Severe Sporotrichoid Fish Tank Granuloma Following Infliximab Therapy

Abstract

Mycobacterium marinum is an atypical mycobacterium usually found in non-chlorinated water. It rarely disseminates, except in the setting of a severely immunosuppressed patient, and usually follows a sporotrichotic type of distribution. We report the case of a 45-year-old man who had ankylosing spondylitis and was receiving infliximab and isoniazid for latent tuberculosis. The patient presented with a 5-month history of painful erythematous and suppurative nodules and abscesses on the right upper extremity. M. marinum was not isolated in cultures and histologic findings together with clinical examination provided evidence of sporotrichoid-like fish tank granuloma. The patient was treated with rifampin (rifampicin) and ethambutol for 8 months and responded satisfactorily while continuing to receive infliximab. In accordance with data in the published literature, isoniazid proved ineffective in preventing M. marinum infection in this patient. While mycobacterial complications of tumor necrosis factor-alpha (TNFalpha) inhibitor therapy are well established, our case appears to be the first reported instance of M. marinum infection in a patient taking infliximab. As anti-TNFalpha agents become increasingly used for a variety of conditions, awareness of the potential infectious complications associated with use of these agents will be vital for clinicians.

Subcutaneous Mycobacterium marinum infection in a patient with chronic rheumatoid arthritis receiving immunosuppressive therapy

“…Tumor necrosis factor (TNF) inhibitors have been associated with an increased risk of serious infections. Several recent reports have documented severe NTM infections in the setting of TNF inhibition, including sporotrichoid M. marinum infection following infliximab therapy for ankylosing spondylitis and M. marinum tenosynovitis during etanercept treatment for RA 6,7 . Similarly, our patient's infection was probably exacerbated by continued therapy with methotrexate and infliximab.…”

Aquarium-borne Mycobacterium marinum skin infection. Report of 15 cases and review of the literature

“…Recently, M. marinum infection has also gained a relevant role as an opportunistic infection in patients treated with anti-tumor necrosis factor (TNF)-␣ or other biological drugs [36][37][38][39][40]; however, recent reports support a safe re-exposition to anti-TNF-␣ therapy after elimination of the bacteria through correct antibiotic therapy [41]. Rare cases of M. marinum infection have been reported in the Italian literature [5,6,12,[42][43][44][45].…”

Cutaneous side effects of anti–tumor necrosis factor biologic therapy: A clinical review

“…The patient was successfully treated with rifampicin and ethambutol for 8 months, while continuing on infliximab therapy. 111,112 There are few data concerning cutaneous infections in psoriatic patients treated with anti-TNF therapy. Similar rates of infections have been reported in patients with psoriasis treated with infliximab versus placebo.…”