Mycobacterium marinum infection of the deep structures of the hand and wrist: 25 years of experience

Mycobacterium marinum: A Case-Based Narrative Review of Diagnosis and Management

Skin and soft tissue infections caused by non-tuberculous mycobacteria are occurring more frequently in recent years. However, chronic skin and soft tissue lesions present a challenge for clinicians, as the diagnostic work-up and definitive diagnosis require knowledge and available laboratory resources. We present here the case of a 66-year-old male patient who presented with painful abscess-like nodules on his right hand and forearm, which worsened after treatment with an anti-TNF-a agent. The fluid specimen taken from the lesion was positive for mycobacteria according to the acid-fast stain. Mycobacterium marinum was identified, first by next-generation sequencing and finally grown on culture, after eight weeks. Acknowledging the complexity of diagnosing and managing infections by non-tuberculous mycobacteria, and especially Mycobacterium marinum, we provide a review of the current epidemiology, clinical characteristics, diagnosis and management of Mycobacterium marinum infection.

Nontuberculous Mycobacterial Tenosynovitis of the Hand: A 10-Year Experience at Two Centers in South Korea

Background

The aim of this study was to investigate the clinical characteristics of nontuberculous mycobacterial tenosynovitis and to report the process of diagnosis and the outcomes of surgical debridement and drug administration in South Korea.

Methods

Between 2010 and 2019, 23 patients (10 men and 13 women) with nontuberculous tenosynovitis of the hand were treated at two centers. Their average age was 64 years, and the average duration of symptoms was 8 months (range, 1-36 months). Eight patients had a history of trauma or surgery. The average number of corticosteroid injections before diagnosis was 2.6 for 7 patients. All 23 patients were treated with a combination of extensive tenosynovectomy and antibiotics.

Results

Of the 23 patients, 20 were available for the final follow-up (1, lost to follow-up; 1, transferred to another hospital; and 1, died from a comorbidity). The most common species was Mycobacterium intracellulare (70%), followed by Mycobacterium abscessus (10%). The frequency of involvement of the extensor/flexor tendon was similar to that of the wrist/finger. The mean number of surgical debridement operations was 2.2. The average duration of antibiotic administration was 9.8 months. At the last follow-up, 3 patients were symptom-free with full range of motion at the involved site, 1 patient complained of localized swelling or pain with full range of motion, 1 patient was found to have a recurrence of infection in a finger, and 15 complained of restricted joint motion.

Conclusions

The most common species noted in patients with nontuberculous mycobacterial tenosynovitis was M. intracellulare. Patients with only 1 finger involved showed good range of motion at the final follow-up. Most patients experienced delayed wound healing and adverse effects from drug therapy during treatment and limited joint motion at the final follow-up.

Unusual presentation of carpal tunnel syndrome due to Mycobacterium marinum infection of hand

We report a case of a fisherman presenting with a rare and unusual carpal tunnel syndrome due to Mycobacterium marinum infection of the hand and wrist. The infection resulted in severe pain, paresthesia and restriction of movement in the hand.Flexor tenosynovectomy, followed by histological and microbiological studies, indicated the presence of atypical mycobacteria. The patient was started on a combination antimicrobial therapy for 6 months. The patient regained full range of motion and returned to perform daily activities with ease.Diagnosis of M. marinum infection of the hand is challenging as the presentation mimics other conditions and may have nonspecific histological findings. This atypical mycobacterium may also show resistance to commonly used antitubercular drugs. Hand surgeons should maintain a high index of suspicion of M. marinum and adopt a multiteam approach to prevent delay in diagnosis for successful treatment.

Idiopathic tenosynovitis of the wrist with multiple rice bodies: A case report and review of literature

BACKGROUND

Multiple rice bodies in the wrist is a rare disorder that requires surgery, and there are still many uncertainties regarding its diagnosis and treatment.

