Fish Tank Granuloma Research Articles

In vivo imaging identified efficient antimicrobial treatment against Mycobacterium marinum infection in mouse footpads

Mycobacterium marinum (M. marinum) is the most common causative bacteria of cutaneous non-tuberculous mycobacterial (NTM) infections, including fish tank granuloma. Treating M. marinum-caused infection takes longer than other NTM diseases because M. marinum is less susceptible to antimicrobial agents. A standard treatment regimen for M. marinum infection has not been established yet, and few in vivo experiments have been performed in mammals to evaluate the bactericidal effects of antimicrobials. In this study, we developed a noninvasive in vivo imaging method to assess the therapeutic efficacy of antimicrobials against M. marinum infection. The data obtained using fluorescent protein or bioluminescence from luciferase will offer valuable insights into bacteria visualization across various bacterial infections. Furthermore, through this imaging technique, we demonstrated that combining clarithromycin, rifampicin, ethambutol, and minocycline effectively cleared M. marinum from the footpad. Granulomas with necrotic abscesses formed on the footpad of M. marinum-infected mice, primarily due to neutrophils involved in the host’s cell-mediated immune response. Inflammatory cytokine and chemokine levels significantly increased 7 days post-infection, aligning with the footpad swelling and granuloma formation observed in the untreated group. Interestingly, immune mediators and cells induced by M. marinum footpad infection were crucial factors associated with hypersensitivity and granuloma formation, as seen in pulmonary tuberculosis. This novel imaging analysis using a cutaneous NTM mouse model might be a powerful tool for the comprehensive analysis of mycobacterial infections.

Postmortem isolation of Mycobacterium marinum from yellow-bellied slider (Trachemys scripta scripta).

Mycobacterium marinum, a slow-growing non-tuberculous mycobacterium, is known for causing skin infections in fish and amphibians, commonly known as “fish tank granuloma” or “swimming pool granuloma”. While its primary impact is on aquatic species, humans also face a potential risk through exposure to contaminated water or aquatic environments. In humans, infections typically are manifested as nodular skin lesions, often on the hands or fingers, leading to a chronic and indolent course. Due to its unique ability to thrive in aquatic environments, M. marinum serves as an infectious agent not only for fish but also for other animal species, including reptiles, especially turtles. The turtle case of postmortem isolation of M. marinum described in this work serves as a reminder of the threat posed by this bacterium, highlighting the relatively low awareness surrounding this subject not only among owners but also among veterinarians. Expanding our understanding of the threats posed by M. marinum is crucial, not only for the well-being of aquatic animals, including turtles, but also for human health. Given the zoonotic potential of M. marinum, a comprehensive understanding of its transmission dynamics, clinical manifestations, and preventive measures is essential. Hence this knowledge can inform strategies to minimize the risk of M. marinum infections overall.

Cutaneous non-tuberculous mycobacterial infections: An update

Non-tuberculous mycobacteria (NTM) are increasingly recognized as causes of skin and soft-tissue infections. They include rapid-growing and slow-growing species. Hospital outbreaks related to contaminated water and in association with surgical and cosmetic procedures have been described. Infections are also associated with immunosuppression. NTM infections have a wide spectrum of clinical manifestations, though Mycobacterium marinum and Mycobacterium ulcerans manifest characteristic lesions – swimming pool granuloma and Buruli ulcer, respectively. NTM infection should be suspected when the skin infection (especially those following trauma or invasive procedure or in a patient with immunosuppression) does not respond to antibiotics. NTM are acid fast, but will be negative on cartridge based nucleic acid amplification tests for Mycobacterium tuberculosis. Diagnosis is confirmed by polymerase chain reaction test which is the gold standard. NTM show variable susceptibility to antimicrobials and no clear treatment guidelines are available. Surgical treatment may also be needed in some cases.

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.

Aquarium granuloma: a diagnosis based on history

Mycobacterium marinum infections are rare but well described in literature. It causes an infection known as aquarium granuloma or swimming pool granuloma since its transmitted through contaminated water. We describe a case of aquarium granuloma in a male patient with skin nodules over his dominant hand whose occupational history helped clinch the diagnosis.

