Continuing Education Activity

Mycobacterium marinum is a non-tuberculous mycobacterium that causes a tuberculosis-like illness in fish and can infect humans when injured skin is exposed to a contaminated aqueous environment. Human infection presents as a nodular granulomatous disease that can spread along with the distribution of the lymphatic system and is usually limited to the skin and soft tissues in immunocompetent patients. Disseminated M. marinum infection in patients with human immunodeficiency virus (HIV) / acquired immune deficiency syndrome (AIDS) has infrequently been reported. This activity reviews the presentation, appropriate diagnostic modality, and management of Mycobacterium marinum infection and the interprofessional team's role in the care of affected patients.

Objectives:

• Describe the epidemiology of Mycobacterium marinum infection.
• Explain when Mycobacterium marinum infection should be considered on a differential diagnosis.
• Outline the management of Mycobacterium marinum infections.
• Review the role of interprofessional team members in optimizing collaboration and communication to ensure patients suspected of having Mycobacterium marinum infections receive appropriate evaluation and care to enhance outcomes.

Introduction

Mycobacterium marinum is a non-tuberculous mycobacterium first isolated from tubercles obtained at necropsy of dead saltwater fish in an aquarium in Philadelphia in 1926.[1][2] It causes a tuberculosis-like illness in fish. In humans, when injured skin is exposed to an aqueous environment contaminated with M. marinum, infection occurs. This infection presents as a nodular granulomatous disease, which can spread along lymphatics similar to a sporothrix infection. M. marinum is found in plants, soil, and fish. The infections are usually limited to the skin and soft tissues and occur in immunocompetent patients. Disseminated M. marinum infections in patients with HIV/AIDS have infrequently been reported.[3]

Etiology

M. marinum is a non-motile, non-spore-forming, gram-positive, acid-fast bacillus. M. marinum is slow-growing mycobacteria, belonging to group 1 of the Runyon classification. It is a photochromogen and produces a yellow pigment when exposed to light. M. marinum grows best on Lowenstein-Jensen medium at 32 degrees Centigrade (C). Unlike Mycobacterium tuberculosis (MTB), the growth of M. marinum is inhibited at 37 degrees C. Phylogenetically, M. marinum is very closely related to M. ulcerans, and both are closely related to M. tuberculosis based on their 99.3%, 16SrRNA sequence homology. In fact, M. marinum causes tuberculosis-like disease in fish and frogs. Like MTB, M. marinum can survive inside host cells and is proposed as a model to study MTB. Like in MTB infection, M. marinum may cause a positive tuberculin test.[4] M. marinum has one rRNA operon per genome, which dictates the pace of mRNA-protein synthesis. Genomic analysis suggests that the rRNA operon is similar in both MTB and M. marinum. Unlike MTB, M. marinum is a rapid grower, so the reason for this difference is unknown. At the infection site, M. marinum has a generation time of 24 hours, similar to MTB, but in the laboratory, at 32 degrees C, the generation time is 4 hours. MTB generation time in the lab is 24 hours when grown at 37 degrees C. There is no one good antibiotic regimen for M. marinum.[5]

Epidemiology

The first human case of M. marinum was reported from Sweden in 1951 by Norden and Linell.[6] The mycobacteria were isolated from skin lesions of swimmers who had bathed in a contaminated pool. Nowadays, chlorination to sanitize swimming pools is a routine practice; therefore, swimming is no longer a risk factor for M. marinum infection. Potential risk factors are working in wet fields, participating in aquatic sports, or cleaning a fish aquarium at home.[7] The annual incidence of M. marinum infection in the USA is 0.27 cases per 100.000 inhabitants.[8] The two conditions required for M. marinum infection are injury or abrasion to the skin and exposure to the contaminated aqueous environment. In one study, almost half (49%) of M. marinum infections were aquarium-related, 27% were related to fish or shellfish injuries, and 9% were related to injuries associated with saltwater or brackish water. Risk factors for individuals with HIV are similar. Disseminated infection can occur in immunocompromised patients.[1][9] 

