in 2005, and the 2010 Pakistan floods. This review attempts to provide a basic field manual of sorts to providers who are engaged in care after a flooding event, with particular focus on the infectious consequences. Bacterial pathogens such as Staphylococcus and Streptococcus are still common causes of skin infections after floods, with atypical bacteria also greatly increased. Vibrio vulnificus is classically associated with exposure to saltwater or brackish water. It may present as necrotizing fasciitis with hemorrhagic bullae, and treatment consists of doxycycline or a quinolone, plus a third-generation cephalosporin and surgical debridement. Atypical mycobacterial infections typically produce indolent cutaneous infections, possibly showing sporotrichoid spread. A unique nontuberculous infection called spam has recently been identified in Satowan Pacific Islanders; combination antibiotic therapy is recommended. Aeromonas infection is typically associated with freshwater exposure and, like Vibrio infections, immunocompromised or cirrhotic patients are at highest risk for severe disease, such as necrotizing fasciitis and sepsis. Various antibiotics can be used to treat Aeromonas infections. Melioidosis is seen mainly in Southeast Asia and Australia, particularly in rice farmers, and can remain latent for many years before presenting as the host's immunocompetence wanes. It can present with a variety of skin findings or as a nonspecific febrile illness, and preferred treatment consists of ceftazidime or a carbapenem with trimethoprim/sulfamethoxazole (TMP/SMX) for 2 weeks, then continuing TMP/SMX for at least 3 months. Leptospirosis is a waterborne zoonosis that is often prevalent after heavy rains or flooding. Different forms exist, including Fort Bragg fever, which produces a distinctive erythematous papular rash on the shins. Doxycycline is often sufficient; however, volume and potassium repletion may be necessary if renal involvement exists. Chromobacterium violaceum infection may occur after open skin is exposed to stagnant or muddy water. Cultured colonies produce a unique violacein pigment, and treatment typically consists of a carbapenem. Both typical and atypical fungal infections are increased in the flooding disaster scenario, such as dermatophytosis, chromoblastomycosis, blastomycosis, and mucormycosis. Appropriate antifungals should be used. In addition, land inundated with water expands the habitat for parasites and/or vectors, thus increased vigilance for regional parasitic infections is necessary after a flood. Lastly, noninfectious consequences of a flooding disaster are also common and include miliaria, immersion foot syndromes, irritant and allergic contact dermatitis, traumatic wounds and animal bites, and arthropod assault, as well as exacerbation of existing skin conditions such as atopic dermatitis, psoriasis, and alopecia areata due to increased stress or nonavailability of daily medications.

An unusual case of sporotrichoid nodules: Metastatic cutaneous squamous cell carcinoma

A 63-year-old immunocompetent patient presented with a 4 month history of 12 painless nodules in a linear array on his right arm. He had a history of a surgery for a cutaneous tumor on the dorsum of his right middle finger about a year prior, but he did not follow up after the surgery. A differential diagnosis of sporotrichosis, atypical mycobacteria, deep fungal infection, and metastatic cutaneous squamous cell carcinoma (SCC) was considered. Skin biopsy revealed islands of dysplastic squamous cells and keratin pearls in a desmoplastic stroma in the deep dermis and subcutaneous tissue. The behavior of the disease was very aggressive, with rapid dissemination in a linear array, mimicking an infectious sporotrichoid spread. To our knowledge, this is the second case report of sporotrichoid metastases to the skin from cutaneous SCC in an immunocompetent patient.

Mycobacterium celatum skin infection with sporotrichoid spread in an HIV-negative immunocompromised man

Mycobacterium celatum skin infection with sporotrichoid spread in an HIV-negative immunocompromised man

Cutaneous infection caused by Nocardiopsis dassonvillei presenting with sporotrichoid spread

To the Editor: Nocardiopsis genus is an environmental actinomycete, which has very rarely been involved in human infections.1 We report an unusual case of cutaneous infection caused by Nocardiopsis dassonvillei showing sporotrichoid distribution of skin lesions. To our knowledge, this peculiar clinical picture has not been documented with Nocardiopsis genus before.

Mycobacterium marinum infection complicated by anti-tumour necrosis factor therapy

Mycobacteria other than tuberculosis infections in patients taking various tumour necrosis factor (TNF)-alpha inhibitors have been reported in the literature. We describe sporotrichoid spread of Mycobacterium marinum in a man with Crohn's disease treated with infliximab. After starting ethambutol and rifampicin and discontinuing infliximab, a worsening appeared. M. marinum infection may have a potential local spread and systemic dissemination in patients treated with TNF-alpha inhibitors.

