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Arch Pediatr Adolesc Med. 1999;153(5):544. doi:.
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Figure 1 and Figure 2. A purplish nodule, which was visible and palpable in the right buccal sulcus, was present in the right cheek.

MYCOBACTERIUM MARINUM is a free-living nontuberculous mycobacterium that causes disease in freshwater and saltwater fish.1 Occasionally, this mycobacterium may cause infection in humans who are involved in aquatic activity (eg, swimming, fishing, boating) or who keep tropical fish. The resulting infection is commonly known as "swimming pool granuloma," "fish tank granuloma," or "fish fanciers finger."14 The organism has been called a "leisure-time pathogen" and the disease has been referred to as a "hobby hazard."2

Mycobacterium marinum is classified as a photochromogen belonging to Runyon group 1 and produces yellow pigment on exposure to light. It grows at an optimal temperature of 30°C to 32°C and seldom grows at 37°C, unlike Mycobacterium kansasii, also a photochromogen that is commonly pathogenic. Mycobacterium marinum colonies are smooth and shiny and generally take 2 to 4 weeks to grow on solid mycobacterial media, which customarily are incubated for 6 weeks.1,2

Skin infection with this bacterium is often preceded by trauma and aquatic exposure to fresh, salt, or brackish water such as unchlorinated swimming pools, lakes, or fish tanks.1,2 After 2 to 6 weeks of incubation, a solitary, painless, red to violet, papulonodular, or verrucous lesion becomes apparent. It can progress to become ulcerated and/or crusted. A sporotrichoid form often occurs and features a primary inoculum site with similar lesions spreading proximally up the lymphatics to regional lymph nodes.Mycobacterium marinum usually infects the extremities, especially a finger, hand, elbow, knee, or foot. Facial presentation has been reported previously.1,3,5 Deep infections such as tenosynovitis, osteomyelitis, arthritis, and bursitis are rare. Cutaneous or systemic dissemination occurs most commonly in the immunocompromised host.17

The diagnosis of infection is established by performing acid-fast staining and cultures from exudates or tissues, and histopathological examination of a surgical biopsy specimen. Cultured organisms must be differentiated from M kansasii by growth characteristics and biochemical tests. The histopathologic specimens often show nonspecific chronic inflammation; however, noncaseating granuloma and Langerhans giant cells may be seen. Acid-fast bacilli are rarely found on staining.1,2 Although antimicrobial susceptibility testing is available, in vitro testing does not necessarily correlate with in vivo response. The purified protein derivative skin test is frequently positive and may offer a clue in distinguishing this infection from other causes of cutaneous masses.

Mycobacterium marinum infection may be self-limited in the normal host. A superficial infection may be managed by watchful waiting or by single antimicrobial therapy. Surgical debridement alone may suffice in some superficial infections. Deep infections, such as tenosynovitis or arthritis, usually require aggressive surgical debridement in addition to combination medical therapy.

Mycobacterium marinum is typically resistant to isoniazid, aminosalicylic acid, and streptomycin sulfate. It is generally susceptible in vitro to ciprofloxacin, clarithromycin, doxycycline, ethambutol hydrochloride, minocycline, rifampin, tetracycline, and trimethoprim-sulfamethoxazole.16,811 Resistance to several of these antibiotics resulting in failure of clinical treatment has been reported; therapy should be guided by susceptibility testing. Antibiotic therapy is continued for 3 to 6 months, since response to treatment is slow. When there is no improvement despite good compliance, impaired intestinal absorption may be suspected. Serum antimicrobial levels may be used to guide optimal dosing.

Poor prognostic factors of M marinum infections include a persistently draining sinus tract after several months of antibiotic therapy, persistent pain in the lesion, and the local administration of steroids. Relapse may occur despite seemingly adequate therapy.

Mycobacterium marinum infection should be considered in a child with a cutaneous lesion that does not respond to standard therapeutic measures including antibiotics, and who has a history of contact with fish tanks, lakes, or nonchlorinated swimming pools.

Accepted for publication September 18, 1998.

