| Abstract|| |
A female patient presented with asymptomatic swellings in old blue-black tattoo marks of her forearms. On careful skin examination, few raised erythematous, circular plaques were also found on the non-tattooed skin on her back, about which she was unaware. The diagnosis of cutaneous and systemic sarcoidosis was confirmed after classical histopathological findings from skin lesions from her non tattooed back and from papulonodular tattooed lesions, ruling out other causes of granulomas and supported by a negative Mantoux test, raised serum angiotensin converting enzyme level, high resolution computed tomography thorax, etc. She responded well to oral steroid therapy. The importance of a careful skin examination, easy access provided by skin lesions in suspected cases of cutaneous/systemic sarcoidosis, the value of sudden tattoo changes in the diagnosis here and the possible contribution of tattoos toward the causation of cutaneous and/or systemic sarcoidosis are highlighted.
Keywords: Cutaneous sarcoidosis, koebner phenomenon, sarcoidosis, tattoo sarcoid
|How to cite this article:|
Ghorpade A. Sarcoidosis detected due to tattoo swellings in an Indian female. Indian J Pathol Microbiol 2015;58:362-4
| Introduction|| |
Sarcoidosis is a systemic granulomatous disease of uncertain etiology involving various organs including the lungs, lymph nodes, eye, and the skin.
About one-fourth of the cases of sarcoidosis may have skin lesions. The diagnosis of sarcoidosis is by exclusion of other granulomas. The importance of skin in the diagnosis of sarcoidosis cannot be over-emphasized.
| Case Report|| |
A 55-year-old Indian female presented with a 5-month history of asymptomatic, swellings on both the forearms, over some of the blue-black tattoo marks of a tattoo design, which was placed about 40 years ago. Cutaneous examination of arms showed swellings over blue-black tattoos on extensor aspects of forearms and multiple papular and nodular lesions over several tattoo marks on flexor aspects [Figure 1]a. In addition, careful examination revealed few mildly erythematous, slightly raised, circular plaques, varying from 3 to 10 mm diameter on the non-tattooed skin of her back [Figure 1]b. There were no other skin lesions or systemic complaints. As is a common custom in this region of India, the blue-black tattoos were placed as a ritual at the time of her marriage by a roadside tattoo artist. The same unsterile needles are used in villages here, for a group of 5-6 ladies. There was no hepatosplenomegaly and abnormal systemic finding. Histology from the erythematous plaques on the back revealed multiple upper and mid dermal non-caseating, predominantly epithelioid cell granulomas with scant lymphocytes and foreign body giant cells some with asteroid body [Figure 2]a, along with an unremarkable epidermis. Skin biopsy from the tattoo papules and nodules revealed similar histology along with clumps of tattoo pigment inside the epithelioid cell granulomas as well as inside some foreign body giant cells within these granulomas [Figure 2]b. Staining and culture for Mycobacteria and deep mycosis were negative. Mantoux test was negative, X-ray chest showed bilateral hilar lymphadenopathy, high-resolution computed tomography (HRCT) thorax revealed multiple interseptal nodular lesions and few subpleural nodules [Figure 3]. The erythrocyte sedimentation rate was 60 mm/1 st h, blood venereal disease research laboratory, ELISA test for HIV 1 and 2 and Hepatitis C serology were negative. Serum angiotensin converting enzyme (ACE) was 145 U/L (reference range 8-65 U/L), serum calcium and urinary calcium, the electrocardiogram, slit-lamp examination, pulmonary function tests and X-ray examination of the hands were normal. Kveim's test and Gallium scanning were not available. After confirming the diagnosis of systemic sarcoidosis, the patient was put on oral prednisolone 30 mg daily, tapered over 6 months, resulting in regression of all skin lesions.
|Figure 1: (a) Blue black tattoo marks with papules and nodules in a few tattoos on flexor aspects of forearms (b) Close up photo erythematous plaques on the lower back|
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|Figure 2: (a) Microphotograph from biopsy of a nodular non-tattooed lesion showing predominantly epitheloid cell granuloma, scant lymphocytes and a foreign body giant cell with an asteroid body inside it. (haematoxylin and eosin; original magnification ´400). (b) Microphotograph from biopsy of a nodular tattoo lesion showing predominantly epitheloid cell granuloma, scant lymphocytes and two foreign body giant cells. Brownish clumps of tattoo pigment are seen inside the granuloma as well as inside one foreign body giant cell (haematoxylin and eosin; original magnification ´400)|
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|Figure 3: HRCT lung showing peribroncho-vascular interstitial thickening with nodular fissural thickening, reticular and nodular opacities (with subpleural nodules) predominantly in bilateral mid zone and upper zone|
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Sarcoidosis is a granulomatous disease of unknown etiology involving mostly the lungs, lymph nodes, eye, and the skin in addition to other organs. Cutaneous sarcoidosis may be seen in about 20-35% patients of systemic sarcoidosis presenting with specific, nonspecific or atypical skin lesions. The histopathology, special staining and culture, suggestive changes in X-ray chest and HRCT, a negative Mantoux test and raised ACE level helped in clinching the diagnosis of cutaneous and systemic sarcoidosis in this patient. Sarcoidosis is uncommonly reported and there are scant reports of cutaneous sarcoidosis from India. , Tattoo sarcoidosis may be a specific lesion, resulting from granuloma formation due to the nidus of the tattoo pigment and may occur alone or with systemic sarcoidosis after systemic spread of the pigment, , presenting in some patients with uveitis or pulmonary involvement. Hanada et al. demonstrated fine fragments of tattoo pigment granules in the skin as well as in lung tissue and suggested that red tattoo pigment was responsible for systemic sarcoidosis in their case. Extra tattoo skin lesions like in the present case, are uncommon in systemic sarcoidosis with tattoo granulomas.  Sarcoidosis after repeated rubbing with a nylon towel and psoriasiform sarcoidosis with koebnerization, are two recent evidences suggestive of koebner phenomenon in sarcoidosis. , The exact mechanism for this is unclear, but local production of cytokines and chemokines followed by activation and recruitment of Th 1 cells and mononuclear phagocytes after trauma have been proposed to play some role. 
Asymptomatic tattoo swellings and skin lesions on the back aroused the suspicion of cutaneous sarcoidosis based on similar report.  Various tattoo pigments are implicated and period between tattooing and development of sarcoidal granulomas could vary from months to several decades. It is difficult to pinpoint the exact reason for Koebnerization after four decades of tattooing in this case. An immunological imbalance favoring Th-1 response after an interplay of trauma, tattoo pigment, ribavirin and interferon-a, probably secondary to stimulation by either exogenous antigens (infectious or environmental) or autoantigens, were blamed for systemic sarcoidosis in a tattooed man, who was undergoing treatment for hepatitis C. 
Skin lesions provide an easy access for histopathology in suspected cases of cutaneous/systemic sarcoidosis, before other investigative modalities are undertaken. A detailed careful cutaneous examination is a must in all such cases, since the patient may not be aware of asymptomatic lesions on the posterior aspect of the body, as happened here. Whether the tattoo pigment alone or with some as yet unidentified microorganism inoculated along with it, acts as an antigen as suggested earlier,  is a moot point.
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Dr. Ashok Ghorpade
A 4/3, Green Betel Residency, Deepak nagar, Durg - 491 001, Chhattisgarh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]