Difficulties in the diagnosis of fish tank granuloma – case report

Introduction: Fish tank granuloma is a rare dermatitis caused by Mycobacterium marinum. Infection occurs through contact of damaged skin with water or aquatic animals infected with these bacteria. Aim: It is likely that skin infection caused by M. marinum transmitted from Clarias gariepinus has as yet not been reported in literature. Our case report is presumably the first publication. Dermatoscopy as a useful method in the diagnosis of skin infections caused by atypical mycobacteria. Our article presents new dermatoscopic features of fish tank granuloma. Case study: The case report applies to a 30-year old, white, Caucasian man referred because of a single, well-demarcated plaque measuring 2 × 4 cm, localized on third finger on left hand above proximal phalanx, without subjective symptoms. The diagnosis was confirmed by medical history, dermoscopy and histopathological examination. Patient was successfully treated with sulfamethoxazole and trimethoprim. Results and discussion: Due to the fact that M. marinum infection is uncommon, in case of clinical suspicion it is necessary to perform skin biopsy, culture and tissue PCR analysis. Knowledge about the opportunities and limitations of theses laboratory tests is pivotal to reasonable clinical decision-making. Conclusions: Dermoscopy is useful to make a diagnosis, but there are still too few accounts in literature. The correct diagnosis determines the effective treatment.

Fish tank granuloma: An emerging skin disease in Iran mimicking Cutaneous Leishmaniasis.

ObjectiveMycobacterium marinum causes a rare cutaneous disease known as fish tank granuloma (FTG). The disease manifestations resemble those associated with Cutaneous Leishmaniasis (CL). The aim of this study was to determine whether FTG was the cause of cutaneous lesions in patients who were referred to the Parasitology laboratory of Imam Reza Hospital in Mashhad to be investigated for CL.Materials/MethodsOne hundered patients, clinically diagnosed with CL between April 2014 and March 2015, were included in this study. Ziehl-Neelsen staining was performed to identify acid-fast Mycobacterium in addition to bacterial cultures using Löwenstein-Jensen medium. Skin lesion samples were also collected and kept on DNA banking cards for PCR testing.ResultsTwenty-nine of the 100 individuals with skin lesions, and therefore suspected of suffering from CL, tested positive for Mycobacterium marinum by PCR. Of these, 21 (72.4%) were male and 8(27.6%) were female. In 97% of these cases the lesions were located on hands and fingers. These patients had a history of manipulating fish and had been in contact with aquarium water. A sporotrichoid appearance was observed in 58.6% of the patients with mycobacterial lesions; 67% of patients had multiple head appearance.ConclusionPatients suspected to have CL and who test negative for CL could be affected by FTG. Therefore, after obtaining an accurate case history, molecular diagnosis is recommended for cases that give a negative result by conventional methods.

Red and Orange Colors as Dermoscopic Clues for Fish-Tank Granuloma.

We report the case of a 34-year-old white man with an 8-month history of erythematoviolaceous papulonodules distributed from the left hand to the arm in a sporotrichoid pattern.

Clinical, Dermatoscopical and Laboratory Essentials of Fish Tank Granuloma

Abstract In immunocompetent individuals Mycobacterium marinum (M. marinum) infection usually presents with localized skin lesions, better known as “swimming pool granuloma” or “fish tank granuloma” (FTG). When establishing the diagnosis of FTG, doctors encounter several problems in the clinical practice: granulomas are detected in less than two thirds of biopsies and acid-fast bacilli are identified only in a minority of cases. Majority of disseminated and aggressive FTG forms are unrecognized at the beginning, and occur in immunosuppressed patients, including organ transplant patients. Functional impairment or even amputation of the extremity, visceral involvement and lethal outcome have been reported. Although more than one thousand cases of FTG have been reported worldwide, dermatoscopy of FTG, as a diagnostic aid, has not been reported yet. Presenting the case of FTG of recent onset where, guided by dermatoscopy, microorganisms were isolated and identified from the biopsy material, we summarize the essentials of clinical and laboratory diagnostics of M. marinum infection.

Manifestations of Mycobacterium marinum in the Immunocompromised Host

Atypical Mycobacterium infections are occasionally encountered in clinical practice. As a result of immune function modulation in some particular populations (i.e., transplant, immunotherapies for chronic rheumatological diseases, chronic steroid therapy), there has been an increase in the number of diagnosed cases with atypical Mycobacterium, in particular M. marinum, associated with a history of exposure to natural or artificial water systems. The aim of this study is to review recent clinical presentations, risk factors, and management of M. marinum infections in immunocompromised individuals. M. marinum exposure may potentially cause skin and soft tissue infections leading to important morbidity with sometimes life-threatening complications among immunocompromised hosts. The diagnosis of this infection is frequently delayed by months due to the often-atypical clinical presentations. A common immunosuppression associated with infection is TNF inhibition secondary to novel TNF inhibitors. These patients often present with infection within the nose. This atypical clinical presentation, in contrast to the classic “fish tank granuloma” hand lesion, may be related to immunosuppressive factors. Increasing awareness of this particular nontuberculous mycobacterial infection among physicians caring for patients with potential exposure to aquatic environments may reduce the time of diagnosis to treatment and avoid further complications.

