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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 83-85

Tattoo reactions as the initial presentation of lepromatous leprosy and cutaneous sarcoidosis: Report of two cases

1 Department of Dermatology and Sexually Transmitted Diseases, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
2 National Institute of Pathology (Indian Council of Medical Research), Safdarjung Hospital Campus, New Delhi, India

Date of Web Publication28-Nov-2019

Correspondence Address:
Dr. Sharma Shruti
National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdpdd.ijdpdd_33_19

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There has been a rising trend of tattooing in the recent years, resulting in an increased incidence of cutaneous adverse effects. A wide range of infectious and noninfectious dermatoses have been described to occur within tattoos. Cutaneous complications developing in tattooed skin as the initial manifestation of the disease are uncommon. We describe two interesting cases with black tattoo-related reactions as the presenting feature of lepromatous leprosy and cutaneous sarcoidosis, respectively.

Keywords: Black tattoo, lepromatous leprosy, sarcoidal tattoo granulomas

How to cite this article:
Khullar G, Khunger N, Mann KK, Shruti S. Tattoo reactions as the initial presentation of lepromatous leprosy and cutaneous sarcoidosis: Report of two cases. Indian J Dermatopathol Diagn Dermatol 2019;6:83-5

How to cite this URL:
Khullar G, Khunger N, Mann KK, Shruti S. Tattoo reactions as the initial presentation of lepromatous leprosy and cutaneous sarcoidosis: Report of two cases. Indian J Dermatopathol Diagn Dermatol [serial online] 2019 [cited 2022 May 26];6:83-5. Available from: https://www.ijdpdd.com/text.asp?2019/6/2/83/271941

  Introduction Top

Tattoos are associated with various complications such as infections, allergic, granulomatous, and lichenoid reactions, and photodermatitis.[1] Tattooing is an underrecognized mode of transmission of leprosy.[2] Besides leprosy, sarcoidal reactions can develop in tattoos and may be the only clinical manifestation of sarcoidosis.[3] Papulonodular lesions in tattoos, particularly black-colored ones, should be considered as markers of cutaneous and systemic sarcoidosis, and these patients should be screened for extracutaneous involvement.[3]

  Case Reports Top

Case 1

A 17-year-old female presented with a 6-month history of asymptomatic raised lesions that first appeared within the black tattoos on the dorsum of her left hand and forearm. In the next 1 month, she developed multiple raised lesions on normal-looking skin on the face, forearms, and back. The tattoos had been performed on the dorsum of the left hand and forearm 7 years back. Her past and family histories were noncontributary for leprosy. On examination, there were multiple skin-colored infiltrated normoesthetic papules, nodules, and plaques with punched-out center, ranging in size from 0.5 cm × 0.5 cm to 2 cm × 2 cm on the face, earlobes, dorsa of hands, forearms, and back. The lesions were localized both to the tattooed and to the nontattooed sites [Figure 1]a, [Figure 1]b, [Figure 1]c. Bilateral ulnar and radial cutaneous nerves were thickened. Glove-and-stocking anesthesia was present. Slit skin smear examination from both the earlobe, lesional, and normal-looking skin showed an average bacteriological index of 5+ with solid staining bacilli. Skin biopsy from one of the papules overlying the tattoo revealed an atrophic epidermis with a grenz zone underneath and diffuse infiltrate of foamy macrophages in the dermis, along with interspersed black pigment clumps [Figure 2]a, [Figure 2]b, [Figure 2]c. Modified Fite–Faraco stain showed solid-staining acid-fast bacilli in globi [Figure 2]d. A diagnosis of tattoo inoculation lepromatous leprosy was made, and the patient started on multidrug therapy–multibacillary regimen for 2 years. She showed significant flattening of lesions after 1 year of follow-up.
Figure 1: (a) Skin-colored infiltrated nodules on the tattooed and nontattooed skin of the dorsum of the left hand. Skin-colored infiltrated plaque with punched-out center present in the vicinity of the tattoo. (b) Papulonodules localized to the black tattoo on the left forearm. (c) Skin-colored infiltrated papules and nodules on the forehead

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Figure 2: (a) Epidermis is atrophic with the presence of grenz zone underneath. The dermis shows diffuse infiltrate of foamy histiocytes with interspersed black pigment granules (H and E, ×100). (b) Lower dermis showing foamy histiocytes with prominent black pigment clumps both in intracellular and in extracellular locations (H and E, ×200). (c) Higher magnification showing foamy histiocytes with interspersed pigment clumps within and outside histiocytes (H and E, ×400). (d) Modified Fite–Farco stain showing acid-fast bacilli in globi (H and E, ×200)

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Case 2

A 45-year-old female presented with a 8-month history of multiple asymptomatic raised lesions confined to the tattooed sites on her forearms and dorsa of feet. Two months later, she also developed skin-colored raised lesions on normal-looking skin over her chin. The tattoos were performed 25 years ago. She denied any systemic complaints. On examination, multiple indurated nodules were localized to black tattoos on the volar aspect of her forearms and dorsa of feet [Figure 3]a. Skin-colored infiltrated papules and plaques were present on nontattooed skin on the left side of the chin [Figure 3]b. Histopathological examination from one of the nodules overlying the tattoo showed multiple compact, naked granulomas throughout the dermis, along with black pigment granules interspersed between the granulomas. The granulomas were composed of epithelioid cells and multinucleated giant cells with sparse cuffing of lymphocytes [Figure 4]a and [Figure 4]b. Staining for acid-fast bacilli and fungus were negative, and no foreign body could be identified on polarizing microscopy. Chest radiograph and abdominal ultrasound did not reveal any abnormality. Ophthalmologic examination was normal. The Mantoux test was negative. Hemogram, liver and renal function tests, and serum levels of calcium and angiotensin-converting enzyme were normal. A diagnosis of cutaneous sarcoidosis presenting as sarcoidal tattoo granulomas was made. She was treated with topical clobetasol propionate 0.05% cream twice daily, with which the lesions resolved completely in 2 months. After 1 year of follow-up, there has been no relapse or extracutaneous involvement.
Figure 3: (a) Multiple indurated nodules restricted to the black tattoos on the volar aspect of the forearms. (b) Skin-colored indurated papules and plaque arising on the nontattooed skin over the left side of the chin

