Acid-fast bacteria as causative agents of skin and soft tissue infections: case presentations and literature review

Spiliopoulou, Anastasia; Kyriakou, Georgia; Georgiou, Sophia; Lekkou, Alexandra; Leonidou, Lydia; Militsopoulou, Maria; Papadogeorgaki, Eleni; Christofidou, Myrto; Kolonitsiou, Fevronia; Paliogianni, Fotini

doi:10.1590/S1678-9946202365029

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REVIEW • Rev. Inst. Med. trop. S. Paulo 65 • 2023 • https://doi.org/10.1590/S1678-9946202365029 copy

Acid-fast bacteria as causative agents of skin and soft tissue infections: case presentations and literature review

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ABSTRACT

Acid-fast bacteria can be implicated in skin and soft tissue infections. Diagnostic identification can be challenging or not feasible by routine laboratory techniques, especially if there is no access to the Matrix Assisted Laser Desorption Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS) technology. Here, we present two cases of skin and soft tissue infections caused by two different acid-fast bacteria, Nocardia brasiliensis and Mycobacterium marinum. They both grew on Löwenstein–Jensen medium, Sabouraud agar medium and blood agar medium. Both bacteria appeared acid-fast by Ziehl–Neelsen stain and Gram-positive by Gram stain. The identification was performed by MALDI-TOF MS and gene analysis. N. brasiliensis and nontuberculous mycobacterium M. marinum represent rare pathogens that cause severe skin and soft tissue infections. Failure to identify the causative agent and subsequent inappropriate or inadequate treatment may lead to severe complications or even disseminated disease, especially in immunocompromised individuals.

Nocardia brasiliensis; Mycobacterium marinum; Ziehl–Neelsen stain; Acid-fast bacteria; Skin and soft tissue infections; MALDI-TOF MS

Article	Gender/Age	Country	Risk factors	Portal of entry	Site	Type of skin lesions	Treatment	Outcome
Lovecchio et al.¹1. Lovecchio A, Bazzacco G, Di Bella S, Di Meo N, Luzzati R. Uncommon lymphocutaneous cellulitis after insect bite: a case report of primary cutaneous nocardiosis and literature review. Infez Med. 2022;30:285-92.	F/45	Italy		Insect bite	Right leg	Lymphocutaneous form painful/necrotizing lesion	Linezolid 10d plus TMP-SMX 5 days (disc. cutaneous rash), Amx/CLV p.o. 5 months and linezolid 3 weeks (disc. to anemia)	Cure
Dumic et al.²2. Dumic I, Brown A, Magee K, Elwasila S, Kaljevic M, Antic M, et al. Primary lymphocutaneous Nocardia brasiliensis in an immunocompetent host: case report and literature review. Medicina (Kaunas). 2022;58:488.	M/66	USA		Injury from gardening	Left hand	Lymphocutaneous form painful/ulcerated nodular lesion	TMP-SXT plus Amx/CLV 8w	Cure
Acevedo et al.³3. Acevedo CT, Imkamp F, Maggio EM, Brugger SD. Primary cutaneous nocardiosis of the head and neck in an immunocompetent patient. BMJ Case Rep. 2021;14:e241217.	F/50	Switzerland (travel to Greece)		Insect bite	Face, neck	Cutaneous painful/ulcerated plaque – abscess formation	TMP-SXT disc. drug eruption switched to Amx/CLV 3 months	Cure
Mangieri et al.⁴4. Mangieri NA, Guevara Nuñez D, Echavarría G, Bertona E, Castello L, Benchetrit G, et al. Nocardiosis esporotricoide por Nocardia brasiliensis. Rev Argent Microbiol. 2021;53:43-7.	F/85	Argentina			Left hand	Lymphocutaneous form ulcerated lesion	TMP-SXT 4 weeks	Cure
Chen et al.⁵5. Chen Y, Liu Y, Ding XJ, Chen YJ, Wang L, Zhang ZZ. Diagnosis and treatment of lymphocutaneous dermatosis caused by Nocardia brasiliensis: a case report. Ann Palliat Med. 2020;9:3663-7.	M/87	China			Left arm	Lymphocutaneous form erythematous papules with purulent secretions	TMP-SXT 4 weeks (Amx/CLV 10d) plus skin lesions debridement/drainage	Cure
