5-aminolevulinic acid-photodynamic therapy ameliorates cutaneous granuloma by killing drug-resistant Mycobacterium marinum

•ALA-PDT significantly inhibited drug-resistant mycobacterial growth in antimycobacterial susceptibility test.•The level of intracellular ROS in M. marinum treated with ALA-PDT was significantly higher than that of M. marinum alone.•The clinical isolates were identified as M. marinum by CFW and acid-fast staining under fluorescence and light microscopy respectively.•The patients with lesions caused by drug-resistant M. marinum fully recovered by ALA-PDT treatment. Although 5-aminolevulinic acid photodynamic therapy (ALA-PDT) has been extensively used to treat various skin diseases, application for the treatment of cutaneous infection caused by Mycobacterium marinum (M. marinum), especially drug-resistant M. marinum, is unclear. We evaluated the efficacy of ALA-PDT on M. marinum in a mouse infection model and tested its killing effect on M. marinum in vitro. We also investigated the clinical effect of ALA-PDT on cutaneous granuloma caused by drug-resistant M. marinum. A total of 9 M. marinum strains isolated from patients were tested for anti-mycobacterial susceptibility. The effects of ALA-PDT on M. marinum in vitro and in mice model were investigated. Therapeutic efficacy was further assessed in two patients with cutaneous granuloma caused by drug- resistant M. marinum. We demonstrated that ALA-PDT directly killed M. marinum in vitro. The cutaneous lesions on mouse paws caused by M. marinum were fully recovered 4 weeks after the ALA-PDT treatment. ALA-PDT was also effective in two patients with cutaneous infection caused by drug-resistant M. marinum. The level of intracellular ROS in M. marinum treated with ALA-PDT was significantly higher than that of M. marinum alone. The results suggest that ALA-PDT is effective in treating M. marinum cutaneous infections by releasing more reactive oxygen species to kill M. marinum directly, and these effects are independent of systemic immune responses. The data highlights that ALA-PDT is a promising therapeutic choice for treatment of M. marinum cutaneous infections, especially drug-resistant M. marinum infections.