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LETTER TO EDITOR  
Year : 2017  |  Volume : 60  |  Issue : 1  |  Page : 141-142
The tattoo dilemma: Reading in between the ink


Department of Pathology, TN Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

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Date of Web Publication14-Feb-2017
 

How to cite this article:
Jashnani K, Desai H, Shetty J, Shinde S, Shah V. The tattoo dilemma: Reading in between the ink. Indian J Pathol Microbiol 2017;60:141-2

How to cite this URL:
Jashnani K, Desai H, Shetty J, Shinde S, Shah V. The tattoo dilemma: Reading in between the ink. Indian J Pathol Microbiol [serial online] 2017 [cited 2017 Oct 17];60:141-2. Available from: http://www.ijpmonline.org/text.asp?2017/60/1/141/200050


Editor,

A 64-year-old woman came with pain in abdomen and 1 cm × 1 cm swelling in the right supraclavicular region [Figure 1]a. The swelling was blackish, firm, fixed, and non-tender with an old sinus tract just lateral to the right side of midline. The aspirated material on fine-needle aspiration cytology (FNAC) was blackish in color and microscopy showed abundant granular necrotic material with fine granular brownish-black pigment [Figure 1]b. Also seen were isolated cells with large ovoid nuclei with prominent nucleoli, their cytoplasm, and cell borders were indistinct with intracytoplasmic brownish-black pigment [Figure 1]c. The cytological diagnosis was given as malignant melanoma (? primary? metastatic).
Figure 1: (a) Clinical photograph of the neck showing the site of FNAC in the supraclavicular region (circled). Also seen is the necklace like tattoo on the neck (blue arrow). (b) Background granular necrotic material (PAP, X100); (c) Isolated spindled cells (PAP, X400). Inset: Isolated cells with intracytoplasmic coarse granular pigment (PAP, X1000). (d) Repeat aspirate showing an epithelioid cell granuloma. Inset: Multinucleate giant cell (MGG, X400)

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A repeat FNAC (on request from clinicians) showed multiple epithelioid cell granulomas, few multinucleate giant cells amidst a necrotic background [Figure 1]d. Also seen were similar isolated large ovoid cells showing coarse granular pigment. This time smear was sent for acid-fast bacilli which was positive and the cytological diagnosis was changed to tuberculous (TB) inflammation. However, in view of the pigment-laden large cells, tissue diagnosis was advised.

The biopsy done from the supraclavicular lesion showed multiple soft tissue bits with no lymphoid tissue and fascicles of oval to fusiform spindled cells with focal areas of necrosis. Background showed few lymphocytes and occasional multinucleate giant cells. Intracytoplasmic and extracellular granular brown pigment was seen which was negative for Prussian blue and Masson Fontana stain and was also bleach negative which ruled out hemosiderin and melanin pigments [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. Immunohistochemistry stains were also negative for Melan-A and S-100 ruling out the diagnosis of melanoma. Thus the final histopathological diagnosis was “favour TB inflammation”.
Figure 2: (a and b) Spindled cells with intracytoplasmic and extracellular brownish black pigment (H and E, X400). (c) The pigment could not be bleached (potassium permanganate and oxalate, X400). (d) Negative Prussian blue stain (PB, X400)

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On persistent questioning, the patient gave a history of 3 months of exposure to a patient (her sister) of pulmonary tuberculosis. Furthermore, on careful external examination, her neck revealed a necklace-like tattoo done in childhood which was close to the site of FNAC [Figure 1]a. Thus, the cause of her enlarged lymph node was diagnosed as that due to TB and the pigment being tattoo pigment. The patient was eventually started on anti-TB treatment. She responded very well to treatment and after 14 months of follow-up, she is absolutely fine.

The recent growth in tattoo culture has led to an influx of complications and diagnostic errors. Tattoo pigment within lymph nodes is commonly described in literature with excised surgical specimens.[1],[2] Surprisingly underreported in the literature are similar findings within fine-needle aspirates. The average size of a tattoo ink particle is commonly 40 nm which is eventually phagocytosed by the fibroblasts, macrophages, and mast cells.[3] The ink aggregates are found within the basal cells, dermal fibroblasts and the dermal connective tissue. Over a period of time, the ink moves into the deeper dermis and regional lymph nodes and eventually fades. In our case, a lot of pigment was found in the dermofibroblasts. Sometimes, the pigment can be very dense making it difficult to observe the background cellular details. In such cases, observation of the cell containing the pigment might be helpful since tattoo pigment is found within histiocytes whereas melanoma pigment will be seen in abnormal melanocytes with increased mitotic activity.[4]

Several studies have mentioned that the known complications of tattooing are just the tip of the iceberg. Gross nature of the cytologic material in cases of pigmented melanoma is usually blackish and often fluid like. Naked eye examination of such fluid material can serve as a “clue” to the metastatic involvement of lymph node by melanoma. However, clinicians as well as pathologists should be aware of the fact that a blackish aspirate may often be related to pigmented fungal infections, to hemorrhage or as in the present case to tattoo lesion. We believe this is the first case report of TB inflammation admixed with tattoo pigment masquerading as melanoma metastasis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Anderson LL, Cardone JS, McCollough ML, Grabski WJ. Tattoo pigment mimicking metastatic malignant melanoma. Dermatol Surg 1996;22:92-4.  Back to cited text no. 1
    
2.
Hurwitz JJ, Brownstein S, Mishkin SK. Histopathological findings in blepharopigmentation (eyelid tattoo). Can J Ophthalmol 1988;23:267-9.  Back to cited text no. 2
    
3.
Jack CM, Adwani A, Krishnan H. Tattoo pigment in an axillary lymph node simulating metastatic malignant melanoma. Int Semin Surg Oncol 2008;2:28.  Back to cited text no. 3
    
4.
Peterson SL, Lee LA, Ozer K, Fitzpatrick JE. Tattoo pigment interpreted as lymph node metastasis in a case of subungual melanoma. Hand (N Y) 2008;3:282-5.  Back to cited text no. 4
    

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Correspondence Address:
Heena Desai
Department of Pathology, TN Medical College and BYL Nair Charitable Hospital, Dr. A. L. Nair Road, Mumbai Central, Mumbai - 400 008, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.200050

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