Failure of doxycycline treatment in aquarium-associated Mycobacterium marinum infections

Current treatment options for Mycobacterium marinum cutaneous infections

INTRODUCTION

Mycobacterium marinum is a slowly growing photochromogenic nontuberculous mycobacterium that has special growth characteristics. It causes a uniquely human disease, a cutaneous syndrome named fish tank granuloma or swimming pool granuloma because of the strong epidemiological links with water. The treatment of this disease involves the use of different antimicrobials alone and in combination, depending on the severity of the disease. The antibiotics most frequently used are macrolides, tetracyclines, cotrimoxazole, quinolones, aminoglycosides, rifamycins, and ethambutol. Other approaches include the use of surgery in some cases. New treatment options, like new antibiotics, phage therapy, phototherapy, and others are currently being developed with good in vitro experimental results. In any case, the disease is usually a mild one, and the outcome is good in most of the treated patients.

AREAS COVERED

We have searched the literature for treatment schemes and drugs used for treatment of M. marinum disease, as well as other therapeutic options.

EXPERT OPINION

Medical treatment is the most recommended approach option, as M. marinum is usually susceptible to tetracyclines, quinolones, macrolides, cotrimoxazole, and some tuberculostatic drugs, usually used in a combined therapeutic scheme. Surgical treatment is an option that can be curative and diagnostic in small lesions.

Sporotrichoid lymphocutaneous pattern in a fish-merchant under immunosuppressant medications: Clues to differential diagnoses

Sporotrichoid-lymphocutaneous-pattern is classically seen in sporotrichosis, though also present in other infections like atypical mycobacteriosis and leishmaniasis. Cutaneous atypical mycobacterial infection presents as localized lesions in immunocompetent and is widespread in immunosuppressed patients. Here, we present a case of sporotrichoid-lymphocutaneous infection due to atypical mycobacteria, in a fish-seller under immunosuppressants.

Diagnosis and therapy of Mycobacterium marinum: a single-center 21-year retrospective analysis

BACKGROUND AND OBJECTIVES

In Europe, infections with Mycobacterium (M.) marinum are rare. We conducted a retrospective single-center study to assess the clinical spectrum of M. marinum infection and its diagnosis, treatment and outcome under real-world conditions.

PATIENTS AND METHODS

Eighteen patients presenting with M. marinum infections between 1998 and 2018 were identified in the data warehouse of the University Hospital Würzburg and considered for detailed analysis.

RESULTS

Twelve patients reported aquatic exposure. In 16/18 cases the upper extremities were affected. No invasive infections were detected. Mean time to diagnosis was 15 weeks. Histology revealed granulomatous inflammation in 14 patients while mycobacterial cultures were positive for M. marinum in 16 cases. Most patients received antibiotic monotherapy (14/18) while combination therapy was administered in four cases. Treatment (with a median duration of 10 weeks) was successful in 13 patients. Five patients were lost to follow-up.

CONCLUSIONS

Our retrospective analysis of M. marinum infections at a German tertiary referral center revealed a considerable diagnostic delay and the relevance of microbiological culture, PCR and histology for diagnosis. Monotherapy with clarithromycin (rather than doxycycline) appeared as a reasonable treatment option while immunosuppressed or -compromised patients and those with extended disease received combination therapy.

Treatment and Outcome of Culture-Confirmed Mycobacterium marinum Disease

Background

Mycobacterium marinum is a nontuberculous mycobacterium that causes skin and soft tissue infections. Treatment consists of multiple antibiotics, sometimes combined with surgical debridement. There is little evidence for the choice of antibiotics, the duration of treatment, and the role of susceptibility testing.

Methods

We performed a retrospective cohort study of culture-confirmed M. marinum infections in the Netherlands in the 2011–2018 period. Clinical characteristics, in vitro susceptibility, extent of disease, treatment regimens, and outcomes were analyzed. Incidence was assessed from laboratory databases.