CASE SUMMARY

We described a rare case of chronic idiopathic tenosynovitis with rice bodies of the wrist in a 71-year-old man and reviewed similar topics in the literature. A total of 43 articles and 61 cases were included in the literature review. Our case had a usual presentation: it was similar to those in the literature. The affected population was mainly older adults, with an average age of 59.43 (range, 3 to 90) years. The male-to-female ratio was 1.54:1 (37/24).Most of them showed limited swelling and pain, only 23.0% had carpal tunnel symptoms, and the average disease duration was 18.03 (0.5-60) mo. Wrist flexor tendon sheath involvement was the most common (95.1%, 58/61), and only 3 cases had extensor tendon sheath involvement.The main causes were tuberculosis (34.4%, 21/61), non-tuberculous mycobacteria (24.6%, 15/61), idiopathic tenosynovitis (31.1%, 19/61), and others (9.84%, 6/61). There were 10 patients with recurrences; in 6 of them, were due to non-tuberculous mycobacterial infections.

CONCLUSION

We reported a case of wrist idiopathic tenosynovitis with rice body formation, and established a clinical management algorithm for wrist tenosynovitis with rice bodies, which can provide some reference for our clinical diagnosis and treatment. The symptoms of rice-body bursitis of the wrist are insidious, nonspecific, and difficult to identify. The aetiology is mainly idiopathic tenosynovitis and mycobacterial (tuberculosis or non-tuberculous) infections; the latter are difficult to treat and require long-duration systemic combination antibiotic therapies. Therefore, before a diagnosis of idiopathic tenosynovitis is made, we must exclude other causes, especially mycobacterial infections.

Mycobacterial Infections in the Hand and Wrist

Mycobacterial hand infections are uncommon. These infections have an indolent course and are marked by variable and nonspecific presentations, often leading to diagnostic and treatment delays. The pathogens involved in mycobacterial hand infections include Mycobacterium tuberculosis complex, atypical mycobacteria, and M leprae. Initial treatment involves a combination of long-term antibiotics and surgical débridement to cure the infection. Reconstructive procedures aid in restoring hand function lost secondary to the disease.

Fishing for a Diagnosis, the Impact of Delayed Diagnosis on the Course of Mycobacterium marinum Infection: 21 Years of Experience at a Tertiary Care Hospital

Background

Mycobacterium marinum is a common but underreported mycobacterial infection. We conducted a large retrospective study to determine risk factors and describe the therapeutic interventions and outcomes in patients with uncomplicated and complicated M. marinum infection.

Methods

Culture-confirmed M. marinum infection cases were identified from the Mayo Clinic Clinical Mycology Laboratory from January 1998 to December 2018. Complicated M. marinum infection was defined as the presence of tenosynovitis, septic arthritis, or osteomyelitis. Differences in complicated vs uncomplicated M. marinum infections were analyzed using statistical comparisons.

Results

Twelve cases had a complicated M. marinum infection. Patients with a complicated infection were older (64.3 ± 11.1 vs 55.8 ± 14.5; P = .03), had longer duration of symptoms (5 vs 3 months; P = .011), and had more surgical debridements (1 vs 0; P < .001). Length of treatment and number of drugs used were not statistically significant. Complicated M. marinum cases received more medications (2 vs 1; P = .263) and were treated longer (5.7 vs 3.5 months; P = .067). Antibiotic susceptibilities were performed in 59% of the patients. All isolates were susceptible to clarithromycin. From the tetracyclines, doxycycline had a better susceptibility pattern.

Conclusions

M. marinum infection is an important cause of skin and soft tissue infection. Poor water exposure documentation, unusual clinical presentation, and empiric antibiotic treatment before definitive M. marinum diagnosis often contribute to a delayed diagnosis. Complicated M. marinum cases had longer duration of symptoms and more surgical debridements. No difference in the number of drugs used or clinical outcome was observed.

Deep infection with Mycobacterium marinum: successful treatment of a frequently misdiagnosed disease

We report a rare yet typical presentation of a severe infection with Mycobacterium marinum that affected the deep structure of the hand and wrist of a 43-old fish breeder. A combination therapy of surgical debridement and antibiotic treatment with clarithromycin and ethambutol for 6 months led to a total resolution of the symptoms. Intensive rehabilitation completely restored the function of the hand.

