Fish Tank Granuloma Research Articles

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

Disseminated Mycobacterium marinum infection in a hematopoietic stem cell transplant recipient

Mycobacterium marinum is a photochromogenic mycobacterium that is ubiquitous in the aquatic environment. In the general population, exposure to aquaria is the most common cause of M. marinum infection. Known as "swimmer's granuloma" or "fish tank granuloma," M. marinum is an occupational hazard for aquarium cleaners and fishermen. There are several reports in the literature of M. marinum infection in immunocompromised hosts, including those with solid organ transplants, but none in patients who have received stem cell transplants (SCTs). To our knowledge, this is a first report of disseminated M. marinum infection in an SCT recipient who continued to develop new skin lesions even after months of targeted therapy. The implications are that elderly patients who receive T-cell-depleted SCTs may be at prolonged risk for pathogens dependent on cellular immunity, and the presentation of illness with such pathogens may be more severe and widely disseminated than might otherwise be expected.

Nasal Fish Tank Granuloma: An Uncommon Cause for Epistaxis

An immunocompetent 28-year-old male aquarium store employee presented with 1 month of intermittent epistaxis. A bleeding granulomatous lesion was identified over the right nasal septum (Figure 1). Histopathology from the incisional biopsy revealed granulomatous inflammation with the presence of acid-fast bacilli (Figure 2). Culture of the homogenized specimen on Middlebrook 7H11 agar after 14 days displayed white clones of non-tuberculous Mycobacterium (NTM) that turned brilliant yellow upon light exposure (Figure 3). Polymerase chain reaction (PCR) amplification of the 65-kDa heat shock protein gene with restriction enzyme analysis using BstE II and Hae III confirmed the diagnosis of Mycobacterium marinum infection. The lesion regressed completely with 3 months of doxycycline treatment. Figure 1. Anterior rhinoscopy revealed a granulomatous lesion with active oozing (arrow) on the right nasal septum. Inferior turbinate was identified as an asterisk. Figure 2. Histopathology of the specimen disclosed acid-fast bacilli (arrow) with the granulation inflammation. Figure 3. Mycobacterium marinum clones on Middlebrook 7H11 agar plates showed the photochromogenic characteristic, which are white when grown in the dark (A) and turn a brilliant yellow soon after exposure to light (B). Fish tank granuloma is a rare granulomatous skin infection caused by Mycobacterium marinum, an opportunistic NTM, commonly found in aquatic environments.1 Extremities are most frequently affected; nasal cavity infection is seldom reported. The diagnosis is generally based on a history of aquatic exposure (occupational or recreational), histopathology of granulomatous inflammation with or without the presence of acid-fast bacilli, and a slow-growing photochromogenic NTM incubated at low temperature (28–30°C). Furthermore, PCR facilitates an early identification of Mycobacterium marinum infection. Superficial lesion sometimes resolves spontaneously, but several months of antimicrobial drug are usually necessary. Various monotherapies, including doxycycline, are effective.2

Mycobacterium marinum induces a marked LC3 recruitment to its containing phagosome that depends on a functional ESX-1 secretion system

Autophagy has been implicated as part of the innate immune system against different intracellular microorganisms. Mycobacterium marinum is the causative agent of the fish-tank granuloma and has been widely used as an alternative model to study pathogenic mycobacteria. In this report, we show an active interaction of M. marinum with the autophagic protein LC3, an event that requires pathogen viability and bacterial protein synthesis. Interestingly, M. marinum lacking the region of difference 1 (RD1) is unable to recruit LC3, indicating that a functional ESX-1 secretion system is an absolute requirement for this process. In addition, phagocytosis of the bacteria is also a condition for the LC3 rearrangement induced by M. marinum. We present evidence that this pathogen resides temporarily in a LC3-decorated compartment with late endocytic features but mostly devoid of lysosomal enzymes or degradative properties. In addition our results indicate that autophagy induction by rapamycin treatment leads to maturation of the M. marinum-containing compartment.

Managing fish tank granuloma

It is important for care providers to recognise fish tank granuloma when it presents and to treat it early, in order to achieve good results.

TB or not TB? Fishing for Molecules Making Permissive Granulomas

Focal accumulations of mononuclear cells, called granulomas, are a hallmark of mycobacterial infections. A common misconception is that granulomas are uniformly protective. In transparent zebrafish larvae infected with Mycobacterium marinum, Volkman et al. demonstrate an interaction of mycobacteria with epithelial cells that helps recruit macrophages to the granuloma as "feeder cells."

Fish tank granuloma: misdiagnosed as cutaneous leishmaniasis

Mycobacterium marinum is an atypical mycobacterium that causes a skin infection known as fish tank granuloma or swimming pool granuloma affecting people who are exposed to aquatic environments. In general, it is managed medically with antimicrobials and variable treatment protocols. Here, we report a Saudi gentleman who acquired this infection in Thailand and was misdiagnosed as cutaneous leishmaniasis. After establishing the correct diagnosis, treatment with minocycline and trimethoprim-sulfamethoxazole resulted in rapid healing.

