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Date: Wed 15 Jun 2011
Source: ABC News Medical Unit [edited]

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]

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HealthMap Alerts via ProMED-mail

[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).

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
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
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]

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