An immunocompetent 28-year-old male aquarium store employee presented with 1 month of intermittent epistaxis. A bleeding granulomatous lesion was identified over the right nasal septum (Figure 1). Histopathology from the incisional biopsy revealed granulomatous inflammation with the presence of acid-fast bacilli (Figure 2). Culture of the homogenized specimen on Middlebrook 7H11 agar after 14 days displayed white clones of non-tuberculous Mycobacterium (NTM) that turned brilliant yellow upon light exposure (Figure 3). Polymerase chain reaction (PCR) amplification of the 65-kDa heat shock protein gene with restriction enzyme analysis using BstE II and Hae III confirmed the diagnosis of Mycobacterium marinum infection. The lesion regressed completely with 3 months of doxycycline treatment.
Figure 1.
Anterior rhinoscopy revealed a granulomatous lesion with active oozing (arrow) on the right nasal septum. Inferior turbinate was identified as an asterisk.
Figure 2.
Histopathology of the specimen disclosed acid-fast bacilli (arrow) with the granulation inflammation.
Figure 3.
Mycobacterium marinum clones on Middlebrook 7H11 agar plates showed the photochromogenic characteristic, which are white when grown in the dark (A) and turn a brilliant yellow soon after exposure to light (B).
Fish tank granuloma is a rare granulomatous skin infection caused by Mycobacterium marinum, an opportunistic NTM, commonly found in aquatic environments.1 Extremities are most frequently affected; nasal cavity infection is seldom reported. The diagnosis is generally based on a history of aquatic exposure (occupational or recreational), histopathology of granulomatous inflammation with or without the presence of acid-fast bacilli, and a slow-growing photochromogenic NTM incubated at low temperature (28–30°C). Furthermore, PCR facilitates an early identification of Mycobacterium marinum infection. Superficial lesion sometimes resolves spontaneously, but several months of antimicrobial drug are usually necessary. Various monotherapies, including doxycycline, are effective.2
Footnotes
Authors' addresses: Wan-Ling Ho, Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan & Fu Jen School of Medicine, Catholic University, New Taipei City, Taiwan, E-mail: santeho@gmail.com. Wen-Yu Chuang, Department of Pathology, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taiwan, E-mail: chuang.taiwan@gmail.com. An-Jing Kuo, Department of Medical Biotechnology and Laboratory Science, Chang Gung Memorial Hospital, Linkou, Taiwan, E-mail: anjing@cgmh.org.tw. Kai-Chieh Chan, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Linkou, Taiwan, E-mail: kjchan5109@gmail.com.
Reprint requests: Kai-Chieh Chan, Division of Otology, Department of Otolaryngology Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan 5, Fu-Shin Street, Kweishan Taoyuan 333, Taiwan, E-mail: kjchan5109@gmail.com.
References
- 1.Gray SF, Smith RS, Reynolds NJ, Williams EW. Fish tank granuloma. BMJ. 1990;300:1069–1070. doi: 10.1136/bmj.300.6731.1069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Rallis E, Koumantaki-Mathioudaki E. Treatment of Mycobacterium marinum cutaneous infections. Expert Opin Pharmacother. 2007;8:2965–2978. doi: 10.1517/14656566.8.17.2965. [DOI] [PubMed] [Google Scholar]