Nontuberculous Mycobacterial Skin Infections

Mycobacterial organisms have re-emerged as an important cause of infectious disease worldwide. Both tuberculosis and nontuberculous mycobacterial infections remain endemic in many parts of the world and are becoming more common in patients with iatrogenic immunosuppression and HIV infection. The nontuberculous mycobacteria, often referred to as mycobacteria other than tuberculosis (MOT), are of special significance to the dermatologist because they often present in the skin, typically after exposure to an aqueous environment. Presentations range from indolent nodules with sporotrichoid spread to acute suppurative folliculitis and abscess formation. Infection with MOT should be considered whenever routine bacterial cultures are negative. Cultures should be obtained, but empiric therapy must often be started while cultures are pending. Some data suggest that clarithromycin may be the best initial empiric therapy.

Subcutaneous nodules with sporotrichoid spread

Mycobacterium marinum is an atypical mycobacterium found worldwide and associated with swimming pools and aquariums. Infections typically present with subcutaneous nodules and lymphangitis. A 61-year-old female presented with a two-month history of subcutaneous nodules. The patient had a significant recent history that included rose gardening and cleaning her aquarium at home. Biopsy for histology and tissue culture proved the presence of infection with Mycobacterium marinum and the patient was treated with minocycline. The nodules eventually healed and no new lesions appeared after initiation of treatment. Mycobacterium marinum is one of many entities that must be considered in a patient with ascending nodules along the lymphatic drainage of an extremity.

Mycobacterium marinum infection complicating Crohn's disease, treated with infliximab

Tumour necrosis factor-alpha inhibitors including infliximab are often used to treat a number of recalcitrant medical conditions. These agents are increasingly associated with infections, particularly mycobacterial infections. We report sporotrichoid spread of Mycobacterium marinum in a 37-year-old woman with Crohn's disease, who had been receiving infliximab infusions for 2 years. An infection had spread up the right leg, after she had been swimming on holiday in the Canary Islands. M. marinum was cultured from the lesions and also identified by PCR on formalin-fixed tissue. To our knowledge, this is the first report of M. marinum occurring in a patient receiving infliximab.

Itraconazole Can be Effective in the Treatment of Sporotrichoid Leishmaniasis

J Travel Med 2004; 11:328–330. Leishmaniasis represents a diverse group of diseases caused by protozoan parasites that are transmitted to humans by the bite of phlebotomine sandflies. Three major clinical forms can be recognized,visceral,cutaneous and mucocutaneous, which are widespread in tropical, subtropical and temperate areas.1 Data on the incidence of cutaneous leishmaniasis in travelers are scarce. In fact, constant parameters (time of exposure,kind of travel,burden of outdoor activities, rural or urban setting) are necessary to determine this incidence. Studies performed in defined groups such as military personnel in the Middle East showed an incidence of about 8/1,000 persons.2 Cutaneous leishmaniasis is sometimes associated with sporotrichoid spread. Sporotrichoid leishmaniasis is characterized by the development of subcutaneous, nontender, slightly erythematous nodules, often associated with lymphangitis, that progress, starting from the mother lesion, along dermal and subcutaneous lymphatics. In sporotrichoid cutaneous leishmaniasis, amastigotes may be found in both primary lesions and subcutaneous nodules.3,4 Sporotrichoid spread is more frequently associated with New World cutaneous leishmaniasis,particularly Leishmania braziliensis, although it can be observed also in association with Old World cutaneous leishmaniasis (L. major).5,6 The factors that trigger lymphatic dissemination are unclear.Some data suggest that both antileishmanial treatment and the host immune status could influence the dissemination.7,8 The diagnosis of cutaneous leishmaniasis is often made clinically on the basis of a typical lesion together with a history of exposure.Confirmation can be obtained by the direct detection of amastigotes during histologic examination of the biopsy of the lesion. The identification of Leishmania spp. is done traditionally through isoenzyme analysis and requires parasite culture. PCR is a suitable and quick tool for the diagnosis and identification of the different species.9 In the differential diagnosis of sporotrichoid infections, we have to consider, apart from Leishmania spp., infections caused by Sporotrix schenkii,Mycobacterium spp., Nocardia spp. and Francisella tularensis.

Mycobacterium marinum infection: epidemiology and presentation in Queensland 1971-1990.

