Rare presentation of Sarcoidosis-Sarcoidal Reaction in a Tattoo

Dr Darosa Lim  and colleagues, at Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada have reported a rare case of Sarcoidal Reaction in a Tattoo.The case has appeared in the New England Journal of Medicine.

Sarcoidosis is a granulomatous disease of unknown etiology. It may affect any organ in the body although the lungs are most commonly involved.A sarcoidal reaction in a tattoo may be an isolated finding or it may represent a cutaneous sign of systemic disease. Reactions in cosmetic tattoos relating to sarcoidosis have been reported as early as 1952.1,2 The cause of sarcoidal reactions in tattoos remains unknown. This finding may be a specific cutaneous manifestation of sarcoidosis in which the pigment in tattoos acts as a nidus for granuloma formation; such reactions may be the only manifestation of cutaneous sarcoidosis.

A 42-year-old man presented to the dermatology clinic with a 5-month history of numerous papules along with the pattern of  his tattoos, which he had received 10 years earlier (Panel A). There was no associated pain or pruritus. He reported that he had not had any dyspnea, fever, arthralgias, visual symptoms, or other systemic symptoms, and the remainder of his physical examination was normal.

A biopsy of the papules showed noncaseating granulomas with black and brown pigment within the superficial and deep dermis (Panel B, arrow), which supported the diagnosis of a cutaneous sarcoidal reaction. Tissue cultures for bacteria, mycobacteria, and fungi were negative. Thoracic computed tomography revealed bilateral hilar and mediastinal lymphadenopathy with no parenchymal abnormalities. Further investigation for systemic sarcoidosis, including ophthalmic, pulmonary function, and cardiac testing, was negative.

Granulomatous reactions to tattoo ink or scars may occur years after the provoking event. The patient's skin lesions resolved after several months of treatment with a potent topical glucocorticoid.

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DOI: 10.1056/NEJMicm1909931