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.

Multiple swimming pool granulomas in an immunocompetent child

Myvobacterium marinum is an atypical Mycobacterium belonging to Runyon's classification group I. It is the most com- mon atypical mycobacterium to cause infection in humans. However, the infection appears to be rare in the pediatric population. Clinically, patients may present a single cutaneous lesion, such as an erythematous papule, nodule, plaque, sporotrichoid lesions or ulcers at the inoculation site. We present an unusual case of multiple swimming pool granulomas in an immunocompetent child who had a history of non-chloridrated water exposure. Our patient presented with lesions located in non-contiguous body sites, suggesting either systemic dissemination or multiple sites of inoculation as possible pathogenesis.

Mycobacterium Marinum Skin Infection

A forty-nine-year-old non-Bahraini housemaid misdiagnosed and inappropriately treated for more than 2 years as a case of uncontrolled hand eczema. On presentation to Dermatology Unit, she was confirmed to have Fish Tank Granuloma (FTG) and ultimately treated with a course of oral Doxycycline and showed excellent outcome. ______________________________________________________________________________ * Senior House Office ** Consultant Dermatology ***Consultant Dermatology/HOD Internal Medicine Dermatology Unit King Hamad University Hospital Kingdom of Bahrain Email: ahmed.aljowder@khuh.org.bh

Treatment of Sporotrichoid Fish Tank Granuloma with Pulsed Clarithromycin

Background: There is no established therapy of choice for Mycobacterium marinum skin infections; clarithromycin monotherapy was used in some anecdotical cases at changeable daily doses and length. Objective: To evaluate the efficacy and safety of pulsed clarithromycin monotherapy. Methods: 29 patients with a clinical diagnosis of sporotrichoid fish tank granuloma were admitted from 2002 to 2013. In 14 patients, the clinical diagnosis was confirmed by history, histopathology and bacteriological examinations. All patients were treated with clarithromycin (500 mg/day for 10 consecutive days/month for 5 months). Results: In 12 out of 14 patients (85.7%) complete clinical remission was recorded. Two patients showed partial remission after 3 months of therapy, but they were lost to follow-up and were therefore not considered evaluable. Conclusion: Our study suggests that pulsed clarithromycin monotherapy is effective and safe in sporotrichoid M. marinum skin infections.

Review of Mycobacterium marinum Infection Reported From Iran and Report of Three New Cases With Sporotrichoid Presentation

Introduction:Mycobacterium marinum infection is the most common nontuberculous mycobacterial skin lesions. It results from skin injury and contact with contaminated water, fish, or shellfish; its infections have low frequency, nonspecific symptoms and lack of specific identification methods that can alter correct diagnosis.This study designed about cases that reported from Iran and comparing their presentation and clinical sign and symptom and outcome.Case Presentation:We find and evaluate three cases that have been reported in indexing sites (PubMed, Google scholar and Iranian indexing databases) since 1980 till end of 2012. Using combinations of the following keywords: “Mycobacterium marinum,” “Iran”, “atypical mycobacterium”, “Sporotrichoid presentation” and “fish tank granuloma”. Three new cases also described that infected with this organism and had Sporotrichoid presentation in 2012 in a referral hospital in north of Iran.Conclusions:Totally we evaluate six patients. Source of infection in all cases were aquarium and four of six cases were male (66.6%). Occurrence to treatment interval were between one month to one year (mean 3.07 months). Infection site in all of them were hands and dominantly in right hand (66.6 % of cases ) and 83.3 % of them had Sporotrichoid presentation and all of the patients finally cured. The only cause of infection with Mycobacterium marinum in Iran is aquarium and its presence in homes and offices increased during these years. Health workers and people should be informed and warned about this disease.

Rare diagnosis of nodular lymphangitis caused by Mycobacterium marinum: MDCT imaging findings

Mycobacterium marinum is an atypical mycobacterium that usually causes a solitary nodule on the hand (“fish tank granuloma”) or less commonly, secondary erythematous channels and nodules spread along lymphatic drainage of the extremity, mimicking sporothricoid skin lesions of nodular lymphangitis. This report presents a case of this rare entity, a nodular lymphangitis caused by Mycobacterium marinum. Multidetector computed tomography (MDCT) imaging was very useful in determining the morphology (cellulitis with a few small subcutaneous nodules and channels) and the extension of the lesion.

