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Swimming Pool Granuloma: Causes, Symptoms and Treatment

Swimming pool granuloma is a rare skin infection caused by the bacterium Mycobacterium marinum, acquired through contact with contaminated water.

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Things worth knowing about "Swimming Pool Granuloma"

Swimming pool granuloma is a rare skin infection caused by the bacterium Mycobacterium marinum, acquired through contact with contaminated water.

What is Swimming Pool Granuloma?

Swimming pool granuloma is a rare, chronic skin infection caused by the bacterium Mycobacterium marinum. This organism thrives in aquatic environments and can enter the human body through small cuts, abrasions, or wounds on the skin. The condition is most commonly seen in people who regularly handle fish tanks, swim in pools, or come into contact with natural bodies of water. It is also commonly referred to as fish tank granuloma or aquarium granuloma.

Causes

The infection is caused by Mycobacterium marinum, a nontuberculous mycobacterium that naturally inhabits aquatic environments. It typically enters the body through existing skin injuries. Common sources of infection include:

Aquariums and fish tanks (especially during cleaning)
Swimming pools and hot tubs
Natural water sources such as lakes, rivers, and coastal waters
Contact with fish or seafood (e.g., among fishermen or seafood workers)

People with compromised immune systems are at higher risk of developing a more severe or widespread infection.

Symptoms

Symptoms usually appear 2 to 4 weeks after initial exposure. Characteristic signs of swimming pool granuloma include:

Reddish, nodular skin lesions (granulomas) at the site of infection, commonly on the hands, fingers, or arms
Slowly growing, painless or mildly tender nodules
Occasional ulceration or crusting of lesions
In advanced cases, spread along lymphatic vessels (known as sporotrichoid spread)
In rare cases, involvement of deeper structures such as tendons or joints

Diagnosis

Diagnosing swimming pool granuloma can be challenging, as the condition is uncommon and may resemble other skin disorders. Key diagnostic steps include:

Medical history: Questions about water contact, aquarium handling, or skin injuries
Skin biopsy: Tissue sampling for microbiological and histological analysis
Culture: Growth of the bacterium at lower temperatures (approximately 30 degrees Celsius), since Mycobacterium marinum does not grow at normal body temperature
Molecular testing: PCR-based tests for pathogen identification

Since the diagnosis is often delayed, a thorough patient history with emphasis on water-related activities is essential.

Treatment

Treatment of swimming pool granuloma typically involves antibiotic therapy. Because Mycobacterium marinum is an atypical mycobacterium, standard antibiotics are not effective. Commonly used medications include:

Clarithromycin or Azithromycin (macrolide antibiotics)
Doxycycline (tetracycline-class antibiotic)
Ethambutol in combination with other antibiotics for more severe cases
Rifampicin as a combination partner in extensive infections

Treatment duration is typically 3 to 6 months, reflecting the slow growth of mycobacteria and the difficulty in eradicating them. In rare cases involving deep tissue structures, surgical intervention may be necessary. In immunocompetent individuals, spontaneous resolution occasionally occurs without treatment.

Prevention

To reduce the risk of swimming pool granuloma, the following precautions are recommended:

Wearing protective gloves when cleaning aquariums or handling fish
Proper wound care for skin abrasions before contact with water
Avoiding water exposure when open wounds are present

References

Gonzalez-Santiago TM, Drage LA. Nontuberculous Mycobacteria: Skin and Soft Tissue Infections. Dermatologic Clinics, 2015; 33(3): 563-577.
World Health Organization (WHO): Nontuberculous mycobacteria and human disease. WHO Technical Report, Geneva, 2022.
Aubry A, Chosidow O, Caumes E, et al. Sixty-three cases of Mycobacterium marinum infection. Archives of Internal Medicine, 2002; 162(15): 1746-1752.

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