Results

Forty cases of M. marinum infection could be studied. Antibiotic treatment cured 36/40 patients (90%) after a mean treatment duration of 25 weeks. Failure/relapse occurred in 3 patients, and 1 patient was lost to follow-up. Antibiotic treatment consisted of monotherapy in 35% and 2-drug therapy in 63%. Final treatment contained mostly ethambutol–macrolide combinations (35%). Eleven patients (28%) received additional surgery. We recorded high rates of in vitro resistance to tetracyclines (36% of isolates). Tetracycline resistance seemed correlated with poor response to tetracycline monotherapy. The annual incidence rate was 0.15/100000/year during the study period.

Conclusions

Prolonged and susceptibility-guided treatment results in a 90% cure rate in M. marinum disease. Two-drug regimens of ethambutol and a macrolide are effective for moderately severe infections. Tetracycline monotherapy in limited disease should be used vigilantly, preferably with proven in vitro susceptibility.

Drug susceptibility testing of nontuberculous mycobacteria

Diseases caused by nontuberculous mycobacteria are emerging in many settings. With an increased number of patients needing treatment, the role of drug susceptibility testing is again in the spotlight. This articles covers the history and methodology of drug susceptibility tests for nontuberculous mycobacteria, but focuses on the correlations between in vitro drug susceptibility, pharmacokinetics and in vivo outcomes of treatment. Among slow-growing nontuberculous mycobacteria, clear correlations have been established for macrolides and amikacin (Mycobacterium avium complex) and for rifampicin (Mycobacterium kansasii). Among rapid-growing mycobacteria, correlations have been established in extrapulmonary disease for aminoglycosides, cefoxitin and co-trimoxazole. In pulmonary disease, correlations are less clear and outcomes of treatment are generally poor, especially for Mycobacterium abscessus. The clinical significance of inducible resistance to macrolides among rapid growers is an important topic. The true role of drug susceptibility testing for nontuberculous mycobacteria still needs to be addressed, preferably within clinical trials.

Fish tank granuloma caused by Mycobacterium marinum

Introduction

Mycobacterium marinum causes skin and soft tissue, bone and joint, and rare disseminated infections. In this study, we aimed to investigate the relationship between treatment outcome and antimicrobial susceptibility patterns. A total of 27 patients with M. marinum infections were enrolled.

Methods

Data on clinical characteristics and therapeutic methods were collected and analyzed. We also determined the minimum inhibitory concentrations of 7 antibiotics against 30 isolates from these patients.

Results

Twenty-seven patients received antimycobacterial agents with or without surgical debridement. Eighteen patients were cured, 8 failed to respond to treatment, and one was lost to follow-up. The duration of clarithromycin (147 vs. 28; p = 0.0297), and rifampicin (201 vs. 91; p = 0.0266) treatment in the cured patients was longer than that in the others. Surgical debridement was performed in 10 out of the 18 cured patients, and in 1 of another group (p = 0.0417). All the 30 isolates were susceptible to clarithromycin, amikacin, and linezolid; 29 (96.7%) were susceptible to ethambutol; 28 (93.3%) were susceptible to sulfamethoxazole; and 26 (86.7%) were susceptible to rifampicin. However, only 1 (3.3%) isolate was susceptible to doxycycline.

Discussion

Early diagnosis of the infection and appropriate antimicrobial therapy with surgical debridement are the mainstays of successful treatment. Clarithromycin and rifampin are supposed to be more effective agents.

Review article: Mycobacterium marinum infection of the hand and wrist

Misdiagnosis and delayed treatment of Mycobacterium marinum infection is common because of its diverse manifestations. This leads to inappropriate use of antimicrobials, extension of the infection from the skin to the tenosynovium, and a poor prognosis (loss of tendons and prolonged immobilisation, secondary to multiple debridements and joint contractures). Clinicians should be aware of this type of infection, especially in subjects at risk (fishermen and aquarium enthusiasts), and those with a history of trauma coupled with exposure to water or marine life. A proactive approach to obtain a biopsy for histopathological and microbiological diagnosis is advised. Anti-mycobacterial treatment should be started promptly. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.