Reprints: Manjusha J. Gaglani, MBBS, Department of Pediatrics, Section of Infectious Diseases, Scott & White Clinic, 2401 S 31st St, Temple, TX 76508.

Gluckman  SJ Mycobacterium marinumClin Dermatol. 1995;13273- 276
Link to Article
Collins  CHGrange  JMNoble  WC Mycobacterium marinum infections in man. J Hyg. 1985;94135- 149
Link to Article
Brady  RCSheth  AMayer  TSchleiss  MR Facial sporotrichoid infection with Mycobacterium marinumJ Pediatr. 1997;130324- 326
Link to Article
Fragoso  MAMurray  DL Mycobacterium marinum infection in a 4-year-old child. Clin Pediatr. 1985;24288- 289
Link to Article
Kuhn  SMRosen  WWong  AJadavji  T Treatment of Mycobacterium marinum facial abscess using clarithromycin. Pediatr Infect Dis J. 1995;14631- 632
Link to Article
Tchomobay  AMClaudy  ALPerrot  ILLevigne  VDenis  M Fatal disseminated Mycobacterium marinum infection. Int J Dermatol. 1992;31286- 287
Link to Article
Lacaille  FBlanche  SBodemer  CDurand  CDe Prost  YGaillard  JL Persistent Mycobacterium marinum infection in a child with probable visceral involvement. Pediatr Infect Dis J. 1990;958- 60
Link to Article
Laing  RBWynn  RFLeen  CL New antimicrobials againstMycobacterium marinum infection [letter]. Br J Dermatol. 1994;131914
Link to Article
Wolinsky  E Mycobacterial diseases other than tuberculosis. Clin Infect Dis J. 1992;151- 10
Link to Article
Wallace  RJ  JrWiss  KBushby  MBHollowell  DC In vitro activity of trimethoprim and sulfamethoxazole against the nontuberculous mycobacteria. Rev Infect Dis. 1982;4326- 331
Link to Article
Edelstein  H Mycobacterium marinum skin infections: report of 31 cases and review of the literature. Arch Intern Med. 1994;1541359- 1364
Link to Article

Tables

References

Gluckman  SJ Mycobacterium marinumClin Dermatol. 1995;13273- 276
Link to Article
Collins  CHGrange  JMNoble  WC Mycobacterium marinum infections in man. J Hyg. 1985;94135- 149
Link to Article
Brady  RCSheth  AMayer  TSchleiss  MR Facial sporotrichoid infection with Mycobacterium marinumJ Pediatr. 1997;130324- 326
Link to Article
Fragoso  MAMurray  DL Mycobacterium marinum infection in a 4-year-old child. Clin Pediatr. 1985;24288- 289
Link to Article
Kuhn  SMRosen  WWong  AJadavji  T Treatment of Mycobacterium marinum facial abscess using clarithromycin. Pediatr Infect Dis J. 1995;14631- 632
Link to Article
Tchomobay  AMClaudy  ALPerrot  ILLevigne  VDenis  M Fatal disseminated Mycobacterium marinum infection. Int J Dermatol. 1992;31286- 287
Link to Article
Lacaille  FBlanche  SBodemer  CDurand  CDe Prost  YGaillard  JL Persistent Mycobacterium marinum infection in a child with probable visceral involvement. Pediatr Infect Dis J. 1990;958- 60
Link to Article
Laing  RBWynn  RFLeen  CL New antimicrobials againstMycobacterium marinum infection [letter]. Br J Dermatol. 1994;131914
Link to Article
Wolinsky  E Mycobacterial diseases other than tuberculosis. Clin Infect Dis J. 1992;151- 10
Link to Article
Wallace  RJ  JrWiss  KBushby  MBHollowell  DC In vitro activity of trimethoprim and sulfamethoxazole against the nontuberculous mycobacteria. Rev Infect Dis. 1982;4326- 331
Link to Article
Edelstein  H Mycobacterium marinum skin infections: report of 31 cases and review of the literature. Arch Intern Med. 1994;1541359- 1364
Link to Article

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