TECHNIQUE TIP and ON-LINE CMEs
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TECHNIQUE TIP
Winter 2010 Update
CASE REPORT: FINGER TENOSYNOVITIS CAUSED BY MYCOBACTERIUM MARINUM INFECTION
By Evilio Prendes, OPA-C
ABSTRACT
Mycobacterium marinum is an unusual atypical mycobacterium with low pathogenicity for humans in comparison with Mycobacterium tuberculosis. Among the non-tuberculous mycobacterial pathogens, Mycobacterium marinum is the most common pathogen to cause skin infections. Mycobacterium marinum infection causes chronic cutaneous lesions and in some cases deeper infections such as tenosynovitis, septic arthritis and rarely osteomyelitis. This report is a case of a male patient presenting with tenosynovitis of the finger, secondary to Mycobacterium marinum infection.
INTRODUCTION
Mycobacterium marinum is an atypical mycobacterium causing chronic cutaneous lesions and in some cases deeper infections such as tenosynovitis, septic arthritis and rarely osteomyelitis. The infection develops as a consequence of skin abrasions or lacerations acquired in contaminated water. The diagnosis of Mycobacterium marinum infection is often delayed due to the rarity of the infection, the lack of clinical suspicion and failure to elicit a history of aquatic exposure, which is always present. Delay in diagnosis or misdiagnosis may result in inappropriate treatments which may worsen the course of the infection.
CASE REPORT
A 54 year old male, right hand dominant, with history of pain in his right index finger for about 10 months. Patient states that he hit the finger against the wall on September 14 and then he noticed the next day that his hand became completely swollen and really painful. The patient’s small finger has a small pustule 5 mm in length over a previous healed scar from an accident that occurred in 1997. (Figure 1)
Upon physical examination of the right hand: He is able to make a fist; Intrinsic strength is 5/5 with pain; Swelling is noted to the thenar area; the A1 Pulley of the index finger and over the dorsal aspect of the hand, as well as over the PIP joint f the index finger; Thenar strength is 5/5; Grip strength is 5/5; MP joint is stable and non-tender with stress; He has full range of motion in all the fingers; Semmes-Weinstein of the thumb, index, long, ring and small are .05 Grams (Green).
An MRI was performed showing edema in the soft tissue of the right index finger reflecting cellulitis, with no evidence of abscess. Mild rind edema around the flexor tendons reflecting tenosinovitis, and no evidence of extensor or flexor tendon injury, no marrow edema and the posibility of septic arthritis. (Figures 2, 3, 4)
Patient was taken to the OR for synovectomy, biopsy, A1 pulley release and culture procedure. Pathology report showed scar cartilage with degeneration as well as synovium tissue inflammation. The microbiology report was consistence with Mycobacterium marinum infection.
DIAGNOSIS
The diagnosis of Mycobacterium marinum infection is often delayed due to the rarity of the infection, the lack of clinical suspicion and a failure to elicit the history of aquatic exposure, which is always present.
Most common misdiagnoses include other infections such as sporotrichosis, gout, rheumatoid arthritis, foreign body reactions, and even a tumor, such as an epithelioid epithelioma. Correct diagnosis depends on a thorough history, correct interpretation of the clinical features, tissue biopsies for cultures, and histology. There is usually a positive history of a puncture wound or trauma within six weeks of the onset of symptoms. Tissue biopsies for histology and cultures are required for a correct diagnosis. Biopsy specimens must be taken from non ulcerated areas adjacent to the cutaneous lesions. Histological appearances are variable depending on the age of the lesion. Acute inflammatory changes, fibrinous exudates and non-caseating granulomas may be present. Granulomas support the diagnosis of a mycobacterium infection but they are not path gnomonic for a Mycobacterium marinum infection. Successful culture of the organism is difficult inspite of the fact that Mycobacterium marinum is a rapidly growing organism. When an infection with Mycobacterium marinum is suspected, the microbiology laboratory should be notified. Whereas other atypical myobacteria grow at a temperature of 37°C, the cultures suspected of Mycobacterium marinum, should be incubated at a temperature of 30-32°C with the use of a Lowenstein-Jensen medium for a period of 7 to 21 days. When incubated at 37° C growth will be delayed or even absent. Tuberculin testing as an attempt to fasten diagnosis has failed. Tuberculin skin testing has been found to be non-specific and difficult to interpret.
TREATMENT
Treatment is usually medical in nature, using bactericidal agents. The duration of therapy is empiric, with recommendations to continue therapy for 4-6 weeks following clinical resolution of the lesions. Treatment of some infections may last as long as 25 months or longer. Spontaneous resolution has been reported.
Surgical debridement is indicated in patients with tenosynovitis or deep involvement, when there is persistent pain, a discharging sinus or a history of a prior local injection of steroids.
CONCLUSION
Mycobacterium marinum is an atypical mycobacterium causing chronic cutaneous lesions and in some cases deeper infections of the extremities. Infections are uncommon in these parts. Diagnosis requires awareness of the existence of the condition, a thorough history with attention for water or fish related activities, correct interpretation of the clinical features and tissue biopsies for cultures and histology. Delay in diagnosis or misdiagnosis may result in inappropriate treatments which may worsen the course of the infection. Chemotherapy is the mainstay of treatment, with surgical debridement reserved for selected clinical circumstances.
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REFERENCES
1) Brown BA, Swenson JM, RJ Wallace JM, Jr. Agar disk elution test for rapidly growing mycobacteria. En: Isenberg HD (ed). Clinical microbiology procedures handbook. Washington DC: American Society for Microbiology, 1992. pp. 5.10.1-5.10.11.
2) Brown BA, Swenson JM, Wallace RJ, Jr. Broth microdiltion test for rapidly growing mycobacteria. En: En H.D. Isenberg (ed). Clinical microbiology procedures handbook. Washington DC: American Society for Microbiology, 1992. pp. 5.11.1-5.11-10.
3) Falkinham III, JO. Epidemiology of infection by nontubeculous mycobacteria. Clin. Microbiol. Rev. 1996; 9: 177-215.
4) Sitjas D, Bartralot R. Infección cutánea por Mycobacterium marinum. Piel 1999; 14: 359-366.5. Flores M.
5) Joe, L. and Hall, E., 1995. Mycobacterium marinum disease in Anne Arundel County. Maryland Medical Journal. Vol. 44 (12): pp 1043-1046.
6) Untergasser, D., 1989. Handbook of Fish Diseases. 160 pp. T. F. H. Publications.
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