Mycobacterium marinum hand infection

Short reports and correspondence

181

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Figure 2--The forearm flap designed and raised on the superficial radial artery.

radial artery can be preserved to make the best use of this anomaly. If this anomaly is suspected before surgery, e.g. by palpation, we recommend duplex scanning so that the forearm flap can be raised on the superficial radial artery alone, avoiding dissection of the main trunk of the radial artery (Fig. 2). One of the veins needs to be incorporated to ensure venous drainage of the flap. We disagree with Sasaki et al's conclusion that 'when this anomaly is confirmed preoperatively, the contralateral forearm or other flap site should be chosen for the donor a r e a ' J Yours faithfully,

Shailesh Vadodaria FRCS(Plast), MS, MCh, Specialist Registrar in Plastic Surgery T. M. Brotherston FRCSEd(Plast), Consultant Plastic Surgeon R. E. Page FRCS, Consultant Plastic Surgeon Department of Plastic Surgery, Northern General Hospital, Sheffield $5 7AU, UK.

and Ziehl-Neelsen stain did not reveal any acid-fast bacilli or granulomata and culture of the tissue failed to grow any mycobacterium bacilli after 6 weeks. In the absence of microbiological or histological confirmation of the diagnosis she was treated empirically with Rifafoure-200, which is a mixture of rifampicin inah, pyrazinamide and ethambutol. After 1 month there was no sign of the eruption on the hand and she was continued on rifampicin and ethambutol for another 2 weeks. There has been no further recurrence of the eruption or the pricking sensation 2 months after treatment was started. As a result of the dramatic improvement following antimycobacterium therapy, we have concluded that this was a case of Mycobacterium marinum infection even though the mycobacterium could not be isolated. It is probable that this condition occurs much more frequently than is diagnosed. Should a chronic eruption be seen on the hand it is worth taking a careful history of contact with fish. Yours faithfully,

E. J. Bowen Jones MBBS, FRCS, FRCS (Plast) MD, Consultant Plastic Surgeon St Augustine's Hospital, 391 Clark Road, Durban 4001, South Africa. K. P. Mlisana MB, ChB, MMed(Mierobiol), Consultant Microbiologist A. K. Peer BSe, MBCh, MMed(Mierobiol), Consultant Microbiologist Lancet Laboratories, Durban, South Africa.

Reference 1. Bhatty MA, Turner DPJ, Chamberlain ST. Mycobacterium marinum hand infection: case reports and review of literature. Br J Plast Surg 2000; 53: 161-5.

Reference

doi: l 0. 1054/bjps.2000.3485

1. Sasaki K, Nozaki M, Aiba H, Isono N. A rare variant of the radial artery: clinical considerations in raising a radial forearm flap. Br J Plast Surg 2000; 53: 445-7.

Ametop gel and suture removal

doi: 10.1054/bjps.2000.3504

Mycobacterium marinum hand infection Sir, The recent article in this journal describing Mycobacterium marinum hand infection I was of particular interest to us having just treated a case of hand infection thought to be caused by

Mycobacterium marinum. Our patient was a 69-year-old Caucasian housewife who presented with a papular eruption in the vicinity of a scar, which subsequently spread proximally. This was associated with a pricking sensation, erythema and swelling. It sometimes subsided for up to 10 days but invariably returned. Eight months previously she had suffered a small transverse cut on the volar surface of her left ring finger on a fish tank. This was such a small injury that she did not immediately seek medical attention. A radiograph was normal. She had been given three different courses of antibiotics during the last 8 months and the scar area had been explored by a general surgeon who looked for a splinter. Following consultation with microbiologists, the eruption was biopsied. Part of the biopsy specimen was cultured and part sent for histological examination. Klebsiella pneumoniae, Streptococcus viridans and Staphylococcus epidermidis were all cultured, sensitive to Augmentin. She was therefore given Augmentin, but with no improvement. Histological examination

Sir, A number of authors have investigated methods to reduce the pain of suture removal 1-3 but no method has found universal acceptance. Topical local-anaesthetic preparations, EMLA and Ametop have been shown to be effective in reducing the pain experienced during venepuncture and venous cannulation. 4'5 Ametop (amethocaine gel, Smith & Nephew Healthcare, Hull, UK) has been shown to have a shorter onset of action than EMLA and is therefore better suited to an outpatient procedure. A prospective, single-blind, placebo-controlled clinical trial was approved by the local ethical committee to determine whether Ametop would lessen the pain suffered by patients during suture removal. Adult patients attending the dressing clinic at the St Andrew's Centre for Plastic Surgery and Burns for removal of their sutures following emergency and elective surgery were sampled during two consecutive weeks, with the patients in the first week receiving the Ametop gel and those in the second week receiving placebo aqueous cream. Patients whose wounds were incompletely healed were excluded from the study as the data sheet for Ametop gel specifically advises against applying it to broken skin. 6 On arrival, the patients were asked to consent to inclusion in the trial and were not told which treatment they were to receive. The treatment or placebo cream was applied to the suture line, covered with an occlusive adherent membrane (Opsite, Smith & Nephew Healthcare, Hull, UK) and then left for 20-30 min. The sutures were then removed. The data collected included the demographic details