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A 77-year-old man presented to the emergency department with a 6-week history of a nonhealing violaceous nodular plaque on the dorsum of his right hand after he sustained a minor puncture injury on the side of a boat while sailing on the Chesapeake Bay. His past medical history was significant for heart failure with preserved ejection fraction, chronic kidney disease stage 3, coronary artery disease, aortic stenosis, and gout. Given lack of healing over the subsequent weeks, he twice sought care at local urgent care centers without response to cephalexin and later clindamycin. He denied a history of fevers, night sweats, or weight loss. Exposure history was relevant for his boating injury as well as a hobby of gardening, including rose bushes. He had no known immunocompromising condition. Due to ongoing progressive pain, erythema extending up the medial forearm, and new subcutaneous nodules on the forearm, he presented to the emergency department.
On admission, he was normotensive, without tachycardia, and afebrile. Physical examination revealed an erythematous to violaceous ulcerated nodular plaque (Figure 1). There were few subcutaneous nontender palpable nodules tracking up the medial forearm (Figure 2). Initial investigations included a white blood cell count of 6.23 × 109/L, an erythrocyte sedimentation rate (ESR) of 11 mm/h, and a C-reactive protein of <0.3 mg/L. A right-hand X-ray revealed soft tissue swelling without osseous abnormality.
A wide differential diagnosis was considered for this presentation of a subacute, progressive, nonhealing, ulcerative, violaceous lesion with ascending nodular lymphangitis. Infectious processes considered in light of the appearance included atypical mycobacterial disease, sporotrichosis, endemic mycoses including histoplasmosis, lymphocutaneous nocardiosis due to Nocardia Brasiliensis, tularemia, erysipeloid, cutaneous anthrax, cutaneous leishmaniasis, and aspergillosis.
Noninfectious causes were also considered including pyoderma gangrenosum and cutaneous lymphoma. Subacute time course and appearance did not favor typical bacterial pathogens responsible for nonsuppurative cellulitis. Mycobacterium marinum and sporotrichosis were ultimately favored based on exposure history to saltwater and rose gardening.
Dermatology was consulted for skin biopsy with pathology and bacterial, fungal, and mycobacterial tissue culture. In the interim, blood cultures were no growth and T-spot testing was positive. Punch biopsy noted mixed inflammatory cells filling the dermis, including large numbers of histiocytes consistent with a granulomatous dermatitis (Figure 3). Acid-fast bacillus (AFB) staining highlighted mycobacterial organisms within the dermis (Figure 4). Mycobacterial cultures ultimately speciated as M. marinum.
Because the AFB tissue stain was positive, empiric treatment for nontuberculous mycobacterial skin and soft tissue infection was initiated with clarithromycin 500 mg twice daily, ethambutol 15 mg/kg daily, and trimethoprim-sulfamethoxazole 160-800 mg twice daily. On follow up in the infectious disease clinic, trimethoprim-sulfamethoxazole was stopped, and he was treated with a 6-month course of therapy with ethambutol and clarithromycin with ongoing resolution of the skin lesions.
Nontuberculous mycobacteria are a miscellaneous collection of acid-fast bacteria other than Mycobacterium tuberculosis complex or Mycobacterium leprae that are widespread in the environment and are known to cause skin and soft tissue infections in humans.
Rapidly growing mycobacteria such as Mycobacterium fortuitum, Mycobacterium abscessus, and Mycobacterium chelonae are common causes of community-acquired skin and soft tissue infections in the United States and have been shown to be inoculated secondary to trauma associated with surgery, cosmetic procedures, acupuncture, tattoos, skin piercings, and nail salons.
Immunocompromised patients such as those with advanced HIV/AIDS may present with cutaneous manifestations from disseminated mycobacterial infection including secondary to Mycobacteria avium complex, Mycobacterium kansasii, Mycobacterium genavense, and Mycobacterium haemophilum.
One should suspect cutaneous nontuberculous mycobacteria infection when a patient presents with a solitary and slowly growing papule or nodule at a site of trauma that then progresses to a verrucous, violaceous plaque or ulcerates.
In contrast to pyogenic infections, cutaneous nontuberculous mycobacteria disease is often less painful or painless, typically lacks signs of systemic inflammation or locoregional lymphadenopathy, and the incubation period is prolonged with an average of approximately 2 to 4 weeks and can be as long as 9 months.
M. marinum is a slow-growing pigmented organism that causes cutaneous infection most frequently from trauma in freshwater or saltwater, including puncture injuries associated with natural bodies of water, aquariums, shellfish, and swimming pools.
Diagnosis may be challenging both because of the lack of recognition of characteristic features of this syndrome and a high percentage of tissue samples negative for AFB by staining or granulomatous inflammation by histopathology. In one case series of 28 patients with confirmed M. marinum infection by tissue culture, only 58 percent of tissue biopsies noted granulomatous inflammation with only 11 percent positive with AFB staining.
Treatment often involves a combination of at least 2 drugs, including a macrolide, trimethoprim-sulfamethoxazole, rifamycin, or ethambutol with duration ranging from 2 to 6 months depending on the extent of involvement and response to therapy.
In this article, we present a case of an elderly immunocompetent gentleman who sustained a waterborne injury with a resultant subacute development of nodular skin lesion that progressed into a violaceous plaque with ulceration and nodular lymphangitic spread not responsive to typical antistaphylococcal and antistreptococcal antibiotics. This case illustrates the importance of detailed history taking and recognizing cutaneous M, marinum on the differential for skin and soft tissue infections, particularly with characteristic examination features, indolent progression, antibiotic failure, or history of penetrating injury with water exposure.
Smego Jr, RA
Lymphocutaneous syndrome. A review of non-sporothrix causes.