Treatment of Mycobacterium marinum cutaneous infections

Mycobacterium marinum is a non-tuberculous mycobacterium found in non-chlorinated water, with worldwide prevalence. It is the most common atypical Mycobacterium that causes opportunistic infection in humans. It presents as a solitary, red-to-violaceous plaque or nodule with an overlying crust or verrucous surface, or as inflammatory nodules or abscesses, usually in a sporotrichotic type of distribution. Deep infections may also occur. Although diagnosis is confirmed by isolation and identification of the organism in practice diagnosis remains largely presumptive based on clinicohistological features and the response to treatment. Polymerase chain reaction allows the routine early detection of the organism from a biopsy specimen. In the near future, it seems possible that histopathological examination might be greatly assisted by the rapidly improving possibilities with in vivo imaging. There have been many therapeutic modalities used effectively in the treatment of M. marinum infections. Spontaneous remission has also been reported in untreated infections and in immunocompetent hosts. However, there is no proven treatment of choice because M. marinum is naturally multi-drug resistant species and treatment is based primarily on the personal experience and preference of individual investigators, without the benefit of large studies. In superficial cutaneous infections minocycline, clarithromycin, doxycycline and trimethoprim-sulfamethoxazole as monotherapy are effective treatment options, but drug resistance varies and thereby combination therapy usually of two drugs may be required. Ciprofloxacin has shown considerable effectiveness. In cases of severe infections, including those with a sporotrichoid distribution pattern, a combination of rifampicin and ethambutol seems to be the recommended regimen. The use of isoniazid, streptomycin and pyrazinamide as empirical treatment options should be avoided. Surgical treatment is not usually recommended and must be cautiously applied. Cryotherapy, X-ray therapy, electrodesiccation, photodynamic therapy and local hyperthermic therapy have been reported as effective therapeutic alternatives. M. marinum infection should always be included in the differential diagnosis of all cases with poor-healing wounds in upper extremities and a history of exposure to aquariums.

Incubation period and sources of exposure for cutaneous Mycobacterium marinum infection: case report and review of the literature

The diagnosis of cutaneous Mycobacterium marinum infection is often delayed for months after presentation, perhaps because important clinical clues in the patient's history are frequently overlooked. Knowledge of the incubation period allows the clinician to target questions about the patient's history. Prompted by a case with a prolonged incubation period, we sought to determine more precisely the incubation period of M. marinum infection. The MEDLINE database for the period 1966-1996 was searched for information regarding incubation period and type of exposure preceding M. marinum infection. Ninety-nine articles were identified, describing 652 cases. Forty cases had known incubation periods (median, 21 days; range, 5-270 days). Thirty-five percent of cases had an incubation period > or =30 days. Of 193 infections with known exposures, 49% were aquarium-related, 27.4% were related to fish or shellfish injuries, and 8.8% were related to injuries associated with saltwater or brackish water. Because the incubation period for cutaneous M. marinum infection can be prolonged, patients with atypical cutaneous infections should be questioned about high-risk exposures that may have occurred up to 9 months before the onset of symptoms.

Antimycobacterial therapy

Tuberculosis is a major cause of illness and death worldwide. The epidemic of the acquired immunodeficiency syndrome and the increased number of other immunocompromised hosts have led to a remarkable increase in Mycobacterium avium-intracellulare complex infections. Adequate diagnostic, prevention, and treatment measures are available; however, resources for implementing these measures are limited. Processes for using these limited resources are not always well organized. This review of prevention and treatment of tuberculosis, including the six major recommendations from the Centers for Disease Control and Prevention, treatment of certain other mycobacterial infections, and information on some antimycobacterial agents, such as isoniazid, rifampin, rifabutine, pyrazinamide, and ethambutol, was written mainly for primary-care providers.

