Disorders of the Pleura |

Indurated Tattoo - A Sign of Sarcoidosis? FREE TO VIEW

Lioudmila Karnatovskaia, MD; Vichaya Arunthari, MD; Joseph Kaplan, MD
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Mayo Clinic, Jacksonville, FL

Chest. 2013;144(4_MeetingAbstracts):483A. doi:10.1378/chest.1679815
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SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: The development of granulomatous lesions within tattoos is a recognized phenomenon in patients with sarcoidosis; however, development of additional skin lesions or progression to pulmonary sarcoidosis is rare.

CASE PRESENTATION: A 46-year-old Caucasian female noticed induration of a right hip tattoo (Figure 1A) in 1995. The induration spontaneously resolved. She was in her usual state of health until 2004, when she noticed raised red nodules over her knees and right elbow (Figure 1B). Biopsy revealed histology showing noncaseating granulomas. A computed tomography (CT) scan of the chest showed extensive mediastinal lymphadenopathy and upper zone nodularity. Pulmonary function tests (PFTs) revealed a mild obstructive ventilatory defect with a moderately reduced total lung capacity. An eye examination was negative for ocular sarcoidosis. A serum angoiotensin converting enzyme level was 65 (normal 7-46). A repeat chest CT several months later (Figure 2) revealed interval progression of the apical consolidation and the patient began a 6 month trial of prednisone. On repeat follow-up 7 years later, the CT chest demonstrated stability and PFTs showed normal spirometry. Skin lesions were again noted and remained indurated despite oral and topical therapy.

DISCUSSION: Sarcoid-like reactions within tattoos have been reported since 1952. Tattoo granulomas are frequently a presenting symptom of cutaneous sarcoidosis. The age of the tattoo before appearance of sarcoidosis varies and can span decades. It is unknown whether tattoo removal has any effect on disease progression. Two cases of patients with known pulmonary sarcoidosis developing granulomas in a tattoo have also been described. The cause of sarcoidal granulomatous reactions in tattoos remains unknown. The appearance of skin lesions elsewhere suggests that that the physiologic response behind this phenomenon might be more complex than the proposed Koebner phenomenon. It has been suggested that pigment itself may spread through the circulation to distant sites and serve as source of the reaction leading to granuloma formation.

CONCLUSIONS: While it is unclear whether our patient already had asymptomatic sarcoidosis at the time of her tattoo or developed it subsequently, it may be important to caution patients with sarcoidosis considering tattoos since cutaneous reactions do appear and can remain refractory to traditional treatment.

Reference #1: Lubeck G, Epstein E. Complications of tattooing. Calif Med 1952;2:83-5

Reference #2: Ali SM, et al. Sarcoidosis appearing in a tattoo. J Cutan Med Surg 2008;12:43

Reference #3: Anolik R et al. Sarcoidal tattoo granuloma. Dermatol Online J. 2010;16(11):19

DISCLOSURE: The following authors have nothing to disclose: Lioudmila Karnatovskaia, Vichaya Arunthari, Joseph Kaplan

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