Gil Redondo et al.⁶6. Gil Redondo R, Melgar Molero V, Martín Fuentes A, Eusebio Murillo E. Primary cutaneous Nocardiosis in a man treated with certolizumab. Actas Dermosifiliogr (Engl Ed). 2019;110:698-9.	M/53	Spain	Leflunomide-certolizumab (psoriatic arthritis)		Left wrist	Cutaneous form erythematous-crusted nodule	TMP-SXT 6 months	Cure
Medina-Torres et al.⁷7. Medina-Torres AM, Toussaint-Caire S, Hernández-Castro R, Bonifaz A. Skin nodules in a pediatric Mexican patient after chest trauma. Enferm Infecc Microbiol Clin (Engl Ed). 2019;37:611-3.	M/12	Mexico		Minor injury due to motor accident	Chest, right axillary and arm	Lymphocutaneous form disseminated nodules	TMP/SXT plus diaminodiphenyl sulfone 6 months	Cure
Wang et al.⁸8. Wang R, Yao X, Li R. Mycetoma in China: a case report and review of the literature. Mycopathologia. 2019;184:327-34.	M/32	China			Left arm	Mycetoma multiple nodules/abscesses	TMP-SXT plus amikacin 6 months	Cure
Li et al.⁹9. Li S, Xu X, Wu M, Zhu J, Cen P, Ding J, et al. Lymphocutaneous nocardiosis caused by Nocardia brasiliensis in an immunocompetent patient: a case report. J Int Med Res. 2020;48:300060519897690.	M/34	China			Both arms	Lymphocutaneous form multiple scattered pustules	TMP-SXT 8 weeks (plus linezolid 2 weeks)	Cure
Mu et al.¹⁰10. Mu YZ, Liu Y, Wang YJ, Zhang ZZ. A case report and review of lymphocutaneous nocardiosis caused by Nocardia brasiliensis reported in China. Dermatol Ther. 2019;32:e13001.	F/42	China		Insect bite	Right hand	Lymphocutaneous form pustule and ulceration	TMP-SXT 6 weeks (14 days amoxicillin)	Cure
Steinmetz et al.¹¹11. Steinmetz G, Panas K, Puffinbarger W. An acute Nocardia infection in a pediatric hand. J Hand Surg Am. 2019;44:343.e1-3.	M/1.5	USA			Left finger	Cutaneous abscesses	TMP-SXT 7 weeks plus drainage	Cure
Abu Sitta et al.¹²12. Abu Sitta E, Hollingshead C, Luttmann K, Elsaghir H. Gardener with primary lymphocutaneous nocardiosis. BMJ Case Rep. 2019;12:e233586.	F/57	USA	Diabetes mellitus	Gardening without gloves	Right index finger, forearm	Lymphocutaneous form nodule with swelling and erythema	TMP-SXT 14 days plus drainage	Cure
Al-Obaydi et al.¹³13. Al-Obaydi S, DeMaio J. Two cases of cutaneous nocardiosis after a natural disaster. Cureus. 2019;11:e6278	M/75	USA		Arm injury	Left forearm, axilla	Lymphocutaneous form abscess, pain and erythema	TMP-SXT 6 weeks	Cure
Al-Obaydi et al.¹³13. Al-Obaydi S, DeMaio J. Two cases of cutaneous nocardiosis after a natural disaster. Cureus. 2019;11:e6278	M/70	USA	Diabetes mellitus	Finger injury while trimming a palm branch	Left ring finger, arm	Lymphocutaneous form draining abscess, cellulitis, lymphadenitis	TMP-SXT 6 weeks	Cure

Article	Gender/Age	Country	Medical history	Portal of entry/source of exposure	Site of infection	Type of skin lesions	Treatment	Outcome
Khadka et al.¹⁴14. Khadka DK, Acharya R, Agrawal S. Sporotrichoid lymphocutaneous pattern in a fish-merchant under immunosuppressant medications: clues to differential diagnoses. Clin Case Rep. 2022;10:e6708.	F/45	Nepal	Corticosteroids, methotrexate, hydroxychloroquine	Fish handler	Left hand, forearm and arm	Lymphocutaneous form erythematous painful nodules with discharge, swelling of the left hand	Ethambutol plus Clarithromycin plus Doxycycline 8 months	Cure
Cascardo et al.¹⁵15. Cascardo CA, Hollis AN, Ansah-Addo S, Smith EH, Mervak JE. Cutaneous Mycobacterium marinum infection secondary to well water exposure masquerading as cutaneous Crohn’s disease. JAAD Case Rep. 2022;30:131-3.	F/41	USA	Infliximab, methotrexate, prednisone (inflammatory polyarthropathy, Crohn’s disease)		Upper back	Pruritic, tender erythematous papules and pustules	Clarithromycin plus Ethambutol – ND	ND
