A Fishmonger's Tale: A Case Report and Review of Literature

Background Fish are vectors of several zoonoses that can pose serious health problems in the immunocompromised patients. The clinical manifestation is often cutaneous and occurs at the site of inoculation. However, bacteremia and deep-seated infection have been described. We report a case of Pseudomonas aeruginosa causing ecthyma gangrenosum in an immunocompromised patient after fish handling and reviewed the literature of previously reported cases of fish handling infections. Methods We retrospectively reviewed the literature of all cases of infection among fishmongers using the PubMed database from 1990 to present. A comparative analysis was performed to explore the risk factors, bacterial pathogens, treatment, and outcomes. Results Thirty-eight cases of infections acquired through fish handling were identified. The median age was 58 years. The most common underlying medical conditions were diabetes mellitus, alcoholism, and rheumatic heart disease. The most common bacteria involved were Streptococcus iniae (11 cases), Vibrio vulnificus (7 cases), and Mycobacterium marinum (7 cases) (Fig. 1). Other pathogens reported were Erysipelothrix rhusiopathiae, Aeromonas hydrophila, Vibrio damsela, Proteus vulgaris, Morganella morganii, Lactococcus garvieae, Mycobacterium abscessus, Streptococcus halichoeri, and in our case P. aeruginosa. Cellulitis was the most common manifestation, but necrotizing fasciitis, tenosynovitis, osteomyelitis, endocarditis, and septic shock have been documented. β-Lactam agents such as penicillin or ampicillin-sulbactam were often prescribed for streptococcal infection, whereas antimycobacterial agents such as rifampin, ethambutol, and clarithromycin were often used for M. marinum infection. Four cases of death were reported, representing a mortality of 11%. Conclusions Chronic medical conditions such as diabetes mellitus, alcoholism, and rheumatic heart disease can predispose patients to infection, particularly among fishmongers. These infections pose significant morbidity and mortality in the immunocompromised hosts if not recognized early. Thus, a thorough history, including occupational and recreational exposure, is essential to prompt the clinician to consider these atypical zoonotic pathogens in the differential diagnosis and provide the appropriate management.