'Fishy' symptoms should spur referral

Joel Schlessinger, M.D., cites his experience with such a patient because the case speaks as something of a metaphor that spotlights the special skills dermatologists bring to problem cases - and shows that doctors need to be more willing to work together for the good of their patients.

Recalcitrant rash

"The young man had been under treatment for the rash with his primary care physician, who had not been able to diagnose the problem," Dr. Schlessinger tells Dermatology Times. "The primary care physician wound up prescribing a topical steroid to treat the rash, but it wasn't working. Eventually the patient sought out a dermatologist and came to see me."

Sizing up signs, symptoms

The young man presented with localized red nodules on both elbows and the backs of both hands.

As Dr. Schlessinger took the patient's history, there didn't appear to be anything in terms of family history or background to indicate what might be causing the rash: The boy was an active, fairly typical teenager from a fairly typical family, went to school and worked part time in a pet shop.

That last piece of information caught the doctor's attention.

"I asked the young man what his pet shop job entailed, and he told me he waited on customers, restocked the shelves, fed the animals and cleaned their stalls, and made sure the tropical fish were fed and the tanks cleaned," Dr. Schlessinger says. "That pretty much did it for me - I had a hunch right then and there what was causing the rash."

Dr. Schlessinger's diagnosis was Mycobacterium marinum, described in medical literature as a slow-growing bacteria that may cause disease in fish and people. According to the literature, skin infection with Mycobacterium marinum is relatively rare and is usually acquired from swimming pools, aquariums or handling fish. The bacteria enters the skin where there are cuts are abrasions - which are fairly typical on the hands and elbows of an active 18-year-old.

"As it turns out, practically everyone he worked with at the pet shop had the same condition," Dr. Schlessinger says. "As for this young man's rash, it was cleared up in a month to a month and a half after the institution of minocycline."

Collaborate, think outside aquarium

The moral to this case history, Dr. Schlessinger says, is that it points to the importance of dermatology in the medical profession.

In this particular instance, it illustrates how the patient's problem would have been cleared up far sooner had the primary care physician thought "outside the box," and referred the young man for a dermatological consult.

"I think this case shows how important dermatology is in the overall practice of medicine," Dr. Schlessinger says.

"It's tough cases like this that show how our special diagnostic training, skills and abilities can be critical in assuring excellent outcomes for patients."