Clinical and Experimentat Dermatology 1992; 17: 446-448.
Case Reports
Sarcoidosis presenting with a granulomatous reaction confined to red tattoos J.M.SOWDEN, P.H.CARTWRIGHT, A.G.SMITH, C.HlLEYf AND T).n.SI.KTY.^* \Departments of Dermatology and Pathology, North Staffordshire Hospital Centre, Stoke-on-Trent and *Department of Pathology, Rotherham District General Hospital, Rotherham, UK Accepted for publication 30 January 1992
Summary A patient with sarcoidosis who presented with a granulomatous tattoo reaction is described. Aithough tattoo granulomata usuaiiy represent a iocai hypersensitivity reaction to tattoo pigments, they can be a manifestation of systemic sarcoidosis. In this case the iesions were conflned to the red areas of tattoos suggesting that tattoo sarcoid may be more than just an exampie of the Koebner response. Case report A 32-year-old machine operator presented with a 3month history of itchy red noduies confined to the red areas of his tattoos. There had been no previous problems with the tattoos which had been performed 15 years earlier. He remained otherwise well and both past medical and famiiy histories were unremarkabie. On examination, there were muitipie smaii tumid reddish-brown nodules confined to the red areas of several tattoos {Fig. 1). The black, orange, yellow, green and biue areas were unaffected. At this stage, physieai examination was unremarkabie. Within 2 weeks of the initiai consuitation he deveioped joint stiflhess and sweiiing with a tender red rash on both iower legs. Further examination reveaied sweiiing and tenderness of the smafl joints of the hands with biiaterai knee effusions. Erythema nodosum was present on both shins. Other than the persistent tattoo nodules there were no other cutaneous signs of sarcoidosis. Biopsy from a tattoo nodule revealed densely packed epitheiioid-ceil granulomata with numerous giant cells and a thin rim of lymphocytes (Fig. 2). Tattoo pigment was seen throughout the dermis, both in macrophages and the extra-cellular space. This pigment demonstrated a positive Perl's Prussian Biue reaction. Anaiysis of the same biopsy by ED AX (Energy Dispersive Anaiysis of XCorrespondence: Dr J.M.Sowden, Dermatology Department, University Hospital, Nottingham NG7 2UH, UK,
446
Figure 1. Photograph of a tattoo sbowing nodules confined to the red bodv and ears of the rabbit with sparing of the black, orange and green
rays) identifled iron as the oniy inorganic eiement present in the red tattoos. Biopsy from the rash on the iower ieg confirmed the diagnosis of erythema nodosum. A Kveim biopsy was positive. Chest x-ray showed biiaterai hiiar iymphadeno-
SARCOIDOSIS AND RED TATTOOS
447
describe the tendency of secondary syphilis to be more pronounced in tattoos. The Koebner response would certainly explain the cases of sarcoidosis associated with granulomata in different tattoo colours. The occurrence of sarcoid iesions confined to singie tattoo eoiours, aithough rare, is an interesting phenomenon which might heip in understanding the pathogenesis of sareoidosis. In one report, three patients were described who deveioped granuiomatous infiammation confined to the biue areas of tattoos in association with biiaterai uveitis.'' One patient deveioped erythema nodosum. None of the patients had puimonary invoivement and Kveim tests were not performed. In two cases, the uveitis improved after excision of the biue tattoos. On the Figure 2. Biopsy trom a tattoo nodule demonstrating densely packed assumption that the biue tattoos contained cobait, patch non-causeating epithelioid cell granulomata associated with a thin rim tests were performed—these were positive to cobait in of lymphocytes. Tattoo pigment can be seen throughout the dermis. two out of the three patients. Another report described a patient with granuiomata confined to the red areas of pathy. Fuii puimonary function tests were normai. The tattoos with an assoeiated granuiomatous uveitis, iymerythrocyte sedimentation rate was 98 mm in the first phadenopathy and puimonary invoivement.'' Again, a hour. Fuii biood count, biochemical screen and blood Kveim test was not performed. EDAX studies reveaied calcium ieveis were normai. The urinary 24 h caicium aiuminium, siiicon and mercury in both the skin and iung excretion was raised at i 1 41 mmol/24 h (normai 2-5-7 5). biopsies. Aithough patch tests to the red tattoo pigment The diagnosis of sarcoidosis with joint, skin and stage and mercury were negative, the authors conciuded that I puimonary invoivement was made. The arthritis the tattoo pigments were responsibie for a systemic improved with a 6-week course of steroids (starting dose granuiomatous condition resembiing