<i>Mycobacterium marinum</i> による Fish Tank Granuloma の1 例

63 歳，女性。熱帯魚観賞用水槽の清掃中に右前腕屈側を擦過し，約 1 カ月後に紅色結節が出現した。1 週間後再び同部を魚水槽の壁で擦過し，さらに 2 個の紅色結節の形成をみた。発疹は前腕一部に限局した多発限局型(固定型)であった。紅色結節の病理組織所見は，組織球，類上皮細胞，多核巨細胞よりなる肉芽腫であった。組織を小川培地に接種し，25℃，2 週間後に乳白色のコロニーを得た。分離菌は DNA-DNA hybridiazation(DDH)法により Mycobacterium marinum と同定された。以上の所見より Mycobacterium marinum による fish tank granuloma と診断した。治療は塩酸テトラサイクリン 1000 mg を 8 週間投与し軽快した。塩酸テトラサイクリンは有用性が高く，眩暈などの副作用が少なく女性例にも処方できる安価な薬剤である。

A rifampicin-resistant Mycobacterium marinum infection in a newly diagnosed HIV-1 individual

Mycobacterium marinum is a rare non-tuberculous mycobacterium known commonly to cause fish tank granuloma. It is found in aquatic surroundings and is common in healthy individuals. We report a case and review the literature in an immunocompromised HIV-1 individual with a first reported case of a rifampicin-resistant M. marinum organism in the literature.

Three cases of swimming pool granuloma

Three cases of swimming pool granuloma are reported.Case 1:a 40-year-old female presented with a 2-month history of nodules and plaques on the right hand and forearm.She was a tropical fish salesperson but denied trauma history.Skin examination revealed multiple irregularly sized,dark-red nodules and plaques on the joints of right fingers,wrist,and elbow,as well as multiple subcutaneous nodules simulating strings of beads on the right upper limb.Case 2:a 48-year-old female presented with a 2-month history of nodules and plaques on the left hand and forearm.There was a history of trauma due to tropical fish tank and filter cleaning.Physical examination showed multiple deep purple plaques and painless subcutaneous nodules scattered on the left hand,wrist,and upper limb.Case 3:a 39-year-old male presented with a 3-month history of nodules on the fingers of both hands.There was no history of trauma,but he was a tropical aquarist.Skin examination revealed multiple soybean-sized dark-red nodules on the extensor aspect of interphalangeal joints of both hands.Fungal examinations yielded negative results in the 3 cases,while histopathology revealed infectious granuloma with a mixed inflammatory cell infiltrate.All of the cases showed positive results in purified protein derivative (PPD)skin test.Mycobacterium marinum was isolated from the lesional tissue of Case 1 and 2,but not from Case 3.All the patients were diagnosed with swimming pool granuloma,and given anti-atypical mycobacterial therapy including oral rifampin and clarithromycin.The lesions disappeared after 1 to 3 months of treatment,with the treatment course varying from 2 to 5 months.No recurrence was observed during a 3- to 12-month follow-up.

Aggressive cutaneous infection with Mycobacterium marinum in two patients receiving anti–tumor necrosis factor-alfa agents

