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Discussion Starter · #1 ·
Just something to remember and keep in mind. The severity of this case is quite rare, but it is always good to remind is that there is some risk of working in our tanks, especially if you small scratches on your hands (that I always seem to get when working in my tanks).


Date: Mon, 4 Jul 2011 16:25:23 -0400 (EDT)
From: ProMED-mail <[email protected]>
Subject: PRO/AH/EDR> Mycobacterium marinum, fish tank - USA: (CA)

MYCOBACTERIUM MARINUM, FISH TANK - USA: (CALIFORNIA)
****************************************************
A ProMED-mail post
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ProMED-mail is a program of the
International Society for Infectious Diseases
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Date: Wed 15 Jun 2011
Source: ABC News Medical Unit [edited]
<http://abcnews.go.com/Health/Wellness/flesh-eating-fish-tank-bacteria-lead-teens-amputation/story?id=13837034>


What started as a small scrape from a corner of the family's fish
tank 5 years ago may end in the amputation of a champion teen
gymnast's hand. [The 13 year old girl] from Oak Hills, California, has
battled a rare, flesh-eating infection she contracted from the tank
when she was 8 and doctors have been unable to stop it from spreading.
The bacterium has now spread to the bones of her right hand. "I can't
use that hand at all. I'm in pain all the time," says Hannele.

Over the years, the infection has forced her to quit sports like
volleyball and gymnastics, despite having won an American Athletic
Union gymnastics championship. The infection has become so severe that
the 8th grader has been unable to write or do school work because her
dominant hand is constantly shaking with pain.

_Mycobacterium marinum_, sometimes referred to as fish tank
granuloma, usually eats away at only the surface of the skin. But in
this case it has infected several bones in her right hand, a
development that could mean amputation of her right hand. Doctors at
the Loma Linda Medical Center and UCLA Medical Center have tried
multiple types of antibiotics and 2 surgeries to remove infected
tissue, but the bacterium seems to have become drug-resistant. Fearing
she may be infected with a "superbug" strain of the bacteria, the Cox
family is seeking further treatment for her with infectious disease
experts at Denver, Colorado's National Jewish Health medical center
next week [week of 20 Jun 2011].

The ordeal began when [the girl] was only 8 years old, playing in the
fish tank that resides in the family's living room. "She had already
gotten in trouble a few times that week for sticking her arm in the
fish tank," says her mother. "So when she cut her hand on it she hid
it from me for a few days because she was worried about getting in
trouble. By the time I saw it, it was red and purple and oozing with
yucky green stuff. I soaked it in peroxide, but the cut wouldn't go
away." It took months for doctors to recognize that the wound was
infected with _M. marinum_. They originally thought it was a staph
infection or even MRSA [methicillin-resistant _Staphylococcus
aureus_].

Then came multiple rounds of antibiotics, some of which made [the
teenager] so sick that she had to quit sports. These drugs and 2
surgeries on her hand have been powerless against this strain of the
bacteria, however.

_M. marinum_ infection is a distant cousin to more serious infections
like tuberculosis and leprosy, but it is "exceedingly rare" for it to
persist and travel deeper into the tissue as it has in this case, says
Dr Michael Iseman, infectious disease expert at National Jewish Health
in Denver, Colorado. "The fact that she's had multiple surgeries
suggests that this is a more virulent, drug-resistant strain than
most," he says.

The bacterium can be found in salt or fresh water and has
historically been associated with surfboarding and more recently, fish
tanks. The bacterium is harmless unless introduced into an open wound
and infections are relatively rare, says Dr William Schaffner, chair
of the department of Preventive Medicine at Vanderbilt University
School of Medicine. _M. marinum_ infections can sometimes heal on
their own, but "it's a long-lasting infection and, without treatment,
it can take one to 2 years to resolve," says Schaffner. Treatment
consists of combinations of antibiotics and surgery.

Mild skin infections with _M. marinum_ are well known among aquarium
hobbyists, but the most famous disease risk among aquarium enthusiasts
is salmonella, says Dr Christopher Ohl, MD, an infectious diseases
expert at Wake Forest University School of Medicine. Salmonella
outbreaks have been periodically tied to fish, amphibian, and reptile
pets and the tanks they reside in; the most recent of which occurred
this April [2011] when 216 people contracted salmonellosis from pet
African dwarf water frogs.

Overall, however, fish tanks "pose very little risk" when properly
maintained, notes Schaffner. He recommends wearing latex gloves while
cleaning pet tanks and washing hands and forearms with soap and water
afterwards.

Ohl also recommends cleaning tanks outside or in a bathtub -- not in
the kitchen sink, to reduce the risk of contamination. Wash the
bathtub with bleach afterwards if used, he says. If you get a cut
while cleaning a fish tank, wash the wound with soap and water
immediately.

[byline: Courtney Hutchison]

- --
communicated by:
HealthMap Alerts via ProMED-mail
<[email protected]>

[The town of Oak Hills is located in San Bernardino County, southern
California, which can be located on the HealthMap/ProMED-mail
interactive map at <http://healthmap.org/r/0*_a>.

