Rheumatology 2001; 40: 1419-1420
© 2001 British Society for Rheumatology
Letters to the Editor |
Mycobacterium marinum tenosynovitis in a patient with Still's disease
Department of Rheumatology,
1Department of Internal Medicine and Systemic Diseases, Dijon University Hospital, Dijon, France
SIR, Still's disease is a systemic disease of unknown aetiology. The prolonged corticosteroid therapy often required to induce remission, can predispose to various infectious side-effects which are sometimes difficult to differentiate from Still's disease manifestations. We describe the case of a young adult with Still's disease and cutaneous and tenosynovial infection caused by Mycobacterium marinum.
A 22-yr-old man had been treated for 5 yr with methylprednisolone (currently 8 mg/day) for Still's disease. He was referred for pain in the right wrist of 1 week duration. Physical examination showed swelling of the wrist and four 3-mm-diameter painless nodular skin lesions on the anterior side of the right wrist. The skin lesions had developed successively during the previous 2 weeks. There was no fever or weight loss. Because of a distal to proximal spread, infection due to M. marinum was suspected. Ultrasound demonstrated tenosynovitis of the palmaris longus tendon connected to one of the cutaneous lesions. The tenosynovitis and skin lesions were surgically removed. Pathological examination showed tuberculoid granuloma with caseous necrosis in the skin and in the palmaris longus tendon sheath. Direct bacterial examination was negative, but the cultures held for 3 weeks demonstrated M. marinum. Risk factors for such an infection include a fish-related hobby and corticosteroid induced immunosuppression. The patient was successfully treated with clarithromycin, ciprofloxacin, and ethambutol for 1 month, changed to ciprofloxacin and rifampicin for 3 months, after an antibiogram was obtained.
In patients with Still's disease, the distinction between inflammatory and infectious tenosynovitis is sometimes difficult. In our patient, cutaneous nodules, with one connected to the tenosynovitis, suggested infection. Moreover, the in-a-line spread of the nodules suggested a sporotrichoïd infection. Finally, M. marinum was suspected on anamnesis (the patient had fish rearing as a hobby and had his own aquarium) [1]. However, surgery was needed to prove infectious disease, to demonstrate mycobacterial infection and to allow optimal management.
Mycobacterium marinum belongs to the atypical or environmental mycobacteria. Aquarium and swimming pool environments provide a suitable habitat for the survival and reproduction of M. marinum, so infections are called the `aquarium disease’ or `swimming pool granuloma’. It can affect either healthy individuals or immunocompromised hosts [2–4]. Mycobacterium marinum is a well-documented cause of cutaneous infection. It has sometimes been noted to involve deeper structures [5]. In that case, tenosynovitis is the most common infection, but arthritis and bursitis have also been described [5, 6]. The natural course is slowly progressive, but can be faster in immunosuppressed patients [6]. The diagnosis needs pathological and bacteriological examination. Pathology usually discloses a granulomatous reaction limiting the development of the infection.
Treatment is usually based on a 2-month period of antibiotherapy [7]. Infections limited to the skin are usually successfully treated with tetracyclines or sulphamethoxazole and trimethoprim. Rifampicin alone or in combination with ethambutol is effective when deep structures are involved. In immunosuppressed patients, the use of combined antibiotics should be prescribed for at least 3 months.
Notes
Correspondence to: J. F. Maillefert, Department of Rheumatology, Hôpital Général, 3 rue du Fb Raines, 21000 Dijon, France. 
References
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- Zenone T, Boibieux A, Tigaud S et al. Non-tuberculous mycobacterial tenosynovitis: a review. Scand J Infect Dis1999;31:221–8.[ISI][Medline]
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