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Mycobacterium marinum, found commonly in salt water and freshwater, is the causative agent of disease in many species of fish and occasionally in humans. MICs to most antimicrobial agents are relatively low. Susceptibility testing is not routinely performed, and single-drug therapy is used for the treatment of most infections. Here, we report an infection caused by a drug-resistant M. marinum strain in an otherwise healthy patient. CASE REPORTA 45-year-old healthy man sought medical care following a fish hook injury to the right third metacarpal area. Over the course of 10 to 14 days, he developed a tender lump over the right third metacarpal joint, which became increasingly tender to the touch. Otherwise, the patient was in good health, and his past medical history was unremarkable. On physical examination, he appeared well and was afebrile and in no acute distress. The examination of the hand was pertinent for no gross peritendinous fluid collection, tenosynovial thickening, or evidence of cellulitis. A magnetic resonance image (MRI) with and without contrast was obtained, indicating soft tissue swelling over the distal third metacarpal and proximal phalanx, with no evidence of osteomyelitis or abscess. Given the patient's history and recent fish hook injury, the possibility of an atypical mycobacterial infection was raised. An incisional biopsy was performed, and a small full-thickness ellipse of the inflamed skin was removed and sent to the laboratory for microscopy and culture. Additional skin samples were sent to pathology for histology and special stains. The patient was treated with doxycycline (100 mg orally [p.o.], twice daily) and topical mupirocin.Two weeks later, the patient returned for a follow-up visit. Physical examination revealed a residual, patchy, erythematous rash over the right third metacarpal, a small circular patchy rash over the right fourth metacarpal, and a similar rash over the dorsum of the right hand. These findings were clinically consistent with and interpreted as psoriasis. Examination of his trunk and extremities showed no other patches or lesions similar to those present on the right hand. He was advised to continue the doxycycline and follow up in 2 to 3 weeks. The patient was also given a prescription for 15 g of 0.05% fluocinonide (Lidex) ointment and instructed to use it sparingly on the affected area.Initial cultures of the wound material grew an acid-fast bacillus after 18 days of incubation at 37°C using LowensteinJensen medium. The patient returned 2 weeks after the prior visit and presented with a persistent, nonhealing, irregular erythematous nodule with a diminished plaque and an individual punctate elevation of the skin. He was advised to continue the doxycycline twice daily, and the fluocinonide was discontinued. Susceptibility testing on this isolate was requested and performed by a large reference laboratory according to established protocols using broth microdilution and a quality control strain of M. avium (ATCC 700898) susceptible to both doxycycline (MIC, 2...

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In an attempt to predict early graft occlusion secondary to poor distal run‐off, the outflow resistance was measured intra‐operatively and compared with the intra‐operative angiogram in 50 patients undergoing lower limb bypass procedures. With arterial inflow occluded, 60mL of plasmalyte was infused via a catheter and the resultant pressure generated in the graft was measured through a second catheter connected to a pressure transducer and recorder. Using the infusion rate and integrated pressure value, outflow resistance was calculated. High resistance measurements were defined as grafts with outflow resistance > 1.1 mmHg/mL per min, low measurements were defined as values < 0.5 mmHg/mL per min and intermediate measurements were those in the range 0.5–1.1 mmHg/mL per min. Angiograms were classified independently of resistance measurements by scoring the numbers of run‐off vessels crossing the ankle and stenoses, with subsequent assignment of the patient to one of three groups with either low, intermediate, or high probability of graft failure. Early graft failure was defined as cessation of graft function within 3 months of surgery. Early graft failure occurred in both cases with high outflow resistance and in seven of 44 with low outflow resistance. Of these nine occluded bypasses, six had been placed in the high probability of occlusion category on angiographic appearance and three in the intermediate category. Assessment of angiographic appearance and prediction of patency on a prospective basis had a sensitivity rate of 67% and a specificity rate of 78%. The corresponding sensitivity and specificity rates with resistance measurements were 22% and 100%, respectively. Thus, intraoperative angiographic assessment of the run‐off was more useful than outflow resistance measurement in predicting early graft patency. The presence of diabetes did not assist in the prediction of patients who subsequently developed early graft occlusion.