sareoidosis. Howprednisolone 40 mg daiiy). The tattoo noduies and hiiar ever, they did not expiain how the tattoo pigments giands resoived within i year. reached the extra-cutaneous sites, and Kveim tests would have been necessary to exclude sarcoidosis. The patient we have described had acute sarcoidosis Discussion with a positive Kveim test. If the tattoo iesions were Aiiergic reactions to tattoos can take a variety of simpiy an example of the Koebner response this would histoiogicai forms. In some, the histology is simiiar to not explain why the red areas were seiectiveiy invoived. It sarcoidosis, with denseiy packed non-causeating granuio- has been suggested that, in sareoidosis, a state of mata consisting mainiy of epitheiioid and giant ceiis. The granuiomatous hypersensitivity exists, with reactions to first report of a sarcoidai tattoo reaction was in 1939'—the different antigens in a variety of organs.** This would patient showed no evidence of systemic sarcoidosis and expiain the granulomatous reaction to red, iron containpatch tests to mereury were positive. Similar reactions to ing tattoos in this patient. In order to prove this theory, green^ and red' tattoos have been reported. It is thought intra-dermai tests wouid be necessary to confirm a that these cases represent a localized form of granuloma- granuiomatous reaction to iron. However, as the patient tous hypersensitivity to tattoo pigments. responded so rapidiy to treatment, we felt further Although granuiomatous reactions confined to singie investigations were inappropriate. tattoo coiours usuaiiy represent a iocai hypersensitivity It was interesting that the oniy element detected by reaction to tattoo pigments, they may be a manifestation EDAX in this patients' red tattoos was iron. Whiist in the of systemic sarcoidosis. Of the iO reported cases of past the commonly used red tattoo pigments such as sarcoidosis with tattoo invoivement, three had granuio- Chinese red (aiso known as cinnabar or vermilion) mata confined to singie tattoo coiours (red in two contained mercury sulphide, the frequency of aiiergic i ^ ^ green in the third^) In the other seven reactions to this compound ied to the use of other red dyes "'^ the granulomata occurred throughout the inciuding sienna/red ochre (ferric hydrate), cadmium red tattoos and were not limited to any specific coiour. (cadmium seienide) and the organic substances sandalSarcoidosis is one of the disorders that demonstrates wood and braziiwood."^ the Koebner response. In a scries of 700 patients with This case demonstrates that granulomatous reactions pulmonary sarcoid, 10% had evidence of sear tissue confined to singie tattoo coiours do not aiways represent a involvement.'-' The term locus minoris resistentiae (area ofIocai hypersensitivity reaction and that they may be a decreased resistance) was first used by Lipschutz'"* to manifestation of systemic sarcoidosis.
448
J.M.SOWDEN 9. Weidman AI, Andrade R, Franks AG, Sarcoidosis: Report of a case of sarcoid lesions in a tattoo and subsequent discovery of Madden JF. Reactions in tattoos. Archives of Dermatology 1939, pulmonary sarcoid. Archives of Dermatology 1966; 4: 320-325, 40: 256-262. 10. Iveson JMI, Cotterill JA, Wright V. Sarcoidosis presenting v\itb Lowcnthal LJA. Reactions in green tattoos. Archives of Dermatomultiple tattoo granulomata. Postgraduate Medical Journat. 1975; logy i960; 82: 237 243, 51:670-672. Goldstein N, Mercury-cadmium sensitivity in tattoos: a photoal- 11. Kennedy C. Sarcoidosis presenting in tattoos. Clinical and lcrgic reaction in red pigment. Annats of Internat Medicine 1967; Experimental Dermatotogy, 1976; 1: 395-399, 67: 984-989, 12. Blobstein SH, Weiss HD, Myskowski PL, Sarcoidal granulomas Dickinson JA. Sarcoidal reactions in tattoos. Archives ofDermatoIn tattoos. Cutis. 1985; 36(5): 423 424. togy 1967; 100:315-319. 13. Olsson SE, Proceedings of the Twelfth International Congress of Hanada K, Chiyoya S, Katabira Y, Systemic sarcoidal reaction in Dermatology, The Hague, 1962. tattoo. Clinical and Experimental Dermatolog)' 1985; 10: 479-484, 14. Lipschutz B. Case reports. German Archives ofDermatotogy iyo6; Farzan S, Sarcoidal reaction in tattoos. Neip York State Journal of 78:38.. Medicine \911; 11: 1477-1479. 15. Rorsman H, Dahlquist I, Jaobsson S et at. Tattoo granuloma and Lubeck G, F,pstein E. Complications of tattooing. California uveitis. The Eancel 1969; ii: 27-28. Medicine 1952; 76: 83-85, 16. Ravits HG. Allergic tattoo granuloma. Archives of Dermatology . Obermayer ME, Hasscn M, Sarcoidosis witb sarcoidal reaction in 1966; 86: 287-289. tattoo. Archives of Dermatology i()SS\ 1^'- l^^-l^l-
References 1. 2. 3. 4. 5. 6. 7. 8.