History and Physical

Patient evaluation should identify the likely exposure of the injured skin to aqueous material contaminated with M. marinum. Skin injury may be in the form of minor abrasions, cuts, or major trauma. Besides the aqueous environment, M. marinum is also found in plants and soil.[6][10] The most common clinical infections due to M. marinum are skin and soft tissue infections, most likely due to its propensity to flourish in the cooler environment.[11] A skin infection may present as a solitary violaceous or red plaque or nodule. The nodular surface can be crusted or verrucous. The nodule may appear inflammatory and may have pus. There can be lymphangitic spread in a sporotrichoid presentation.[12][13] 

M. marinum should be in the differential diagnosis of poorly healing nodular lesions not responding to antibiotics in the upper extremities.[11] Based upon the exposure to M. marinum, skin lesions can also be present in the lower extremities. M. marinum infections in patients with HIV have been reported in the pre-anti-retroviral therapy (ART) era but are uncommon in the post-ART era. Disseminated infection can occur in non-HIV immunocompromised hosts as well.

Evaluation

Communication with the diagnostic laboratory is essential to make the diagnosis. When M. marinum infection is suspected, the laboratory team will utilize Lowenstein-Jensen agar cultures which can be incubated at 28 to 32 degrees C, in addition to incubating at 37 degrees C. Cultures will need to be observed for six weeks. The positivity rate of cultures ranges from 70% to 80%. Lesions have a very low concentration of microorganisms; hence cultures should be obtained even in the absence of microscopic evidence of bacilli. Typical tuberculoid granulomas are seen only in two-thirds of the cases, and the histopathology of nodules can be confused with rheumatoid nodules. One in five nodules may not appear to be of infectious origin in histology. Samples from the deeper parts of the nodule or skin or synovial biopsy may provide information at times, and repeating biopsy can be helpful. M. marinum infections can mimic other histopathological patterns such as a sarcoid-like granuloma or granuloma annulare as well.[14]

Polymerase chain reaction (PCR) amplification techniques using Mycobacterium genus-specific primers can help diagnose M. marinum infection directly in the biopsy sample. Ziehl-Neelson stain of biopsy specimens or yellowish discharge is only rarely positive since the number of mycobacteria in clinical specimens is low.  

M. marinum infection can also be an opportunistic infection in patients treated with anti-tumor necrosis factor (TNF)-alpha and other biological drugs.[15] Therefore an underlying immunosuppressed state must be excluded upon the diagnosis of M. marinum infection. Tuberculin skin test using purified protein derivative is positive in 67% to 100% of cases. Quantiferon-TB Gold and the enzyme-linked immuno-spot assay may also be positive in M. marinum infections but are unhelpful for diagnosis. Positive blood culture findings have also been reported in disseminated infections. Recently in vivo imaging to monitor long-term anti-mycobacterial therapy has been proposed, and such diagnostic tools are being developed.[16]

Treatment / Management

Routine susceptibility testing is not recommended when treating M. marinum infections. There is not much correlation between in vitro susceptibilities and clinical response. The therapy is not standardized. Rifampin is the most active drug against M. marinum with MIC90 of < 0.5mg/mL.[17] In one study, the MIC for ethambutol was 2.0 mg/mL to 4.0 mg/mL, for doxycycline was 16.0 mg/mL, for imipenem was 8.0 mg/mL, and for INH was 8.0 mg/mL. M. marinum is intrinsically resistant to pyrazinamide. M. marinum has moderately high MIC90 for ciprofloxacin and levofloxacin but is susceptible to moxifloxacin (MIC90) of 1 mg/mL to 2 mg/ml). Linezolid has activity against M. marinum as well.[18] Clinically clarithromycin-based regimens have had a high success rate irrespective of the in vitro MIC values.[19]