Li et al.¹⁶16. Li L, Li M. Diagnosis of Mycobacterium marinum infection based on photochromogenicity: a case report. Rev Inst Med Trop Sao Paulo. 2022;64:e76.	F/35	China		Lobster pinch	Right index finger	Progressive swelling, pus drainage	Rifampicin plus Clarithromycin 3m plus surgical drainage	Cure
Iwata et al.¹⁷17. Iwata K, Takai Y, Kitada N, Morishita N, Kiyona H. Mandibular nodule caused by Mycobacterium marinum with false positive interferon-γ release assay: a case report. Intern Med. 2022 In Press.	F/63	Japan			Submandibular	Submandibular nodule	Clarithromycin plus Ethambutol 4 weeks	Cure
Liu et al.¹⁸18. Liu J, Yao Q, Cheng W, Ren H, Hu W. Mycobacterium marinum infection on both hands masquerading as ‘eczema’. Am J Med. 2023;136:e5-6.	F/68	China		Wound on left middle finger, cleaning fish from local market	Both hands	Painless plaques	Doxycycline plus Clarithromycin 5 months	Cure
Riccardi et al.¹⁹19. Riccardi N, Antonello RM, Canetti D, Polidori M. An octopus gift: Mycobacterium marinum multiple skin lesions. Infection. 2022;50:1631-2.	M/51	Italy	Adalimumab (psoriasis)	Octopus fisherman, skin puncture while fishing	Left hand and wrist	Reddened ulcerated lesion	Clarithromycin, plus Rifampicin plus Ethambutol 6–9 months	Cure
Seidel et al.²⁰20. Seidel A, Nunes DH, Fernandes C, Funchal GG. Skin infection by Mycobacterium marinum: diagnostic and therapeutic challenge. An Bras Dermatol. 2022;97:366-8.	M/36	Brazil		Fishing, trauma with a perforating-cutting tool	Left hand, especially the fifth finger	Papule and exudation, progression to an erythematous-verrucous plaque with nodules and crusts, evident atrophy of the fifth finger	Clarithromycin plus Doxycycline plus Rifampicin	Cure
Patel et al.²¹21. Patel PM, Camps N, Rivera CI, Tuda C, VanOstran G. Mycobacterium marinum infection and interferon-gamma release assays cross-reactivity: a case report. Cureus. 2022;14:e21420.	M/61	USA	Adalimumab (psoriatic arthritis)		Right forearm	Small blister-like lesion which upon removal/resection became ulcerative	Azithromycin (disc. diarrhea) plus Rifampin, then Ethambutol plus Rifampin (disc. resistance), then Ethambutol plus Rifabutin 5 months	Cure
Xing et al.²²22. Xing F, Lo SK, Ma Y, Ip JD, Chan WM, Zhou M, et al. Rapid diagnosis of Mycobacterium marinum infection by next-generation sequencing: a case report. Front Med (Lausanne). 2022;9:824122.	M/38	China		Owner of a seafood market, fish bite	Right middle finger, right hand and elbow	Lymphocutaneous form poorly healed primary wound on the right middle finger, secondary ulcerated mass on right hand, subcutaneous nodule at the right elbow and supratrochlear lymph nodes	Rifampin plus Minocycline plus Clarithromycin 9 months	Cure
Vanhooteghem et al.²³23. Vanhooteghem O, Theate I, De Schaetzen V. Periungual Mycobacterium marinum infection following a fish manicure. Skin Appendage Disord. 2021;7:393-6.	M/41	Belgium		Fish manicure-Thailand vacation	Left thumb	Hardened, rough, brownish erythematous periungual plaque	Doxycycline 4 months	Cure
Trčko et al.²⁴24. Trčko K, Plaznik J, Miljković J. Mycobacterium marinum hand infection masquerading as tinea manuum: a case report and literature review. Acta Dermatovenerol Alp Pannonica Adriat. 2021;30:91-3.	M/37	Slovenia		Aquarium owner (tropical fish, exotic snakes, lizards)	Right hand	Small warty papule progressed to erythematous scaling plaque on the fourth finger, after a few months a new lesion appeared on the back of his hand and the extensor side of the right wrist.	Rifampicin plus Clarithromycin 6 months	Cure
Wenlong et al.²⁵25. Wenlong H, Qiunan Y, Wenhao C, Yumo L, Tingting Z, Hong R. The combination of photodynamic therapy and fractional CO2 laser for Mycobacterium marinum infection. Photodiagnosis Photodyn Ther. 2021;35:102391.	M/18	China		Chef	Left hand	Plaques and nodules	Photodynamic therapy combined with fractional CO₂ laser ablation	Cure
