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The patient was submitted to another spindle biopsy of the lesion and histopathology disclosed a difuse lymphomononuclear infiltrate rich in plasma cells&#44; neutrophils &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; while culture &#40;in solid Lowenstein-Jensen medium&#41; showed <span class="elsevierStyleItalic">Mycobacterium marinum</span> growth&#46; The treatment with clarithromycin&#44; doxycycline&#44; and rifampicin was started&#44; due to the lesion extension&#44; with a good response &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mycobacterium marinum</span> lives in aquatic environments&#44; preferably untreated saltwater&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> Since 1954&#44; its infection has been known as &#8220;swimming pool&#8221; or &#8220;fish tank&#8221; granuloma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> It is an uncommon infection&#44; with an incidence of 0&#46;04 to 0&#46;27&#47;100&#44;000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It predominates in the second and third decades of life&#44; with no sex predilection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Regarding the incidence in immunosuppressed and immunocompetent patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> studies are still scarce to confirm a predominance in either group since the data in the literature remain discordant&#46; Its incubation period lasts two to eight weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The lesion presents as a single&#44; purplish papule&#44; plaque&#44; or nodule&#44; usually on the extremities &#40;such as the dorsal region of the hands or feet&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It may progress to suppuration&#44; ulceration&#44; or even a debilitating&#44; disseminated infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical suspicion is necessary for the diagnosis to be made&#46; A biopsy with histopathological analysis and culture of the lesion should be performed&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The anatomopathological analysis reveals a granulomatous and suppurative process in the dermis&#44; and the culture identifies the bacillus in a few cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment depends on the species&#44; extent of the lesion&#44; and the patient&#39;s immunological status&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Mild cases with superficial infection can be treated with monotherapy &#40;clarithromycin&#44; minocycline&#44; doxycycline&#44; trimethoprim&#47;sulfamethoxazole&#41;&#46; Whereas patients with severe and long-term conditions require the association of two or more drugs &#40;rifampicin&#44; ethambutol&#44; macrolides&#44; trimethoprim&#47;sulfamethoxazole&#41; and eventually resection and debridement&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This case report describes a case of skin infection caused by <span class="elsevierStyleItalic">Mycobacterium marinum</span> with a long evolution and difficult diagnosis&#44; emphasizing the importance of clinical suspicion&#44; and of performing multiple biopsies of the lesion for culture and histopathological confirmation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#39; contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Ang&#233;lica Seidel&#58; Design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Daniel Holthausen Nunes&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Camilo Fernandes&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Gabriella Di Giunta Funchal&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; design and planning of the study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Tropical/Infectoparasitary Dermatology
Skin infection by Mycobacterium marinum – diagnostic and therapeutic challenge
Angélica Seidela,
Corresponding author
seidelangel@gmail.com

Corresponding author.
, Daniel Holthausen Nunesa,b, Camilo Fernandesb, Gabriella Di Giunta Funchala
a Hospital Universitário Professor Polydoro Ernani de São Thiago, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
b Hospital Nereu Ramos – Secretaria de Estado de Saúde Santa Catarina, Florianópolis, SC, Brazil
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or by hematogenous spread&#44; especially in immunocompromised patients&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Its diagnosis is difficult and requires clinical suspicion due to a history of local trauma with subsequent contamination&#44; which is confirmed by culture of the lesion&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The treatment is prolonged&#46; When possible&#44; it should be based on the susceptibility rates of the bacteria causing the infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> However&#44; in the absence of an antibiogram and in cases of diagnosis obtained through molecular tests&#44; it is recommended to guide the choice of treatment according to the group of mycobacteria responsible for the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors of the present study report below a case of cutaneous infection by <span class="elsevierStyleItalic">Mycobacterium marinum</span> addressing its diagnostic difficulty and therapeutic management&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 36-year-old healthy male patient&#44; who lived in the city of Florian&#243;polis&#44; state of Santa Catarina&#44; Brazil&#44; and worked as a construction worker&#44; had the occasional habit of fishing in mangroves&#46; He mentioned the appearance of a lesion on the 5<span class="elsevierStyleSup">th</span> left finger &#40;LF&#41; 15 years before&#44; after trauma with a perforating-cutting tool&#46; It developed a papule and exudation&#44; with subsequent progression of the lesion to the dorsal aspect of the hand&#44; forming an erythematous-verrucous plaque with nodules and crusts and evident atrophy of the 5<span class="elsevierStyleSup">th</span> finger &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; He denied systemic symptoms&#46; The patient was submitted to punch biopsies&#44; whose histopathological analysis suggested an infectious process but with negative cultures&#46; The patient received several empirical treatments without improvement&#46; A tomography of the left hand ruled out bone involvement and the serologies were negative&#46; The patient was submitted to another spindle biopsy of the lesion and histopathology disclosed a difuse lymphomononuclear infiltrate rich in plasma cells&#44; neutrophils &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; while culture &#40;in solid Lowenstein-Jensen medium&#41; showed <span class="elsevierStyleItalic">Mycobacterium marinum</span> growth&#46; The treatment with clarithromycin&#44; doxycycline&#44; and rifampicin was started&#44; due to the lesion extension&#44; with a good response &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mycobacterium marinum</span> lives in aquatic environments&#44; preferably untreated saltwater&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> Since 1954&#44; its infection has been known as &#8220;swimming pool&#8221; or &#8220;fish tank&#8221; granuloma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> It is an uncommon infection&#44; with an incidence of 0&#46;04 to 0&#46;27&#47;100&#44;000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">It predominates in the second and third decades of life&#44; with no sex predilection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Regarding the incidence in immunosuppressed and immunocompetent patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> studies are still scarce to confirm a predominance in either group since the data in the literature remain discordant&#46; Its incubation period lasts two to eight weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The lesion presents as a single&#44; purplish papule&#44; plaque&#44; or nodule&#44; usually on the extremities &#40;such as the dorsal region of the hands or feet&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> It may progress to suppuration&#44; ulceration&#44; or even a debilitating&#44; disseminated infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical suspicion is necessary for the diagnosis to be made&#46; A biopsy with histopathological analysis and culture of the lesion should be performed&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> The anatomopathological analysis reveals a granulomatous and suppurative process in the dermis&#44; and the culture identifies the bacillus in a few cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment depends on the species&#44; extent of the lesion&#44; and the patient&#39;s immunological status&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Mild cases with superficial infection can be treated with monotherapy &#40;clarithromycin&#44; minocycline&#44; doxycycline&#44; trimethoprim&#47;sulfamethoxazole&#41;&#46; Whereas patients with severe and long-term conditions require the association of two or more drugs &#40;rifampicin&#44; ethambutol&#44; macrolides&#44; trimethoprim&#47;sulfamethoxazole&#41; and eventually resection and debridement&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">This case report describes a case of skin infection caused by <span class="elsevierStyleItalic">Mycobacterium marinum</span> with a long evolution and difficult diagnosis&#44; emphasizing the importance of clinical suspicion&#44; and of performing multiple biopsies of the lesion for culture and histopathological confirmation&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#39; contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Ang&#233;lica Seidel&#58; Design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Daniel Holthausen Nunes&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Camilo Fernandes&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Gabriella Di Giunta Funchal&#58; Approval of the final version of the manuscript&#59; critical review of the manuscript&#59; design and planning of the study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Article information
ISSN: 03650596
Original language: English
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