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Disseminated Mycobacterium marinum skin infection due to chronic lymphedema in an immunocompetent patient

A 64-year-old woman presented with a four-week history of unilateral erythematous, slightly pruritic papules and nodules on her right leg, which were unresponsive to broad-spectrum antibiotics. The patient denied any fever or other systemic symptoms, had no allergies and took no regular medication. Her medical history included endometrial carcinoma with pelvic lymphadenectomy seven years ago, resulting in chronic lymphedema of the right leg with two previous episodes of erysipelas. Dermatological investigation revealed disseminated, hair-follicle-associated reddish papules, plaques and nodules on the right leg in combination with lymphedema (Figures 1 a, b, 2 ). The results of routine laboratory tests were unremarkable, except for a positive interferon-gamma release assay (IGRA) for Mycobacterium (M.) tuberculosis . Pulmonary tuberculosis (TB) as well as sarcoidosis were ruled out by chest X-ray and sputum analysis. Soluble IL2 receptor (sIL2R) and angiotensin converting enzyme (ACE) were within the normal range. Histopathological examination of a skin biopsy from a nodule revealed a dense periadnexal, granulomatous infi ltrate