Wenlong et al.²⁵25. Wenlong H, Qiunan Y, Wenhao C, Yumo L, Tingting Z, Hong R. The combination of photodynamic therapy and fractional CO2 laser for Mycobacterium marinum infection. Photodiagnosis Photodyn Ther. 2021;35:102391.	F/70	China		Stabbed by a fish	Right arm	Painful ulcer on her right forearm	Photodynamic therapy combined with fractional CO₂ laser ablation	Cure
Patel et al.²⁶26. Patel AA, Akusoba CN, Yetmar ZA, Tabaja H, Schuetz AN, Camilleri MJ, et al. Mycobacterium marinum following a knife injury. IDCases. 2021;24:e01102.	F/61	USA	Sjögren’s syndrome, chronic left upper extremity edema (breast cancer – mastectomy, lymphadenectomy, chemotherapy)	Knife injury to her left thumb while cutting fish	Left arm	Lymphocutaneous form pustule at the primary site, additional nodular lesions ascended up her arm to the level of her elbow with associated erythema and drainage	Clarithromycin plus Ethambutol plus Rifampin. Plan for surgical debridement (due to slow improvement at follow-up)	Slow improvement
Su et al.²⁷27. Su Q, Wang F. Painful nodules on the arms. N Engl J Med. 2021;384:e41.	F/63	China		Cut injuries on her hands while cleaning fish	Both arms	Painful pink nodules and ulcerations with hemorrhagic crust on both arms	Moxifloxacin plus Rifampin plus Clarithromycin 6 months	Cure
Rathish et al.²⁸28. Rathish B, Mohammed SM, Ullal K, Hassan S, Wilson A. Tropical aquatic skin and soft tissue infections: a series of three cases. Cureus. 2021;13:e13170.	F/30	India		Cut injury to the right wrist while cleaning a fishbowl	Right forearm	Lymphocutaneous form multiple nodules with a large nodule that had formed an abscess	Rifampicin plus Clarithromycin – ND	Cure
Costescu Strachinaru et al.²⁹29. Costescu Strachinaru DI, Vanbrabant P, Stinga P, Strachinaru M, Soentjens P. Diagnosis of Mycobacterium marinum Infection with sporotrichoid pattern. Acta Derm Venereol. 2021;101:adv00414.	F/60	Belgium		Owner of a tropical fish tank. Injured by a plant thorn while gardening	Right arm	Lymphocutaneous form nodular lesions	Clarithromycin 14 months	Cure
Rida et al.³⁰30. Rida MA, Bardawil T, Ibrahim D. First reported Mycobacterium Marinum infection case in a patient with psoriatic arthritis maintained on Golimumab. Arch Rheumatol. 2020;35: 454-5.	F/53	Lebanon	Golimumab	Exposure to fresh fish	Right hand	Non-resolving indurated plaque over the base of the right fifth digit right hand	Clarithromycin plus Doxycycline – ND	Cure
Tuan et al.³¹31. Tuan J, Spichler-Moffarah A, Ogbuagu O. Mycobacterium marinum: nodular hand lesions after a fishing expedition. BMJ Case Rep. 2020;13:e238835.	M/46	USA		Fishing expedition, finger injury and wound exposure to shellfish	Left hand	Hyperkeratotic plaques without erythema	Rifampin plus Clarithromycin plus Ethambutol 4 months	Cure
Briand et al.³²32. Briand C, Gaudart A, Demonchy D, Hubiche T. Subacute multifocal abscesses related to a Mycobacterium marinum infection in a child. J Pediatr. 2021;230:255-6.	M/7	France		Played in a pond a few weeks before the abscesses	Both hands and right arm	Lymphocutaneous form multiple inflammatory cutaneous lesions on both hands and suppurative adenopathy of the right arm	Clarithromycin 1 month	Cure
Bezerra et al.³³33. Bezerra GH, Honório ML, Costa VL, Vechi HT, Alves MM, Britto MH, et al. Mycobacterium marinum infection simulating chromomycosis: a case report. Rev Inst Med Trop Sao Paulo. 2020;62:e95.	M/52	Brazil		Bathing in ponds, fishing activities and handling fish, trauma caused by a cactus thorn	Right lower limb	Chronic and extensive cutaneous infection Dyschromic atrophic center plate and verrucous borders with hematic crusts	Ethambutol plus Rifampicin plus TMP-SXT 6 months leaving a dystrophic atrophic plaque	Cure