_Mycobacterium marinum_ is one of the non-tuberculous mycobacterium
or NTM (that is, a grouping outside of the _M. tuberculosis_ complex)
that is found in cold or warm, fresh or salt water. NTM are
characterized by their rate of growth in vitro and pigment production.
Organisms in the _Mycobacterium chelonae-abscessus_ group are
non-pigmented rapidly growing NTM species (RGM) that produce mature
growth on agar plates within 7 days of incubation and include _M.
fortuitum_ and the _M. chelonae-abscessus_ group. Slowly growing NTM
include _M. kansasii_ and _M. avium/intracellulare_ complex and
require more than 7 days to produce mature growth on agar plates. _M.
marinum_ is an intermediately growing NTM and a photochromogen,
meaning pigment is produced when cultured and exposed to light. 7-10
days are required to produce mature growth of _M. marinum_ on agar
plates and growth is optimal at 32 deg C [89.6 deg F].

_M. marinum_ infection occurs following skin and soft-tissue injuries
that are exposed to an aquatic environment or fish. First described as
"swimming-pool granuloma", when swimming pools were not routinely
chlorinated, _M. marinum_ skin infections are now most often acquired
from aquarium maintenance and called "fish tank granuloma". The
infection usually presents as indolent, localized nodular or
ulcerating skin lesions on mainly the upper limb of otherwise healthy
hosts, but can evolve into an ascending lymphangitis that resembles
sporotrichosis or can spread to deeper tissues, resulting in
tenosynovitis, arthritis, and osteomyelitis. Spread to deeper
structures, such as tendon, joint, and bone, was noted in 29 per cent
of the 63 cases of culture-confirmed _M. marinum_ infection in a
national survey conducted in France (1). Delay in diagnosis (2) and
immunologic impairment (2) have been noted to be a frequent component
of invasive _M. marinum_ infections. Bone marrow invasion and
bacteremia are rare and have been seen only in profoundly
immunocompromised patients (2,3).

Rifampin and ethambutol in combination are reported to be the
antibiotics used most often (1,2,4). Other antibiotic options with
reliable activity include clarithromycin, doxycycline, and minocycline
(4). Antimicrobial agents that have been noted to have less reliable
activity include trimethoprim/sulfamethoxazole (5) and the
fluoroquinolones (6). _M. marinum_ is also susceptible to linezolid
(6), but resistant to isoniazid and pyrazinamide (4). The duration of
therapy is at least 3 months (4) and is significantly longer for
patients with deeper structure infections than for patients with
infections limited to the skin and soft tissue -- the median duration,
7-11 months (1,2) vs 4 months (2), respectively. Most cases of
invasive _M. marinum_ infection will also require surgical debridement
as an adjunct to antimicrobial treatment (1,2,4,7).

References
- ----------
1. Aubry A, Chosidow O, Caumes E, et al. Sixty-three cases of
_Mycobacterium marinum_ infection: clinical features, treatment, and
antibiotic susceptibility of causative isolates. Arch Intern Med 2002;
162(15): 1746-52. Available at
<http://archinte.ama-assn.org/cgi/content/full/162/15/1746>.
2. Lahey T. Invasive _Mycobacterium marinum_ infections. Emerg Infect
Dis 2003; 9(11): 1496-7. Available at
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035536/>.
3. Parent LJ, Salam MM, Appelbaum PC, Dossett JH. Disseminated
_Mycobacterium marinum_ infection and bacteremia in a child with
severe combined immunodeficiency. Clin Infect Dis 1995; 21(5): 1325-7.
Abstract available at <http://www.ncbi.nlm.nih.gov/pubmed/8589169>.
4. Diagnosis and treatment of disease caused by nontuberculous
mycobacteria. Am J Respir Crit Care Med 1997; 156(2 Pt 2): S1-S25.
Available at
<http://ajrccm.atsjournals.org/cgi/content/full/156/2/S1>.
5. Rhomberg PR, Jones RN. In vitro activity of 11 antimicrobial
agents, including gatifloxacin and GAR936, tested against clinical
isolates of _Mycobacterium marinum_. Diagn Microbiol Infect Dis 2002;
42(2):145-7. Abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/11858912>.
6. Braback M, Riesbeck K, Forsgren A. Susceptibilities of
_Mycobacterium marinum_ to gatifloxacin, gemifloxacin, levofloxacin,
linezolid, moxifloxacin, telithromycin, and quinupristin-dalfopristin
(Synercid) compared to its susceptibilities to reference macrolides
and quinolones. Antimicrob Agents Chemother 2002; 46(4): 1114-6.
Available at <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC127113/>.
7. Wendt JR, Lamm RC, Altman DI et al. An unusually aggressive
_Mycobacterium marinum_ hand infection. J Hand Surg 1986; 11(5):
753-5. Abstract available at
<http://www.ncbi.nlm.nih.gov/pubmed/3760509>. - Mod.ML]

.................................................sb/ml/mj/sh
 

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I got this infection back when I worked at a tropical fish store in my college days. It was on my left middle finger where I had the skin broken from a sea urchin and the dorsal spine of a Synodontis cat during tank maintenance.

I got the classic granuloma the size of a dime and then it slowly started moving up towards the knuckle. I eventually got sent to a dermotologist and he did a biopsy to id the source.

After some expensive abs it went away in about 2 weeks.

Eric
 

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As a vet school student, this article is a great resource and example of how doctors and veterinarians have to work together to warn people of the potential threats when working and owning all types of animals. Thanks for the post, I'll add Mycobacterium to my list of bugs to talk to clients about
 

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Discussion Starter · #4 ·
Jonas -

If you (or anyone else for that matter) are interested in infectious diseases and the interface between animal disease and human disease (and therefore MDs and DVMs), I encourage you to subscribe to the ProMED email lists. You can subscribe as a digest, so you only get 1-2 emails a day - but it is a good way to stay on top of emerging diseases and disease outbreaks both in animals and humans.

Oz
 
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