Atypical Mycobacterial Infections of the Upper Extremity

Atypical mycobacterial infections of upper extremity synovial-lined structures are often misdiagnosed and unrecognized. Despite an increasing incidence, lack of physician awareness of these pathogens may result in considerable delay in diagnosis and management, potentially leading to permanent disability. The authors conducted a literature review and analyzed 31 cases of penetrating atypical mycobacterial infection to better understand the clinical characteristics and to evaluate their posttreatment complication rate compared with available literature. Medical records for culture-positive cases of tenosynovial or intra-articular atypical mycobacterial infections of the upper extremity that were treated were retrospectively reviewed. Treatment outcomes were analyzed against published case reviews and case series. Thirty-one cases of penetrating atypical mycobacterial infection were identified. Mycobacterium marinum (n=11) was the most common organism and was associated with aquatic exposure. Twenty-eight cases received empiric treatment, 17 of which received contraindicated treatment. Patients saw an average of 5 physicians prior to receiving an accurate diagnosis, and the mean time to diagnosis was 10 months. All cases received antibiotic treatment in addition to surgical management. Twenty cases (68%) failed treatment outcomes. Delay in diagnosis and inappropriate management of atypical mycobacterial infections may lead to a treatment failure rate that is higher than what has been reported in the literature. Mycobacterium avium and M fortuitum had significantly higher failure rates than other organisms. A high index of suspicion is required to make a diagnosis and prevent residual disability. [Orthopedics. 2018; 41(3):e383-e388.].

Septic arthritis of the wrist caused by Mycobacterium intracellulare: a case report

Septic arthritis of the wrist is rare entity, especially; atypical mycobacterial infection of the wrist is extremely rare. We report a case of septic arthritis of the wrist caused by Mycobacterium intracellulare, which was successfully treated by radical debridement followed by wrist arthrodesis using vascularised fibular grafting.

Mycobacterium marinum infection from sea monkeys

A case of cutaneous Mycobacterium marinum infection acquired from Artemia nyos (sea monkeys) is presented. The infection was unresponsive to initial antimicrobial therapies. A biopsy of a lesion revealed granulomatous inflammation with cultures that subsequently grew M marinum. A three-month course of clarithromycin provided complete resolution.

Mycobacterium marinum infection of the hand and wrist

PURPOSE

To review records of 166 patients who underwent treatment for Mycobacterium marinum tenosynovitis of the hand and wrist to identify factors associated with functional outcome.

METHODS

Records of 97 men and 69 women aged 13 to 85 (mean, 50) years who underwent treatment for suspected M marinum tenosynovitis of the hand and wrist were retrospectively reviewed. All underwent open biopsy; synovectomy was performed when florid synovitis was present. Rifampicin and ethambutol were usually prescribed. Clarithromycin, minocycline and/or levofloxacin were used as adjuvants if there was drug intolerance, allergy, or relapse. The duration of antibiotic treatment depended on the clinical recovery. Patients were followed up for one year after completion of drug treatment. Functional outcome was considered excellent for those with >195º total active motion (TAM) and >75% return of motion, good for those with 130º to 195º TAM and 50 to 75% return of motion, fair for those with 65º to 129º TAM and 25 to 49% return of motion, and poor for those with<65º TAM and <25% return of motion.

RESULTS

The mean delay in presentation was 4.9 (0.3-120) months. 93 of the patients presented with disabilities (flexion deformity or reduced range of motion), 64 of whom presented one month after injury. 37 (22%) of the patients had received intralesional steroids prior to admission, 30 of whom presented one month after injury. 32 (19%) patients were treated with antibiotics alone, whereas 134 (81%) patients underwent debridement in addition to antibiotic treatment. The mean duration of antibiotic treatment was 7.2 (range, 0-29) months. Of the 156 patients who completed the follow-up, functional outcome was satisfactory in 128 (82%) and unsatisfactory in 28 (17%). Steroid injections and late presentation led to worse functional outcome. Patients with unsatisfactory outcome were more likely to have received intralesional steroid injections (43% [16/37] vs. 10% [12/118], p<0.001, Pearson Chi squared test), have presented >2 months after injury (27% [21/79] vs. 9% [7/77], p=0.004, Pearson Chi squared test), and have undergone synovectomy (23% [28/124]) vs. 0% [0/32], p=0.001, Fisher's exact test). Worse functional outcome correlated with late presentation (r=0.218) and the greater number of debridement procedures (r=0.453).

CONCLUSION

Delayed antibiotic treatment of M marinum infections and steroid injections were associated with unsatisfactory outcome. Clinicians must have a high index of suspicion for this condition and avoid inappropriate management such as intralesional steroid injections. Public awareness to this condition should be raised.