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Figure 4: (a) Epidermis is unremarkable. There is pandermal involvement with compact epithelioid cell granulomas (H and E, ×40). (b) Discrete naked granulomas composed of epithelioid cells, multinucleated giant cells, and sparse infiltrate of lymphocytes with black pigment clumps and granules surrounding the granulomas (H and E, ×200)

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  Discussion Top

A wide spectrum of infectious, inflammatory, and neoplastic complications are reported to occur within the tattoos. It is essential to perform a histopathological examination of tattoo reactions to enable an accurate diagnosis. Among infections, lupus vulgaris, leprosy, herpes simplex, warts, hepatitis, and human immunodeficiency virus have been documented following tattooing.[4] Leprosy subsequent to tattooing occurs due to sharing of unsterile needles, thereby inoculating Mycobacterium leprae into the skin.[2] The incubation period ranges between 10 and 20 years in majority of the patients.[2] In a study of 31 cases of tattoo leprosy, 29 had paucibacillary and 2 had multibacillary disease.[2] Tuberculoid leprosy was diagnosed in 25 cases; indeterminate in 3; and borderline tuberculoid, borderline lepromatous, and lepromatous leprosy in one patient each, respectively. Absence of any skin lesion before tattooing, occurrence of first leprosy lesion over tattoo, no family history of leprosy, presence of tattoo pigment inside the granulomas on histopathology, and response to antileprosy treatment support the diagnosis of tattoo inoculation leprosy.[2] Among inflammatory complications, hypersensitivity reaction to tattoo pigments is common. Histologically, tattoo reactions comprise of granulomatous, lichenoid, eczematous, pseudoepitheliomatous hyperplasia, and pseudolymphomatous types.[1],[4] Granulomatous reactions can be sarcoidal or nonsarcoidal.[1] Sarcoidal granulomas can occur in tattoos as an isolated local reaction, as a presenting sign of cutaneous or systemic sarcoidosis or in patients with diagnosed pulmonary sarcoidosis.[4] Multiple theories have been postulated for sarcoidal tattoo granulomas. Koebnerization and scar sarcoidosis have been proposed as the underlying pathomechanisms in patients with systemic sarcoidosis.[4] In those without systemic involvement, tattoo pigment may act as an antigenic stimulus that can induce persistent immunologically mediated granulomatous state of sarcoidosis in genetically predisposed individuals. This may result in a systematized hypersensitivity response, as similar tattoo pigments have been identified concurrently in pulmonary granulomas.[4],[5] However, Collins et al. proposed that pigment does not provoke inflammation, rather it reduces the local resistance to granuloma formation.[6] Therefore, granulomatous tattoo reaction is a specific cutaneous manifestation of sarcoidosis, instead of hypersensitivity reaction to tattoo pigment, particularly for reactions that develop many years after tattooing. The latency period for tattoo sarcoidosis ranges between 18 months and 20 years. In a study by Sepehri et al., sarcoidosis comprised 27 of 494 (5%) tattoo reactions and 27 of 92 (29%) papulonodular black tattoo reactions.[3] Of these 27 reactions, 7 were sarcoidosis manifesting in tattoos only, 3 were sarcoidosis in tattoos with other cutaneous lesions of sarcoidosis but no systemic involvement, and 17 had systemic sarcoidosis in addition to tattoo sarcoidosis.[3] Papageorgiou et al. reported a case of sarcoidosis manifesting as multiple tattoo granulomas and extra-tattoo cutaneous granuloma, which on further evaluation revealed pulmonary involvement.[7]

The present cases were unusual as lepromatous leprosy initially presenting in tattoos and sarcoidal tattoo granulomas with subsequent extra-tattoo cutaneous sarcoidosis in the absence of systemic disease are rarely described.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Valbuena MC, Franco VE, Sánchez L, Jiménez HD. Sarcoidal granulomatous reaction due to tattoos: Report of two cases. An Bras Dermatol 2017;92:138-41.  Back to cited text no. 1
Ghorpade A. Inoculation (tattoo) leprosy: A report of 31 cases. J Eur Acad Dermatol Venereol 2002;16:494-9.  Back to cited text no. 2
Sepehri M, Hutton Carlsen K, Serup J. Papulo-nodular reactions in black tattoos as markers of sarcoidosis: Study of 92 tattoo reactions from a hospital material. Dermatology 2016;232:679-86.  Back to cited text no. 3
Ali SM, Gilliam AC, Brodell RT. Sarcoidosis appearing in a tattoo. J Cutan Med Surg 2008;12:43-8.  Back to cited text no. 4
Antonovich DD, Callen JP. Development of sarcoidosis in cosmetic tattoos. Arch Dermatol 2005;141:869-72.  Back to cited text no. 5
Collins P, Evans AT, Gray W, Levison DA. Pulmonary sarcoidosis presenting as a granulomatous tattoo reaction. Br J Dermatol 1994;130:658-62.  Back to cited text no. 6
Papageorgiou PP, Hongcharu W, Chu AC. Systemic sarcoidosis presenting with multiple tattoo granulomas and an extra-tattoo cutaneous granuloma. J Eur Acad Dermatol Venereol 1999;12:51-3.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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