Stephen Mitchell
Resident
Atrium Health
Charlotte, North Carolina
Disclosure information not submitted.
John Wynne, MD
Pulmonary Critical Care Medicine - Attending Physician
Carolinas Medical Center - Atrium Health, United States
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Title: Tattoo Induced Sarcoidosis: A Late Rare Tattoo Parlor Complication
Case Report Body:
Introduction: Sarcoidosis is a systemic disease characterized by immune mediated fibrosis and formation of noncaseating granulomas. Although etiology is unknown, there have been a limited number of documented cases of tattoo induced sarcoidosis in the last 75 years.
Description: A 57-year-old woman presented with chronic dyspnea with exertion and two weeks of pruritus and scab formation over a tattoo she had received over 20 years previously. Lesion failed to improve with steroids or antibiotics. Punch biopsy revealed fibrosis and noncaseating granulomas. Pulmonology work up showed enlarged mediastinal lymph nodes on non-contrast chest CT. Labs were significant for hypercalcemia and elevated Vitamin D 1,25 OH consistent with sarcoidosis. Although the patient had mediastinal lymphadenopathy, her spirometry results were within normal limits confirming no parenchymal disease. Her symptoms improved on a slow prednisone taper as she didn’t want to pursue Plaquenil.
Discussion: Sarcoidosis pathophysiology consists of T cell dysfunction in combination with increased B cell activity resulting in immune hyperactivity and inflammation. Acute sarcoidosis consists of an abrupt onset of constitutional systems as well as nonproductive cough, arthralgias, erythema nodosum, and anterior uveitis that is self-limiting. While chronic sarcoidosis has an insidious onset that is often asymptomatic that primarily targets the lungs. Tattoo sarcoidosis have been reported as early as 1952, although only a few cases have been described. The pathophysiology is not clear. The leading hypothesis focuses on “pigment induced disease”. It is hypothesized that tattoo pigments provide chronic antigenic stimulation resulting in an imbalance of Th1/Th2 in a genetically predisposed patient ultimately triggering sarcoidosis. It would be expected for pigment induced tattoos to only cause cutaneous sarcoidosis but in 2005, the tattoo sarcoidosis cases were reviewed via meta-analysis and it was concluded that the majority of cases (14/19) had pulmonary involvement with the tattoo reaction. Given these findings, it is possible inflamed tattoos are manifestations of sarcoidosis and not causes. Granulomatous reactions following tattoos are rare but should be considered in the differential. Once confirmed, systemic sarcoidosis should be investigated.