Furuichi et al.³⁴34. Furuichi Y, Ito Y, Tanese K, Mukai M, Uwamino Y, Hasegawa N, et al. Two case reports of Mycobacterium marinum infection with psoriatic arthritis treated by tumor necrosis factor-α inhibitors. J Dermatol. 2021;48:e106-7.	M/49	Japan	Infliximab (psoriatic arthritis)	Caring for tropical fish	Right arm	Lymphocutaneous form indurated erythema appeared on the dorsal surface of the third digit of the right hand, followed by painful subcutaneous nodules that spread along the lymphatic vessels on the right arm	Infliximab infusion was discontinued. Moxifloxacin plus Doxycycline plus TMP-SXT 4 months. Infliximab was restarted due to arthritis recurrence within the last 3 months	Cure
Furuichi et al.³⁴34. Furuichi Y, Ito Y, Tanese K, Mukai M, Uwamino Y, Hasegawa N, et al. Two case reports of Mycobacterium marinum infection with psoriatic arthritis treated by tumor necrosis factor-α inhibitors. J Dermatol. 2021;48:e106-7.	M/58	Japan	Adalimumab, methotrexate (psoriatic arthritis)	Caring for tropical fish	Right arm	Lymphocutaneous form erosive erythema on the dorsal surface of the third digit of the right hand and subcutaneous nodules along the lymphatic vessels of the right arm	Adalimumab was discontinued. Clarithromycin plus Ethambutol plus Doxycycline 5 months, Brodalumab was administered because of arthritis recurrence	Cure
Zimmerlich et al.³⁵35. Zimmerlich S, Eder IB, Simon JC, Kunz M. Mycobacterium marinum infection in an immunocompromised patient with infliximab. Eur J Dermatol. 2020;30:436-7.	M/48	Germany	Infliximab (ulcerative colitis)	Small wound on his right ring finger – cleaning his two aquariums without gloves	Right arm	Lymphocutaneous form, lesion on the nailfold of the right ring finger and multiple painless skin lesions on his right upper extremity	Clarithromycin plus Ethambutol plus Rifampicin 12 months plus Percutaneous abscess drainage. Then Clarithromycin plus Rifampicin 14 months	Cure
Nachimuthu et al.³⁶36. Nachimuthu N, Ganesh SY. Diagnosis of Mycobacterium marinum infection based on seroconversion of QuantiFERON-TB Gold Test. Cureus. 2020;12:e9208.	F/53	USA	Golimumab (rheumatoid arthritis), diabetes	Cleaning her fish tank with bare hands, use of lancets for checking blood glucose, injuries from rose thorns	Left arm	Lymphocutaneous form tender nodules with surrounding redness on her left index finger and forearm.	Minocycline plus Clarithromycin 9 months	Cure
Berman et al.³⁷37. Berman HS, Thomas L, Beynet D, Gates G, Shi V, Hsiao J. Fish tank granuloma during tumor necrosis factor-alpha inhibitor treatment: a case report and literature review. Dermatol Ther. 2020;33:e14058.	M/70	USA	Golimumab (ulcerative colitis)	Cleaning his fish tank	Left hand, arm	Lymphocutaneous form, single erythematous indurated plaque with a central ulcer on his left hand and painful nodules on his left arm	Minocycline 1 week, then Rifampin plus Minocycline (given his immunomodulatory state) 10 weeks	Cure
Bachiyska et al.³⁸38. Bachiyska E, Atanasova Y, Baykova A, Yordanova S, Todorova Y. First etiologically confirmed cases of Mycobacterium marinum infection in Bulgaria. Folia Med (Plovdiv). 2020;62:398-402.	F/66	Bulgaria		Hand injury, cleaning an ornamental tropical fish aquarium without using protective gloves.	Right arm	Lymphocutaneous form small red-violet papules on right hand and forearm, some progressed to pustules and ulcers, in straight line proximally	Rifampicin plus Ethambutol, after 2 months disc. joint pain, candidiasis, diarrhea, intestinal pain – continued with symptomatic therapy, lesions slowly improved after 8 months	Cure
