Tropical/Infectoparasitary Dermatology
Skin infection by Mycobacterium marinum – diagnostic and therapeutic challenge
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class="elsevierStyleTextfn">Tropical/Infectoparasitary Dermatology</span>" "titulo" => "Skin infection by <span class="elsevierStyleItalic">Mycobacterium marinum</span> – diagnostic and therapeutic challenge" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "366" "paginaFinal" => "368" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Angélica Seidel, Daniel Holthausen Nunes, Camilo Fernandes, Gabriella Di Giunta Funchal" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Angélica" "apellidos" => "Seidel" "email" => array:1 [ 0 => "seidelangel@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Daniel Holthausen" "apellidos" => "Nunes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Camilo" "apellidos" => "Fernandes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Gabriella Di Giunta" "apellidos" => "Funchal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Universitário Professor Polydoro Ernani de São Thiago, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Nereu Ramos – Secretaria de Estado de Saúde Santa Catarina, Florianópolis, SC, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1083 "Ancho" => 1674 "Tamanyo" => 155991 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical improvement after 4 months of treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The number of skin infections caused by non-tuberculous mycobacteria (NTM) has been increasing in recent decades.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> There are an average of 130 species and of these, 1/3 can cause infection in humans.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Some have a worldwide distribution, such as the fast-growing ones, while others predominate in Africa and Australia, causing endemic skin infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The cutaneous disease usually arises after the contact of interruptions in the integrity of the skin (such as wounds caused by trauma or surgery)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> with water or other contaminated products, or by hematogenous spread, especially in immunocompromised patients.<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, which is confirmed by culture of the lesion.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The treatment is prolonged. When possible, it should be based on the susceptibility rates of the bacteria causing the infection.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> However, in the absence of an antibiogram and in cases of diagnosis obtained through molecular tests, it is recommended to guide the choice of treatment according to the group of mycobacteria responsible for the disease.<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.</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, who lived in the city of Florianópolis, state of Santa Catarina, Brazil, and worked as a construction worker, had the occasional habit of fishing in mangroves. He mentioned the appearance of a lesion on the 5<span class="elsevierStyleSup">th</span> left finger (LF) 15 years before, after trauma with a perforating-cutting tool. It developed a papule and exudation, with subsequent progression of the lesion to the dorsal aspect of the hand, forming an erythematous-verrucous plaque with nodules and crusts and evident atrophy of the 5<span class="elsevierStyleSup">th</span> finger (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). He denied systemic symptoms. The patient was submitted to punch biopsies, whose histopathological analysis suggested an infectious process but with negative cultures. The patient received several empirical treatments without improvement. A tomography of the left hand ruled out bone involvement and the serologies were negative. The patient was submitted to another spindle biopsy of the lesion and histopathology disclosed a difuse lymphomononuclear infiltrate rich in plasma cells, neutrophils (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), while culture (in solid Lowenstein-Jensen medium) showed <span class="elsevierStyleItalic">Mycobacterium marinum</span> growth. The treatment with clarithromycin, doxycycline, and rifampicin was started, due to the lesion extension, with a good response (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</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, preferably untreated saltwater.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> Since 1954, its infection has been known as “swimming pool” or “fish tank” granuloma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a> It is an uncommon infection, with an incidence of 0.04 to 0.27/100,000 inhabitants.<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, with no sex predilection.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Regarding the incidence in immunosuppressed and immunocompetent patients,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> studies are still scarce to confirm a predominance in either group since the data in the literature remain discordant. Its incubation period lasts two to eight weeks.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The lesion presents as a single, purplish papule, plaque, or nodule, usually on the extremities (such as the dorsal region of the hands or feet).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> It may progress to suppuration, ulceration, or even a debilitating, disseminated infection.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Clinical suspicion is necessary for the diagnosis to be made. A biopsy with histopathological analysis and culture of the lesion should be performed.