There is no consensus on the regimen or the duration of therapy in M. marinum infections. A spectrum of antibiotic regimens has been used in published cases or case series. There are no randomized controlled trials. Minocycline monotherapy in immunocompetent patients has been used. Generally, combination therapy for immunosuppressed patients is used. Consider treatment with a chosen regimen for three months prior to changing the antibiotic therapy as the response to therapy is slow. Surgical debridement is often needed. Effective antibiotic therapy is usually associated with the healing of all skin lesions within one month of commencing therapy. After that, immunocompetent patients should continue the medications for two more months. Patients who are immunocompromised will need to be treated with two agents for at least six months. In one report, a patient with AIDS was successfully treated with rifampin and ethambutol for six months. The lesion recurred after stopping therapy, so therapy was restarted with a clarithromycin regimen. Sometimes chronic lifelong suppressive therapy may be necessary.[3][17]

Based on the available evidence, it seems prudent to treat immunocompromised hosts with M. marinum infection with two agents, including clarithromycin. The optimal duration of therapy in the setting of the immunocompromised host is unknown. Most experts would treat for six months and possibly lifelong in cases of a persistent immunocompromised state. Disseminated disease is treated for a duration of one year in published case reports. Rifampin and ethambutol were frequently used in invasive M. marinum infections. In a study of 61 clinical isolates, rifamycins and clarithromycin were the most potent against M. marinum.[20]

Differential Diagnosis

Cutaneous nodular infections, especially fungal and granulomatous infections, are in the differential. These include:

• Blastomycosis
• Coccidioidomycosis
• Cryptococcosis
• Histoplasmosis

Other cutaneous lymphatic infections that might have a similar presentation include: 

• Leishmaniasis
• Nocardiosis
• Sporotrichosis

Prognosis

In most cases, especially in patients with immunocompetent status, M. marinum infection with treatment carries an excellent prognosis. Treatment failure may result due to deeper-structure involvement and ulcerative skin lesions. There is a very low risk of antimicrobial resistance. Clinical outcomes of M. marinum infections in patients with HIV infection do not differ from those without HIV infections. A continued immunocompromised state and ongoing risk of exposure can increase the risk of disease. Some patients may need lifelong suppression therapy.

Complications

Chronic complications of the disease are minimal with early diagnosis and adequate treatment. Some patients may develop persistent ulceration at the site of initial exposure. With delayed treatment or improper selection/duration of antibiotic therapy, patients may develop deeper infections, including osteomyelitis, tenosynovitis, and disseminated disease, which may require amputation of involved tissue. 

Deterrence and Patient Education

Once a diagnosis of M. marinum infection is made, it is important to instruct the patient on limiting his/her risks of exposure to the bacterium. The patients themselves are not infectious to other individuals, which is of most concern to patients and family members. Avoiding contact with aquatic environments when skin abrasions/cuts are present is ideal. When exposure is unavoidable, such as in the case of individuals who work near saltwater, they should be instructed on proper cleansing of the skin after water exposure with an antibacterial preparation and to cover abrasions with waterproof bandages. Individuals who work with aquariums should wear gloves at all times. 

Pearls and Other Issues

Surgical debridement is frequently necessary and should be included in the management plan. Antibiotic therapy is still needed after surgical debridement.[21] 

Enhancing Healthcare Team Outcomes

Mycobacterium marinum infections are on the rise as more people take to water activities. The infection is not easy to diagnose, and its management can be difficult in some cases. The infection predominantly affects the extremities and is best managed by an interprofessional healthcare team that includes clinicians, mid-level practitioners, nurses, and pharmacists to optimize clinical outcomes. The clinician needs to maintain a high degree of suspicion for the disease in patients with exposure to aquatic environments to diagnose the condition early and accurately. The clinician must communicate with the clinical laboratory technicians and pathologists to ensure appropriate culture mediums and the correct duration of observation is set. The specialized wound care nurse plays a vital in assisting the medical team with the treatment of the disease. The nurse helps educate the patient on proper wound care to ensure wound healing and decreasing the risk of superimposed infections. The pharmacists assist the interprofessional team by educating the patient on potential side-effects of therapy and the need for compliance with the long duration of therapy. The pharmacist can help identify adverse reactions and decreased compliance with therapy and recommend the optimal treatment regimen for the patient based on their individual comorbidities. A collaborative interprofessional team can help decrease patient morbidity and mortality with this disease. [Level 5]