Images in Clinical Medicine
N Engl J Med 2014; 370 June 5, 2014
A 29-year-old man presented with an acute onset of right pleuritic chest pain and a 3-month history of dyspnea, cough, and skin lesions. Physical examination revealed crackles in both lungs and multiple nonerythematous papules along the ink lines of a tattoo (Panel A). A chest radiograph (Panel B) showed a right perihilar infiltrate with bilateral hilar lymphadenopathy (arrows) and reticulonodular opacities (arrowheads). Bronchoscopy revealed diffuse nodules in the tracheobronchial mucosa (Panel C, arrow). The results of tissue stains and cultures for acid-fast bacilli and fungal organisms were negative. Examination of specimens from a skin biopsy showed noncaseating granulomas (Panel D, arrow) and black tattoo pigment (Panels D and E, arrowheads) (hematoxylin and eosin). The patient's respiratory symptoms improved with the administration of systemic glucocorticoids, but he was lost to follow-up after discharge.
Cutaneous manifestations may occur in up to one third of patients with sarcoidosis, and the tendency of sarcoid granulomas to infiltrate old scars and tattoos is well documented. Skin lesions or sarcoidosis involving tattoos may occur even decades after tattooing, possibly as a result of chronic antigenic stimulation from the ink in a person who is genetically predisposed to such lesions. The differential diagnosis of skin lesions involving tattoos includes infections, discoid lupus erythematosus, keloid formation, and local reaction.