16 November 2024: Articles
Diagnostic Challenges of Multiple Sporotrichoid Skin Lesions Caused by
Unknown etiology, Challenging differential diagnosis, Diagnostic / therapeutic accidents
Kazuhiro Ishikawa 1F*, Minori Otake2D, Kyoko Tsumura2D, Satoru Arai 2DE, Kayo Okumura3BCD, Nobuyoshi Mori 1AEFDOI: 10.12659/AJCR.945992
Am J Case Rep 2024; 25:e945992
Abstract
BACKGROUND: Mycobacterium marinum is a slow-growing non-tuberculous mycobacterium that is known to cause skin and soft tissue infections, even in healthy patients, and is commonly associated with fish and aquatic environments.
CASE REPORT: A 23-year-old man working in aquarium management presented with a chronic progression of multiple skin nodules on his right forearm and thumb. The patient was referred from the Dermatology Department to the Outpatient Clinic due to suspected skin tuberculosis, as indicated by a positive T-SPOT.TB test. A second excisional biopsy tested positive for M. marinum via PCR sequencing by the National Institute of Infectious Diseases, confirming the diagnosis. The initial treatment consisted of rifabutin at 300 mg/day and clarithromycin at 800 mg/day. However, due to liver dysfunction, the regimen was changed to moxifloxacin at 400 mg/day and rifabutin. Moxifloxacin was discontinued due to nausea. Finally, the treatment was adjusted to linezolid at 1200 mg/day and clarithromycin. The patient’s skin condition improved, with the nodular lesions showing a trend toward resolution. Culturing is time-consuming, and the sensitivity can be reduced when using N-acetyl-l-cysteine–sodium hydroxide in the pre-treatment process; therefore, caution with its use is necessary. Pathological examination can initially show inflammatory changes, and granulomatous lesions with caseous necrosis are not always present. Antibiotics such as rifampicin, rifabutin, moxifloxacin, and clarithromycin are used, but there is scant evidence for treatment regimens, often resulting in prolonged monotherapy or combination therapy.
CONCLUSIONS: In cases presenting chronic lesions resembling multiple sporotrichoid forms, repeated biopsies are crucial due to the challenges associated with culturing.
Keywords: Mycobacterium Infections, Nontuberculous, Diagnosis, Nontuberculous, Drug Therapy, Mycobacterium marinum
Introduction
Case Report
A 23-year-old man who was employed in aquarium management and had no significant medical history was referred from the Dermatology Department to our Outpatient Clinic on suspicion of cutaneous
Due to liver dysfunction 1 month after starting the treatment, the regimen was changed to moxifloxacin 400 mg/day plus clarithromycin 800 mg/day. Three months later, the patient developed nausea due to moxifloxacin. The treatment was then switched to linezolid 1200 mg/day and clarithromycin. Following these changes, there were no further complications, and the skin findings demonstrated a trend of improvement. The nodule flattened, and the postinflammatory pigmentation had faded over 7 months (Figure 3). We are now continuing treatment until the skin lesions are diminished.
Discussion
We experienced the case of a 23-year-old man working in aquarium management with a diagnosis of
Although
In our case, the T-SPOT.TB test, which is designed primarily for
Pathological findings from biopsies can be obtained more rapidly than culture results and are therefore considered valuable. Certain case series have specifically identified the histopathology of
In general, the antibiotic regimen should avoid monotherapy and instead prefer a combination of 2 or 3 drugs. Regarding antimicrobial susceptibility, in vitro studies suggest that the minimum inhibitory concentrations for antibiotics such as rifampicin, rifabutin, moxifloxacin, minocycline, doxycycline, and clarithromycin tend to be low [14]. Although there is no established evidence for the optimal treatment regimen, recent retrospective studies have frequently cited doxycycline, clarithromycin plus ethambutol, clarithromycin, trimethoprim/sulfamethoxazole, and minocycline as frequently used in the initial therapy [14]. Regarding the duration of therapy, there is no clear evidence, with retrospective studies indicating an average of 25±14 weeks [14]. Conversely, another review suggests treatment durations ranging from 1 to 25 months, with a median of 3.5 months; significantly longer durations were noted in cases in which the infection had spread to deep tissues [6]. As mentioned above, infections that have spread to many deep structures require caution, as surgery or debridement is often performed [7]. In our case, magnetic resonance imaging confirmed the absence of deep abscesses and tendinitis, and the treatment duration was determined in consultation with the Dermatology Department, until the nodular lesions improved. We are currently considering concluding the treatment.
Conclusions
We presented a case of
Figures
Figure 1.. Skin nodule on the right upper extremity and right digit before treatment. The nodule is firm to the touch. There is no tenderness upon palpation. Figure 2.. Pathological examination of the skin biopsy. Moderate infiltration of inflammatory cells is observed in the relatively superficial part of the dermis. Epithelioid granulomas, multinucleated giant cells, and necrosis are not observed. No significant organisms are identified with periodic acid-Schiff, Grocott, or Ziehl-Neelsen staining. Figure 3.. Skin nodule after treatment. The nodule has flattened, but scarring remains.Tables
Table 1.. Laboratory values.References:
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