Evaluation of the clinical and epidemiological features of Mycobacterium marinum infection in Queensland. Laboratory identification and in-vitro susceptibility tests of 29 isolates from the Queensland Health Department Tuberculosis Reference Laboratory were retrospectively gathered and followed up by contacting referring practitioners and obtaining clinical details of patients involved. 29 patients from whom M. marinum was isolated, with a male:female ratio of 3.1:1, and a mean age of 47.4 years. Of 26 patients for whom adequate information was available, 12 had evidence of involvement of deep tissues (including two cases of arthritis) and five suffered sporotrichoid spread of infection. The delay between onset of symptoms and consultation with a medical practitioner was five months (range, two weeks to two years), with a further mean delay to definitive diagnosis of 4.4 weeks. Cure was apparent in 22 of 23 cases. Chemotherapy alone was adequate in 11 cases, as was surgical intervention in three, while a combination approach was successful in eight cases. Trimethoprim/sulfamethoxazole was successful in seven of nine cases and combination rifampicin and ethambutol in six of seven. Tetracyclines were employed as single-agent therapy in nine patients and were effective in seven. Synovitis was a common presenting feature of M. marinum infection in Queensland patients. Occupational and recreational exposure to salt or fresh water was common, and although this history was available to practitioners a mean delay to definitive diagnosis of 4.4 weeks still occurred. The data suggest that chemotherapy alone is often adequate, even with deep tissue involvement. Combinations of conventional antimycobacterial drugs may be the therapy of choice, especially for serious infections, although success was recorded with trimethoprim/sulfamethoxazole alone.

The turtle's revenge: a case of soft tissue Mycobacterium chelonae infection

A case of cutaneous Mycobacterium chelonae infection with sporotrichoid spread and extensive antibiotic resistance is presented. Control of this problem was only achieved after extensive debridement and grafting of the involved limb. The importance of surgery in management is discussed and the literature is reviewed.

SPOROTRICHOID CUTANEOUS INFECTION DUE TO MYCOBACTERIUM CHELONEI IN A RENAL TRANSPLANT PATIENT.

Atypical mycobacterial infections are becoming more common in dermatological practice due to increasing numbers of immunosuppressed patients. A case of cutaneous Mycobacterium chelonei infection with sporotrichoid spread in a renal transplant patient is described, and the current literature regarding clinical spectrum, histopathology and management of infection with this pathogen is reviewed.

Cowpox presenting with sporotrichoid spread: a case report

We describe a patient with cowpox infection who presented with a sporotrichoid pattern of cutaneous lesions. This is the first report of a sporotrichoid pattern of spread in cowpox infection.

Sporotrichoid leishmaniasis in patients from Saudi Arabia: Clinical and histologic features

The clinical and pathologic presentations of cutaneous leishmaniasis in the various countries of the Middle East are well documented. The defined patterns currently encountered in the region emphasize the rarity of local extension of the infection from the bite site. Between 1970 and 1980 we have seen 24 patients with cutaneous leishmaniasis who acquired the infection in Saudi Arabia. In these patients there were several interesting variations from the hitherto described patterns of Oriental sore. The variations include, clinically, the appearance of satellite lesions and the presence of sporotrichoid spread of infection; and histologically, the presence of stellate intradermal abscesses. Such variations in the clinical and pathologic presentations may be due to differences either in the host’s immunologic reactivity or in the Leishmania organisms found in Saudi Arabia. Speculative evidence supports the possibility of a different strain and/or species of Leishmania tropica in Saudi Arabia, which in turn may be responsible for this unique clinicopathologic presentation.

Failure of Doxycycline Treatment in Aquarium-associated Mycobacterium marinum Infections

Two cases of aquarium-associated Mycobacterium marinum infections are described. Neither was cured by the initial therapy consisting of surgical excision followed by doxycycline treatment. Both strains of M. marinum were shown to be resistant to doxycycline. In one patient the lesions were subsequently healed with cotrimoxazole. The other patient, a 12-year-old girl with sporotrichoid spread of the lesions on the lower arm, failed to respond satisfactorily to a combination of rifampicin and ethambutol despite favourable effect in vitro of both drugs. Nine months after the initial treatment, the infection was finally cured with renewed surgery followed by additional chemotherapy with rifampicin and ethambutol. No signs of immunological disorder could be detected in the patient. Increased awareness of the possibility of tetracycline resistance of M. marinum is advocated. A combination of adequate chemotherapy and surgical intervention may be required at least in complicated cases.