Nontuberculous Mycobacteria in Solid Organ Transplant Recipients

Nontuberculous Mycobacteria in Solid Organ Transplant Recipients

Severe sporotrichoid fishtank granuloma following infliximab therapy for Crohnʼs disease

Severe sporotrichoid fishtank granuloma following infliximab therapy for Crohnʼs disease

Dermatology Identifying fish tank granuloma

The diagnosis of this uncommon condition is often delayed, says Dr Nigel Stollery.

Clinical presentation and therapy of Mycobacterium marinum infection as seen in 12 cases

Mycobacterium marinum (M.m.) is the causative pathogen of skin infections that have been called "swimming pool granulomas". An increasing number of reports that deep structures are involved in these infections was the reason for studying the clinical presentation and response of the infection to different therapeutic regimens. All patients (eight men, four women, age range 18-73 years) were included in whom, between january 1991 and February 1995, M.m. infection had been proven by culture. The clinical data of these patients were retrospectively obtained by standardized questionnaire. The infection was limited to the skin in four of the twelve patients, deep structures only were involved in three, and five had both. Infections limited to the skin were successfully treated with sulphamethoxazole and trimethoprim or with tetracyclines, while rifampicin, alone or in combination with ethambutol, was efficacious when deep structures were involved. No surgical intervention was--or should be--performed. Infections with M.m. often involve deep structures, even in the absence of the skin being involved. The term "swimming pool granuloma" is, therefore, misleading when the infection is limited to he skin. A history of a chronic and indolent course, frequent changes of doctor and striking polypharmacy in its treatment are pointers to this infection.

Importation of mycobacteriosis with ornamental fish: Medico-legal implications

Mycobacterium fortuitum, as well as Mycobacterium marinum and Mycobacterium chelonae, are the etiological agents of fish Mycobacterioses. Mycobacteriosis has been reported to affect a wide range of freshwater and marine fish species, suggesting an ubiquitous distribution, and can cause zoonotic infections (known as "fish tank granuloma" or "swimming pool granuloma") in humans exposed to fish and contaminated water. Infection in human consists of nodular cutaneous lesions that can progress to tenosynovitis, arthritis, and osteomyelitis, depending on the immunological status. Authors describe some cases observed during routinary diagnostic activity in aquarium fish. Fish were sampled and histopathological, microbiological, and biomolecular exams were carried out. Histopathology showed systemic granulomatosis. Microbiological and biomolecular exams allowed us to identify the M. fortuitum as a main species. Finally, some considerations on the legal aspects of such disease are discussed.

53-Year-Old Man With a Swollen Finger

53-Year-Old Man With a Swollen Finger

A pregnant woman with fish tank granuloma

The patient was a 20 year old in her first pregnancy. Maternal weight was 124 kg and booking BMI 38. She presented to the dermatology department at 12 weeks gestation with skin lesions (Figure 1). ...

Hautinfektionen durch atypische Mykobakterien

Atypical mycobacteria are environmental saprophytes. Occasionally they may enter human skin through injuries and cause localized infection. Papules, nodules, plaques, ulcers and panniculitis-like lesions are common manifestations. Disseminated infection occurs in immunocompromised patients. Evidence of mycobacterial infection can be obtained by tissue specimens, culture being most important for diagnosis. Because many mycobacteria only grow on special media and at special temperatures it is crucial that clinical suspicion is raised so correct testing is performed. Buruli ulcer caused by M. ulcerans is the most prevalent atypical mycobacteriosis worldwide; its occurrence is restricted to tropical areas. In European countries fish tank granuloma caused by M. marinum is most commonly observed. M. avium-complex, M. kansasii und rapidly growing mycobacteria of M. fortuitum-complex are other atypical mycobacteria that can cause cutaneous infection. Treatment is difficult because many atypical mycobacteria are resistant to common antibiotics.

Severe Sporotrichoid Fish Tank Granuloma Following Infliximab Therapy

Mycobacterium marinum is an atypical mycobacterium usually found in non-chlorinated water. It rarely disseminates, except in the setting of a severely immunosuppressed patient, and usually follows a sporotrichotic type of distribution. We report the case of a 45-year-old man who had ankylosing spondylitis and was receiving infliximab and isoniazid for latent tuberculosis. The patient presented with a 5-month history of painful erythematous and suppurative nodules and abscesses on the right upper extremity. M. marinum was not isolated in cultures and histologic findings together with clinical examination provided evidence of sporotrichoid-like fish tank granuloma. The patient was treated with rifampin (rifampicin) and ethambutol for 8 months and responded satisfactorily while continuing to receive infliximab. In accordance with data in the published literature, isoniazid proved ineffective in preventing M. marinum infection in this patient. While mycobacterial complications of tumor necrosis factor-alpha (TNFalpha) inhibitor therapy are well established, our case appears to be the first reported instance of M. marinum infection in a patient taking infliximab. As anti-TNFalpha agents become increasingly used for a variety of conditions, awareness of the potential infectious complications associated with use of these agents will be vital for clinicians.

