Mycobacterium marinum as a cause of chronic granulomatous tenosynovitis in the hand
Introduction
Mycobacterium marinum is an uncommon cause of chronic granulomatous flexor tenosynovitis in the hand. These infections are associated with injuries by marine animals and occur following inoculations from skin abrasions or punctures.1 They usually cause cutaneous lesions2 though deeper infections involving the tendon sheaths, bursae, bones and joints do occur in 29% of the reported M. marinum infections.3
Diagnosis is often delayed because of the indolent course of the disease, its non-specific presentation and the long time needed to culture this organism. Therefore, it is paramount to have a high index of suspicion to send tissues for the appropriate cultures and institute anti-microbial therapy expediently as M. marinum flexor tenosynovitis has a definite worse prognosis than the subcutaneous infections. We report a series of five cases with their clinical manifestations, treatments and outcomes.
Section snippets
Methods
A review was done of all patients with pyogenic flexor tenosynovitis treated surgically in our department, from 2001 to 2006. We also reviewed the operative records in our department's surgical logbook. The following intra-operative findings were used as definitive diagnosis: tendon sheath distended and filled with serous fluid or pus, granulomatous synovium, necrotic tendon or pulleys. The diagnosis was confirmed by positive microbiological cultures.
We looked into the following variables (
Results
There were five cases of Mycobacterium marinum flexor tenosynovitis in our institution from 2001 to 2006. The clinical characteristics of these patients are summarized in Table 1. The average age of these patients was 37.6 years old (range 17–62 years). There were two females and three males in this series. All were immuno-competent individuals with no history of diabetes or steroid use and they were all right hand dominant. Three of them were cooks, one was a home-maker while the other one was a
Discussion
Mycobacterium marinum is a rare cause of infective flexor tenosynovitis and diagnosis is often delayed. A high index of suspicion is needed in so that the appropriate diagnostic tests and treatment can be instituted. Outcomes are usually poor, with stiffening of the fingers and development of sinuses in persistent infections.
Mycobacterium marinum was first isolated from seawater fish by Aronson in 1926. Swift reported the first Mycobacterium balnei infection humans from an abrasion from a
Acknowledgements
We are indebted to Dr Ban-Hock Tan, Head and Senior Consultant, Department of Internal Medicine, Singapore General Hospital, Singapore, for his invaluable input regarding the use of anti-microbial therapy for Mycobacterium marinum infections in our institution.
References (22)
- et al.
Mycobacterium marinum infections of the hand
J Hand Surg (Am)
(1987) - et al.
Mycobacterium marinum infection of the hand involving the deep structures
J Hand Surg (Am)
(1983) - et al.
Granulomas of the skin due to Mycobacterium balnei after abrasion froma fish tank
N Engl J Med
(1962) - et al.
Swimming pool granuloma
Arch Dermatol
(1963) - et al.
Sixty-three cases Mycobacterium marinum infection: clinical features, treatment and antibiotic susceptibility of causative isolates
Arch Intern Med
(2002) - Kanavel AB. The treatment of acute suppurative tenosynovitis—discussion of technique. In: Infections of the hand, 5th...
American Society for Surgery of the Hand
The hand—examination and diagnosis
(1983)- et al.
Intracellular replication of Mycobacterium marinum within Dictyostelium discoideum: efficient replication in the absence of host coronin
Infect Immun
(2003) Procedures for the isolation and identification of mycobacteria
U.S. Department of Health and Human Services publication no. (CDC) 81-8230
(1981)Mycobacterium marinum of the skin
Unusual dissemination of a tropical fish tank granuloma
Cutis
Cited by (28)
Mycobacterial Infections in the Hand and Wrist
2020, Hand ClinicsFlexor Tenosynovitis
2017, Orthopedic Clinics of North AmericaCitation Excerpt :Although less frequent, MRSA-induced FTS has shown a higher rate of complications including tissue necrosis, long-term stiffness, and amputation.30,33,34 Mycobacterium species should be considered in cases of indolent infections.35,36 Mycobacterium marinum should be suspected when a penetrating injury happens in a marine setting.
Atypical Hand Infections
2017, Orthopedic Clinics of North AmericaCitation Excerpt :Histopathology from tissue taken intraoperatively from M marinum infections typically shows noncaseating granulomas, unlike M tuberculosis, which typically shows caseating granulomas.3 Only 46% of patients have positive pathologic findings.8 Although commonly performed, Ziehl-Neelsen staining (for acid-fast bacilli) is frequently negative.
Non-tuberculous mycobacterial infections of the hand
2015, Chirurgie de la MainCitation Excerpt :Only two true recurrences occurred. Amputation was performed in 5 patients [21,22] due to the mechanical consequences of uncontrolled infection, e.g. non-functional digits due to stiffness and persistent pain. Functional results were better in patients who had only one operation, if it was done early [94% of good range of motion (ROM)].
Benign acquired superficial skin lesions of the hand
2012, Journal of Hand SurgeryUpper extremity Mycobacterium marinum infection
2010, Revue de Chirurgie Orthopedique et Traumatologique