Bachiyska et al.³⁸38. Bachiyska E, Atanasova Y, Baykova A, Yordanova S, Todorova Y. First etiologically confirmed cases of Mycobacterium marinum infection in Bulgaria. Folia Med (Plovdiv). 2020;62:398-402.	M/50	Bulgaria		Fisher and diver, stab wound on the right hand little finger by a fish fin	Right hand	Lesions on the little finger and the thumb, progression to deep tissue infection of wrist	Rifampicin plus Ethambutol for 1 month, plus Clarithromycin for the next 6 months	Cure
Peña Merino et al.³⁹39. Peña Merino L, Mendieta-Eckert M, Méndez Maestro I, Gardeazabal García J. Mycobacterium marinum infection in a woman taking adalimumab. Actas Dermosifiliogr (Engl Ed). 2020;111:525-6.	F/54	Spain	Adalimumab (rheumatoid arthritis)	Cut on the finger while preparing fish in her workplace.	Left hand	Multiple erythematous-violaceous papules on the left hand and wrist	Minocycline 2 months; despite marked improvement, some active lesions persisted; treatment was switched to Clarithromycin	Cure
Park et al.⁴⁰40. Park JB, Seong SH, Kwon DI, Jang JY, Suh KS, Jang MS. Mycobacterium marinum infection spreading in a “birds in flocks” pattern: all caseating granuloma is not tuberculosis. Acta Derm Venereol. 2020;100:adv00200.	F/74	Korea	Local steroid injection in the elbow to treat arthritis	Trimming oysters	Left arm, trunk	Diffuse tender erythematous and yellow cellulitis-like patches on her left arm, discrete papules on the left trunk	Doxycycline plus Clarithromycin plus Rifampin 3 months, moderate improvement – lost to follow-up	Moderate improvement –lost to follow-up.
Bollam et al.⁴¹41. Bollam R, Phan T. Mycobacterium marinum infection of the hand presenting as a nodular skin lesion. J Clin Tuberc Other Mycobact Dis. 2020;20:100166.	M/33	USA		Landscape work, in which he might have a skin injury, owner of fish tank (without fish)	Right hand	Nodular skin lesion on the right index finger	Incision and drainage of the nodule with excision of a deep mass, advised to follow-up outpatient for further care	ND
Chokevittaya et al.⁴²42. Chokevittaya P, Apisarnthanarak A, Chansirikarnjana S, Boonyasirikool C, Kintarak J, Weber DJ. Photo quiz: a 53-year-old Thai man with progressive swelling of the left index finger. J Clin Microbiol. 2020;58:e02058-18.	M/53	Thailand		Ant bite while gardening near a pond, hobbies: gardening, decorating corals at his home.	Left hand	Progressive swelling of his left index finger for 4 months, abscess formation	Rifampin plus Clarithromycin plus Streptomycin plus multiple surgical debridements	Cure
Drakou et al.⁴³43. Drakou A, Psifis M, Mitrou A, Zygoggianis K, Argyropoulou O. Unresolved swelling of the hand: think of Mycobacterium marinum infection. Trauma Case Rep. 2020;26:100283.	M/48	Greece	Infliximab (ankylosing spondylitis), oral steroid treatment	Puncture on his left index finger while working at an underwater ship repair	Left hand and forearm	Lymphocutaneous form painful swelling over the affected area, subcutaneous abscesses	Anti-TNFa was discontinued, surgical intervention, Clarithromycin plus Ethambutol plus Rifampicin	Cure
Conforti et al.⁴⁴44. Conforti C, Zalaudek I, Vichi S, Di Meo N. Dermoscopy of Mycobacterium marinum skin infection: a challenging diagnosis. Acta Dermatovenerol Croat. 2019;27:278-9.	M/66	Italy		Aquarium owner	Left hand	Two purplish painful nodules on the left hand	Clarithromycin 4 weeks	Cure
Assiri et al.⁴⁵45. Assiri A, Euvrard S, Kanitakis J. Cutaneous Mycobacterium Marinum infection (fish tank granuloma) in a renal transplant recipient: case report and literature review. Cureus. 2019;11:e6013.	M/72	France	Cyclosporin, steroids, mycophenolic acid (kidney transplant patient)	Minor trauma (cut) while cleaning his fish tank	Right hand	Asymptomatic, erythematous, scaly nodule over the proximal interphalangeal joint of the right index finger	Immunosuppressive treatment was reduced (cyclosporin dosage was lowered), Minocycline 2 months, switched to Doxycycline 3 months	Cure