Preseptal cellulitis due to Mycobacterium marinum

Mycobacterium marinum is an atypical mycobacterium found in both salt and fresh water. It occasionally causes soft tissue infections after minor trauma, principally affecting the limbs. A 17-year-old male aquarium worker presented with preseptal cellulitis of his right eye, after attempting to lance a hordeolum some days previously. The condition failed to respond to antibiotics and a necrotic area developed, which subsequently required debridement. Histology of the debrided area demonstrated granulomatous inflammation which when considered with his occupation led to the diagnosis of Mycobacterium marinum--'fish-tank granuloma'. A Medline search did not demonstrate any previous cases of Mycobacterium marinum infection occurring peri-orbitally. The current literature regarding diagnosis and management is reviewed. Although infection with Mycobacterium marinum is rare in the general population, this case demonstrates the importance of considering the diagnosis when dealing with patients frequently exposed to fresh or salt water.

Mycobacterium marinum Infection in Caviar Fishes and Fisherman`s in a Caspian Sea Province in North of Iran

Mycobacterium marinum is the etiologic agent of fish tank granuloma in human. Determination of the fish tank granuloma in Fishermen and Mycobacterium marinum infection in Caviar fishes in Ashorade, in south east Caspian Sea were our objectives. Any suspected lesions in 387 subjects of Fishermen and 113 autopsy samples from gills of fish of Caviar were obtained and culture in Lowenstein Jensen media. The mycobacterial species were determined by conventional biochemical tests. No fish tank granuloma was proved in human, but 11 (9.73%) strains of Mycobacteria were isolated from Caviar fishes, that only 2 strains (1.76%) belong to M. marinum. © 2006 Asian Network for Scientific Information.

Distribution of mycobacteria in clinically healthy ornamental fish and their aquarium environment

Some mycobacterial species (particularly Mycobacterium marinum) found in aquarium environments may cause chronic diseases in fish and cutaneous infections in humans, the so-called 'fish tank granuloma'. The presence and distribution of mycobacterial species in clinically healthy aquarium fish and their environment has not been adequately explored. The present study analysed the occurrence of mycobacteria in a decorative aquarium (Brno, South Moravia) and in five aquaria of a professional fish breeder (Bohumin, North Moravia). After Ziehl-Neelsen staining, acid-fast rods (AFR) were observed in six (14.3%) and mycobacteria were detected by culture in 18 (42.9%) of 42 tissue samples from 19 fish. Sixty-five samples of the aqueous environment from all six aquaria were examined; AFR were found in 16 (24.6%) and mycobacteria were detected by culture in 49 (75.4%) samples. Forty-one (70.7%) of 58 selected mycobacterial isolates were identified biochemically as follows: M. fortuitum, M. flavescens, M. chelonae, M. gordonae, M. terrae, M. triviale, M. diernhoferi, M. celatum, M. kansasii and M. intracellulare. The clinically important species for humans and fish, M. marinum, was not detected. Mycobacterium kansasii was isolated from one sample of the aquarium environment from North Moravia, which is a region of the Czech Republic with endemic incidence of M. kansasii in water. The incidence of other conditionally pathogenic mycobacterial species in healthy fish and in all investigated constituents of the aquarium environment including snails and crustaceans used for fish feeding, was quite high. Accordingly, mycobacterial species from aquarium environments may serve as a possible source of infection for both aquarium fish and immunodeficient fish handlers.

Identification of Mycobacterium marinum 65 kD heat shock protein gene by polymerase chain reaction restriction analysis from lesions of swimming pool granuloma

Nontuberculous mycobacterium (NTM) had been reported to cause cutaneous infections which are difficult to interpret due to the variability of the clinical manifestations. Among NTM infections, Mycobacterium marinum (M. marinum) are mostly seen to cause skin infection. It is therefore important to establish a rapid approach for detection and identification of M. marinum from lesions of patients with suspected M. marinum infections. Specimens were obtained from 5 patients with swimming pool granuloma. DNA was extracted and polymerase chain reaction (PCR) was performed. PCR products were digested with Hae III and BstE II, then analysed by pattern restriction analysis to detect heat shock protein (hsp) 65 kD gene. The 65 kD hsp gene was found in all specimens from patients with swimming pool granuloma. PCR restriction analysis (PRA) identified all 5 samples to be M. marinum infections, and the result was consistent with that of routine bacteriological identification. The lesions subsided or markedly improved upon treatment. PRA is a sensitive, specific and rapid method in identification of mycobacteria. Application of this method will be helpful for early diagnosis of mycobacterial skin infections.