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The anatomopathological analysis reveals a granulomatous and suppurative process in the dermis, and the culture identifies the bacillus in a few cases.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The treatment depends on the species, extent of the lesion, and the patient's immunological status.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Mild cases with superficial infection can be treated with monotherapy (clarithromycin, minocycline, doxycycline, trimethoprim/sulfamethoxazole). Whereas patients with severe and long-term conditions require the association of two or more drugs (rifampicin, ethambutol, macrolides, trimethoprim/sulfamethoxazole) and eventually resection and debridement.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</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, emphasizing the importance of clinical suspicion, and of performing multiple biopsies of the lesion for culture and histopathological confirmation.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors' contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Angélica Seidel: Design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Daniel Holthausen Nunes: Approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Camilo Fernandes: Approval of the final version of the manuscript; critical review of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Gabriella Di Giunta Funchal: Approval of the final version of the manuscript; critical review of the manuscript; design and planning of the study.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1711208" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1513458" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Authors' contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-03-03" "fechaAceptado" => "2021-03-17" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1513458" "palabras" => array:3 [ 0 => "Bacteria" 1 => "Infections" 2 => "Skin" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The number of skin infections caused by atypical mycobacteria has increased in recent decades. They usually appear after contact with wounds and interruptions in the integrity of the skin. The present report describes a case of cutaneous infection by <span class="elsevierStyleItalic">Mycobacterium marinum</span>, in a young, immunocompetent patient, with a prolonged evolution, diagnosed through a skin lesion culture (from a spindle biopsy of the skin). The patient was treated with multidrug therapy, including clarithromycin, doxycycline, and rifampicin, due to the lesion extent, with satisfactory results. A brief review of the literature is also provided.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Medical Residency Service in Dermatology, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1032 "Ancho" => 1674 "Tamanyo" => 216575 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous and verrucous plaque, with nodules and crusts, located on the 4th and 5th fingers, in addition to the dorsal aspect of the left hand.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3805 "Ancho" => 1674 "Tamanyo" => 975085 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Histopathological analysis of skin biopsy. (A) Pseudoepitheliomatous hyperplasia, (Hematoxylin & eosin, ×20). (B) Multinucleated giant cells, (Hematoxylin & eosin, ×200). (C) Plasma cells, (Hematoxylin & eosin, ×400).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1083 "Ancho" => 1674 "Tamanyo" => 155991 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical improvement after 4 months of treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous and soft skin infections due to non-tuberculous mycobacteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "F. Alcaide" 1 => "J. Esteban" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2010" "volumen" => "1" "paginaInicial" => "46" "paginaFinal" => "50" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Phylogenomics and Comparative Genomic Studies Robustly Support Division of the Genus Mycobacterium into an Emended Genus Mycobacterium and Four Novel Genera" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.S. Gupta" 1 => "B. Lo" 2 => "J. Son" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3389/fmicb.2018.00067" "Revista" => array:5 [ "tituloSerie" => "Front Microbiol" "fecha" => "2018" "volumen" => "9" "paginaInicial" => "67" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29497402" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nontuberculous mycobacterial infections of the lower extremities: A 15-year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.A.A. Diaz" 1 => "T.N. Huff" 2 => "C.R. Libertin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "J Clin Tuberc Other Mycobact Dis" "fecha" => "2019" "volumen" => "15" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mycobacterial Skin and soft tissue infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.H. Wang" 1 => "P. Pancholi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11908-014-0438-5" "Revista" => array:5 [ "tituloSerie" => "Curr Infect Dis Rep" "fecha" => "2014" "volumen" => "16" "paginaInicial" => "438" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25339245" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009700000003/v1_202205170747/S0365059622000332/v1_202205170747/en/main.assets" "Apartado" => array:4 [ "identificador" => "80635" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Tropical/Infectoparasitary Dermatology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009700000003/v1_202205170747/S0365059622000332/v1_202205170747/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059622000332?idApp=UINPBA00008Z" ]
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