The role of surgery in the management of uncommon skin infections

BACKGROUND

Some infections do not respond readily to antibiotic therapy. In particular, fungi and mycobacteria often require prolonged treatment, which is expensive and prone to adverse effects.

OBJECTIVE

To investigate the role of surgery in the treatment of skin infections.

METHODS

Literature review.

RESULTS

Infections caused by atypical mycobacteria, certain fungi, and those involving joints often respond well to surgical treatments. In several situations excision produces a higher cure rate than antibiotic treatment.

CONCLUSION

Excision, drainage, or debridement has been shown to be superior to drug therapy in several infections and a reasonable alternative in others.

Antibiotic susceptibility of Mycobacterium marinum

A radiometric respirometric technique (Bactec) which is highly standardized for Mycobacterium tuberculosis was used for antibiotic susceptibility testing of clinical isolates of M. marinum. Ciprofloxacin, clarithromycin, rifampicin and trimethoprim/sulfamethoxazole were effective at clinically relevant concentrations. Doxycycline, erythromycin and roxithromycin were ineffective. These in vitro results are discussed in relation to documented clinical experience.

Mycobacterium marinum infection: epidemiology and presentation in Queensland 1971-1990

OBJECTIVE

Evaluation of the clinical and epidemiological features of Mycobacterium marinum infection in Queensland.

DESIGN

Laboratory identification and in-vitro susceptibility tests of 29 isolates from the Queensland Health Department Tuberculosis Reference Laboratory were retrospectively gathered and followed up by contacting referring practitioners and obtaining clinical details of patients involved.

SUBJECTS

29 patients from whom M. marinum was isolated, with a male:female ratio of 3.1:1, and a mean age of 47.4 years.

RESULTS

Of 26 patients for whom adequate information was available, 12 had evidence of involvement of deep tissues (including two cases of arthritis) and five suffered sporotrichoid spread of infection. The delay between onset of symptoms and consultation with a medical practitioner was five months (range, two weeks to two years), with a further mean delay to definitive diagnosis of 4.4 weeks. Cure was apparent in 22 of 23 cases. Chemotherapy alone was adequate in 11 cases, as was surgical intervention in three, while a combination approach was successful in eight cases. Trimethoprim/sulfamethoxazole was successful in seven of nine cases and combination rifampicin and ethambutol in six of seven. Tetracyclines were employed as single-agent therapy in nine patients and were effective in seven.

CONCLUSIONS

Synovitis was a common presenting feature of M. marinum infection in Queensland patients. Occupational and recreational exposure to salt or fresh water was common, and although this history was available to practitioners a mean delay to definitive diagnosis of 4.4 weeks still occurred. The data suggest that chemotherapy alone is often adequate, even with deep tissue involvement. Combinations of conventional antimycobacterial drugs may be the therapy of choice, especially for serious infections, although success was recorded with trimethoprim/sulfamethoxazole alone.

A case of disseminated Mycobacterium marinum infection in an immunocompetent patient

An unusual case of Mycobacterium marinum cutaneous infection is described. As a result of marked delay in the diagnosis, extensive local inflammation and destructive osteomyelitis occurred together with cutaneous dissemination in an immunocompetent host. Pathologic fractures in the infected bone necessitated amputation of the involved digit. The most striking feature of this case was the development of multiple widespread cutaneous lesions for several months following amputation of the infected digit and initiation of appropriate antimicrobial therapy. These new cutaneous lesions may reflect local immune and inflammatory reactions to previously disseminated microorganisms.

Osteomyelitis and synovitis produced by Mycobacterium marinum in a fisherman

We report a case of osteomyelitis and synovitis produced by Mycobacterium marinum in the left index finger of a fisherman. A combination of surgical intervention and antimicrobial therapy with minocycline, rifampin, and ethambutol was efficacious.