Case Reports
Sarcoidosis presenting with a granulomatous reaction confined to red tattoos J.M.SOWDEN, P.H.CARTWRIGHT, A.G.SMITH, C.HlLEYf AND T).n.SI.KTY.^* \Departments of Dermatology and Pathology, North Staffordshire Hospital Centre, Stoke-on-Trent and *Department of Pathology, Rotherham District General Hospital, Rotherham, UK Accepted for publication 30 January 1992
Summary A patient with sarcoidosis who presented with a granulomatous tattoo reaction is described. Aithough tattoo granulomata usuaiiy represent a iocai hypersensitivity reaction to tattoo pigments, they can be a manifestation of systemic sarcoidosis. In this case the iesions were conflned to the red areas of tattoos suggesting that tattoo sarcoid may be more than just an exampie of the Koebner response. Case report A 32-year-old machine operator presented with a 3month history of itchy red noduies confined to the red areas of his tattoos. There had been no previous problems with the tattoos which had been performed 15 years earlier. He remained otherwise well and both past medical and famiiy histories were unremarkabie. On examination, there were muitipie smaii tumid reddish-brown nodules confined to the red areas of several tattoos {Fig. 1). The black, orange, yellow, green and biue areas were unaffected. At this stage, physieai examination was unremarkabie. Within 2 weeks of the initiai consuitation he deveioped joint stiflhess and sweiiing with a tender red rash on both iower legs. Further examination reveaied sweiiing and tenderness of the smafl joints of the hands with biiaterai knee effusions. Erythema nodosum was present on both shins. Other than the persistent tattoo nodules there were no other cutaneous signs of sarcoidosis. Biopsy from a tattoo nodule revealed densely packed epitheiioid-ceil granulomata with numerous giant cells and a thin rim of lymphocytes (Fig. 2). Tattoo pigment was seen throughout the dermis, both in macrophages and the extra-cellular space. This pigment demonstrated a positive Perl's Prussian Biue reaction. Anaiysis of the same biopsy by ED AX (Energy Dispersive Anaiysis of XCorrespondence: Dr J.M.Sowden, Dermatology Department, University Hospital, Nottingham NG7 2UH, UK,
446
Figure 1. Photograph of a tattoo sbowing nodules confined to the red bodv and ears of the rabbit with sparing of the black, orange and green
rays) identifled iron as the oniy inorganic eiement present in the red tattoos. Biopsy from the rash on the iower ieg confirmed the diagnosis of erythema nodosum. A Kveim biopsy was positive. Chest x-ray showed biiaterai hiiar iymphadeno-
SARCOIDOSIS AND RED TATTOOS
447
describe the tendency of secondary syphilis to be more pronounced in tattoos. The Koebner response would certainly explain the cases of sarcoidosis associated with granulomata in different tattoo colours. The occurrence of sarcoid iesions confined to singie tattoo eoiours, aithough rare, is an interesting phenomenon which might heip in understanding the pathogenesis of sareoidosis. In one report, three patients were described who deveioped granuiomatous infiammation confined to the biue areas of tattoos in association with biiaterai uveitis.'' One patient deveioped erythema nodosum. None of the patients had puimonary invoivement and Kveim tests were not performed. In two cases, the uveitis improved after excision of the biue tattoos. On the Figure 2. Biopsy trom a tattoo nodule demonstrating densely packed assumption that the biue tattoos contained cobait, patch non-causeating epithelioid cell granulomata associated with a thin rim tests were performed—these were positive to cobait in of lymphocytes. Tattoo pigment can be seen throughout the dermis. two out of the three patients. Another report described a patient with granuiomata confined to the red areas of pathy. Fuii puimonary function tests were normai. The tattoos with an assoeiated granuiomatous uveitis, iymerythrocyte sedimentation rate was 98 mm in the first phadenopathy and puimonary invoivement.'' Again, a hour. Fuii biood count, biochemical screen and blood Kveim test was not performed. EDAX studies reveaied calcium ieveis were normai. The urinary 24 h caicium aiuminium, siiicon and mercury in both the skin and iung excretion was raised at i 1 41 mmol/24 h (normai 2-5-7 5). biopsies. Aithough patch tests to the red tattoo pigment The diagnosis of sarcoidosis with joint, skin and stage and mercury were negative, the authors conciuded that I puimonary invoivement was made. The arthritis the tattoo pigments were responsibie for a systemic improved with a 6-week course of steroids (starting dose granuiomatous condition resembiing sareoidosis. Howprednisolone 