To the Editor: Cutaneous infections with Mycobacterium marinum usually affect people in contact with water or fish, especially from tropical areas. We report two additional cases of unusually aggressive cutaneous infection with M marinum in fish tank owners receiving anti–tumor necrosis factor-alfa (TNFα) antibodies, underscoring the pitfalls of histologic diagnosis. Case 1, a 41-year-old woman who had received methotrexate and infliximab for psoriatic arthritis over the previous 2 years, developed a rapidly progressive nodular lesion on her right index finger followed by the onset of inflammatory nodules on the right hand and forearm with a sporotrichoid pattern (Fig 1). Because she regularly cleaned a fish tank, infection with M marinum was first considered and confirmed by skin culture and molecular identification using polymerase chain reaction amplification of the 16S-23S ribosomal DNA spacer followed by hybridization with specific probes (GenoType Mycobacterium; Hain Diagnostika, Nehren, Germany). A biopsy specimen taken from a forearm nodule revealed a nonspecific neutrophil-rich inflammation with no significant granuloma formation and Ziehl–Nielsen staining was negative (Fig 2). Infliximab was discontinued, and a treatment with minocycline and clarithromycin was introduced, but the sporotrichoid nodules continued to increase in size. Rifabutin and ethambutol were then added to the patient's regimen and a complete clinical clearance was seen by 4 months posttreatment.Fig 2Biopsy specimen from the forearm lesion (patient 1) revealed a neutrophil-rich inflammatory infiltrate without significant granuloma formation. (Hematoxylin-eosin stain; original magnification: ×10.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Case 2 was a 50-year-old woman who had been treated with adalimumab for rheumatoid arthritis over the previous 18 months. She was referred for an inflammatory lesion on her right index finger that was rapidly followed by the development of several nodules on her right forearm. The regular care of a fish tank containing tropical fish led to the suspicion of M marinum infection, which was confirmed by the presence of acid-fast bacilli upon direct examination by auramine and Ziehl–Nielsen staining of smears obtained from cutaneous biopsy, skin culture, and identification procedures. The histologic examination revealed nonspecific inflammation with no significant granulomas, and Ziehl–Nielsen staining was also negative. Adalimumab was discontinued, and treatment with minocycline and clarithromycin resulted in complete clinical clearance after 3 months. Humans usually become infected by M marinum after a small traumatic wound in an aquatic environment. Rather surprisingly, M marinum infection during anti-TNFα treatment has been reported in only three patients,1Chopra N. Kirschenbaum A.E. Widman D. Mycobacterium marinum tenosynovitis in a patient on etanercept therapy for rheumatoid arthritis.J Clin Rheumatol. 2002; 8: 265-268Crossref Scopus (38) Google Scholar, 2Rallis E. Koumantaki-Mathioudaki E. Frangoulis E. Chatziolou E. Katsambas A. Severe sporotrichoid fish tank granuloma following infliximab therapy.Am J Clin Dermatol. 2007; 8: 385-388Crossref Scopus (38) Google Scholar, 3Fallon J.C. Patchett S. Gulmann C. Murphy G.M. Mycobacterium marinum infection complicating Crohn's disease, treated with infliximab.Clin Exp Dermatol. 2008; 33: 43-45Google Scholar including two receiving infliximab, with cutaneous lesions displaying unusually rapid sporotrichoid extension as in our patients.2Rallis E. Koumantaki-Mathioudaki E. Frangoulis E. Chatziolou E. Katsambas A. Severe sporotrichoid fish tank granuloma following infliximab therapy.Am J Clin Dermatol. 2007; 8: 385-388Crossref Scopus (38) Google Scholar, 3Fallon J.C. Patchett S. Gulmann C. Murphy G.M. Mycobacterium marinum infection complicating Crohn's disease, treated with infliximab.Clin Exp Dermatol. 2008; 33: 43-45Google Scholar This aggressive outcome is reminiscent of the accelerated progression of other mycobacterial infections in patients receiving anti-TNFα agents and is probably partly related to the inhibition of granuloma formation. As a consequence, histologic examination is unlikely to show granulomas but may instead display a misleading nonspecific inflammation with a prominent infiltrate of macrophages and neutrophils, as in our two patients. The inhibition of granuloma formation and subsequent more aggressive disease with rapid sporotrichoid extension, or disseminated lesions caused by M marinum, are not specific features of anti-TNFα agents because they also have been reported in immunocompromised patients on different medications.4Bartralot R. Pujol R.M. García-Patos V. Sitjas D. Martín-Casabona N. Coll P. et al.Cutaneous infections due to nontuberculous mycobacteria: histopathological review of 28 cases. Comparative study between lesions observed in immunosuppressed patients and normal hosts.J Cutan Pathol. 2000; 27: 124-129Crossref Scopus (154) Google Scholar, 5Streit M. Böhlen L.M. Hunziker T. Zimmerli S. Tscharner G.G. Nievergelt H. et al.Disseminated Mycobacterium marinum infection with extensive cutaneous eruption and bacteremia in an immunocompromised patient.Eur J Dermatol. 2006; 16: 79-83Google Scholar No specific therapeutic guidelines have been issued in this specific setting. As illustrated by our first patient, first-line antibiotics may fail to control the disease, and other antimycobacterial agents may have to be added. Discontinuation of anti-TNFα treatment must be considered but is not always mandatory.2Rallis E. Koumantaki-Mathioudaki E. Frangoulis E. Chatziolou E. Katsambas A. Severe sporotrichoid fish tank granuloma following infliximab therapy.Am J Clin Dermatol. 2007; 8: 385-388Crossref Scopus (38) Google Scholar