Feng et al.⁴⁶46. Feng H, Su Y, Fu S, Zhou Y, Xiao R, Wu R, et al. Image gallery: fish tank granuloma on the face with sporotrichoid cervicofacial lymphadenitis and abscesses due to Mycobacterium marinum infection. Br J Dermatol. 2019;180:e180.	M/53	China		Scratch on the nose root by a rusty shrimp cage	Face, neck	Lymphocutaneous form erythematous papules and plaques on the nose root, abscesses on the neck and face, cervicofacial lymphadenitis	Rifampin plus Ethambutol plus Minocycline 3 months	Cure
Vemulakonda et al.⁴⁷47. Vemulakonda LA, Tschen JA. Slow-growing and linearly spreading cutaneous lesion: often misdiagnosed Mycobacterium marinum infection. Cureus. 2019;11:e4154.	M/69	USA		Cleaning an aquarium at home	Right arm	Lymphocutaneous form verrucous plaques on the right elbow and ulcerated papulonodules on the right arm	Rifampin plus Ethambutol, ongoing therapy	Considerable improvement
Esteves et al.⁴⁸48. E steves M, Nogueira A, Azevedo F. A case of cutaneous nodules in a sporotrichoid pattern. Dermatol Online J. 2019;25:12.	M/65	Portugal		Gardening-rose thorn injury to the left thumb. Cleaning an aquarium.	Left hand and forearm	Lymphocutaneous form erythematous nodules in a linear distribution along the left hand and forearm.	Clarithromycin plus Rifampicin 6 months	Cure
Bouceiro-Mendes et al.⁴⁹49. Bouceiro-Mendes R, Ortins-Pina A, Fraga A, Marques T, Viveiros M, Machado D, et al. Mycobacterium marinum lymphocutaneous infection. Dermatol Online J. 2019;25:10.	M/33	Portugal		Minor cut on the finger, cleaning an aquarium of tropical fish without hand protection.	Right hand and forearm	Lymphocutaneous form ulcerated nodule on the right fingertip, painful plaques and nodules, some suppurative, on the right hand and forearm	Clarithromycin plus Ethambutol plus Rifampicin 9 months	Cure
Kobayashi et al.⁵⁰50. Kobayashi T, Ford B, Sekar P. A case of severe cutaneous Mycobacterium marinum infection in a patient with Crohn’s disease on chronic high-dose prednisone. BMJ Case Rep. 2019;12:bcr-2018-228516.	M/73	USA	Prednisone (Crohn’s Disease)	Salt and fresh water fish tank that he routinely cleaned and maintained	Hands, face and trunk	Several erythematous nodular lesions on bilateral hands and erythematous papules on his chest, abdomen, face and extremities	TMP-SXT (Nocardia was suspected – rash improved) plus Rifabutin, ongoing therapy	Improvement
Koushk-Jalali et al.⁵¹51. Koushk-Jalali B, Freitag AP, Tigges C, Oellig F, Hillemann D, Kreuter A. Sporotrichoid fish tank granuloma. QJM. 2019;112:147.	M/66	Germany	Myelodysplastic syndrome (treated with subcutaneous erythropoietin injections)	Aquarium hobbyist	Right hand and arm	Lymphocutaneous form, nodules and plaques that firstly occurred on the right index finger and spread to the fore- and upper arm along the lymphatic vessels	Rifampicin plus Ethambutol was initiated, with almost complete clearance of the skin lesions within 8 weeks, ongoing therapy	Cure
Sahuquillo-Torralba et al.⁵²52. Sahuquillo-Torralba A, Calle-Andrino A, Gil-Brusola A, Évole-Buselli M. Granulomatous plaque of the right knee in a 10-year-old boy. Enferm Infecc Microbiol Clin (Engl Ed). 2019;37:58-9.	M/10	Spain		Skin abrasion, bathing with a tortoise, swimming in pools	Right knee	Erythematous plaque	Clarithromycin 5 months	Cure

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[1] Correspondence to: Anastasia Spiliopoulou University General Hospital of Patras, Department of Microbiology, Patras, 26504, Greece E-mail:spil@upatras.gr