40 mg daiiy). The tattoo noduies and hiiar ever, they did not expiain how the tattoo pigments giands resoived within i year. reached the extra-cutaneous sites, and Kveim tests would have been necessary to exclude sarcoidosis. The patient we have described had acute sarcoidosis Discussion with a positive Kveim test. If the tattoo iesions were Aiiergic reactions to tattoos can take a variety of simpiy an example of the Koebner response this would histoiogicai forms. In some, the histology is simiiar to not explain why the red areas were seiectiveiy invoived. It sarcoidosis, with denseiy packed non-causeating granuio- has been suggested that, in sareoidosis, a state of mata consisting mainiy of epitheiioid and giant ceiis. The granuiomatous hypersensitivity exists, with reactions to first report of a sarcoidai tattoo reaction was in 1939'—the different antigens in a variety of organs.** This would patient showed no evidence of systemic sarcoidosis and expiain the granulomatous reaction to red, iron containpatch tests to mereury were positive. Similar reactions to ing tattoos in this patient. In order to prove this theory, green^ and red' tattoos have been reported. It is thought intra-dermai tests wouid be necessary to confirm a that these cases represent a localized form of granuloma- granuiomatous reaction to iron. However, as the patient tous hypersensitivity to tattoo pigments. responded so rapidiy to treatment, we felt further Although granuiomatous reactions confined to singie investigations were inappropriate. tattoo coiours usuaiiy represent a iocai hypersensitivity It was interesting that the oniy element detected by reaction to tattoo pigments, they may be a manifestation EDAX in this patients' red tattoos was iron. Whiist in the of systemic sarcoidosis. Of the iO reported cases of past the commonly used red tattoo pigments such as sarcoidosis with tattoo invoivement, three had granuio- Chinese red (aiso known as cinnabar or vermilion) mata confined to singie tattoo coiours (red in two contained mercury sulphide, the frequency of aiiergic i ^ ^ green in the third^) In the other seven reactions to this compound ied to the use of other red dyes "'^ the granulomata occurred throughout the inciuding sienna/red ochre (ferric hydrate), cadmium red tattoos and were not limited to any specific coiour. (cadmium seienide) and the organic substances sandalSarcoidosis is one of the disorders that demonstrates wood and braziiwood."^ the Koebner response. In a scries of 700 patients with This case demonstrates that granulomatous reactions pulmonary sarcoid, 10% had evidence of sear tissue confined to singie tattoo coiours do not aiways represent a involvement.'-' The term locus minoris resistentiae (area ofIocai hypersensitivity reaction and that they may be a decreased resistance) was first used by Lipschutz'"* to manifestation of systemic sarcoidosis.
448
J.M.SOWDEN 9. Weidman AI, Andrade R, Franks AG, Sarcoidosis: Report of a case of sarcoid lesions in a tattoo and subsequent discovery of Madden JF. Reactions in tattoos. Archives of Dermatology 1939, pulmonary sarcoid. Archives of Dermatology 1966; 4: 320-325, 40: 256-262. 10. Iveson JMI, Cotterill JA, Wright V. Sarcoidosis presenting v\itb Lowcnthal LJA. Reactions in green tattoos. Archives of Dermatomultiple tattoo granulomata. Postgraduate Medical Journat. 1975; logy i960; 82: 237 243, 51:670-672. Goldstein N, Mercury-cadmium sensitivity in tattoos: a photoal- 11. Kennedy C. Sarcoidosis presenting in tattoos. Clinical and lcrgic reaction in red pigment. Annats of Internat Medicine 1967; Experimental Dermatotogy, 1976; 1: 395-399, 67: 984-989, 12. Blobstein SH, Weiss HD, Myskowski PL, Sarcoidal granulomas Dickinson JA. Sarcoidal reactions in tattoos. Archives ofDermatoIn tattoos. Cutis. 1985; 36(5): 423 424. togy 1967; 100:315-319. 13. Olsson SE, Proceedings of the Twelfth International Congress of Hanada K, Chiyoya S, Katabira Y, Systemic sarcoidal reaction in Dermatology, The Hague, 1962. tattoo. Clinical and Experimental Dermatolog)' 1985; 10: 479-484, 14. Lipschutz B. Case reports. German Archives ofDermatotogy iyo6; Farzan S, Sarcoidal reaction in tattoos. Neip York State Journal of 78:38.. Medicine \911; 11: 1477-1479. 15. Rorsman H, Dahlquist I, Jaobsson S et at. Tattoo granuloma and Lubeck G, F,pstein E. Complications of tattooing. California uveitis. The Eancel 1969; ii: 27-28. Medicine 1952; 76: 83-85, 16. Ravits HG. Allergic tattoo granuloma. Archives of Dermatology . Obermayer ME, Hasscn M, Sarcoidosis witb sarcoidal reaction in 1966; 86: 287-289. tattoo. Archives of Dermatology i()SS\ 1^'- l^^-l^l-
References 1. 2. 3. 4. 5. 6. 7. 8.
