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Sarcoidal tattoo granuloma

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Sarcoidal tattoo granuloma
Robert Anolik MD, Rajni Mandal MD, Andrew G Franks Jr MD
Dermatology Online Journal 16 (11): 19

Department of Dermatology, New York University, New York, New York


A 41-year-old man presented for evaluation of a widespread eruption. The eruption started six months beforehand as bumps within pre-existing black tattoos over his trunk and arms. One month later, the patient developed eye pain and the diagnosis of a uveitis was made. A different eruption soon followed, which the patient described as patches of rough skin. Finally, the patient developed discrete patches of hair thinning. The clinical examination, history, skin biopsy findings, and elevated angiotensin-1 converting enzyme and immunoglobulin levels supported the diagnosis of systemic sarcoidosis, which manifested as a sarcoidal tattoo granuloma, perifollicular cutaneous sarcoidosis, and uveitis.


Figure 1Figure 2

Figure 3

A 41-year-old man presented to the Dermatology Clinic at Bellevue Hospital Center for evaluation of a widespread eruption. The eruption started six months beforehand as mutable bumps within pre-existing black tattoos over his trunk and arms. One month later, the patient developed eye pain, which prompted a visit to an ophthalmologist, and a diagnosis of uveitis was made. A different eruption soon followed, which the patient described as patches of rough skin. Neither the changes in the tattoo nor areas of rough skin were symptomatic. Finally, the patient developed discrete patches of hair thinning that he attempted to conceal by shaving his head and wearing a hat. A biopsy specimen was obtained from a patch of rough skin.

The patient’s medical history and family history were otherwise unremarkable.

Physical examination

Tattoo-colored (dark black) papules were located sporadically within the numerous tattoos over the chest, abdomen, back, and upper extremities. Sandpaper-textured, thin, discrete plaques of coalescing, follicular, skin-colored papules were noted over the chest, abdomen, flanks, back, and buttocks. The scalp showed distinct patches of diminished terminal hair concentration. Lacrimal mucosal surfaces of the eyes demonstrated clusters of fine, mucosa-colored papules.

Laboratory data

Immunoglobulin (Ig) levels were elevated, with IgA 508 mg/dL, IgG 1980 mg/dL, and IgE 1629 IU/mL. IgM level was normal. Angiotensin-1 converting enzyme level was elevated at 141 U/L. C-reactive protein and erythrocyte sedimentation rate were normal. A rapid plasma reagin test was non-reactive. Hepatitis B antigen and C antibody and a human immunodeficiency virus test were negative. A chest radiograph and computed tomography scan of the thorax were normal.


There are well-formed granulomas that are composed of epithelioid histiocytes and a sparse, perifollicular, lymphocytic infiltrate. Gomori-Grocott methenamine silver, acid fast, and periodic acid-Schiff stains do not show microorganisms.


Sarcoidosis is a granulomatous disease of unknown etiology. It may affect any organ in the body although the lungs are most commonly involved [1]. On average, 25 percent of patients have cutaneous manifestations and 30 percent to 50 percent have ocular findings [2]. Uveitis is the most common ophthalmologic expression of sarcoidosis and lacrimal gland enlargement often is associated [2].

The patient in this report demonstrated several components of systemic sarcoidosis within a short time. At the time of presentation, clinical examination showed sarcoidal granulomas within tattoos, perifollicular cutaneous sarcoidosis, resolving uveitis, and lacrimal gland enlargement. These clinical findings, along with the patient’s African-American status, skin biopsy findings, elevated angiotensin-1 converting enzyme level, and elevated immunoglobulin levels support the diagnosis of systemic sarcoidosis [3].

The typical histopathology of cutaneous sarcoidosis is a non-caseating granuloma [4]. Similar histopathologic features may be found in settings of localized, foreign-body granulomas [5]. The discovery of foreign material within granulomas, however, should not exclude further investigation for sarcoidosis, if suspected. The reaction to the foreign body can be related to systemic sarcoidosis and represent one feature of its broader manifestations.

A sarcoidal tattoo granuloma initially was described in 1939, although the report involved a patient without evidence of systemic sarcoidosis [6]. The first report of tattoo granulomas arising as part of systemic sarcoidosis was published in 1952 [7]. In this report, the tattoo granuloma was the presenting sign in an evaluation that showed bilateral hilar lymphadenopathy, iritis, and arthritis. Since then, other cases of sarcoidal tattoo granulomas in patients with and without systemic sarcoidosis have been reported [5, 8]. Tattoos consisting of various pigments have been implicated, which include tattoos intended to serve as permanent make-up [5, 8]. In addition, the age of the tattoo before sarcoidal manifestations is widely variable and ranges from months to decades [9, 10]. In one report, sarcoidal granulomas developed in a 45-year-old blue tattoo and ultimately led to the discovery of pulmonary sarcoidosis on chest imaging [11]. It is uncommon in the literature to find reports of tattoo granulomas of systemic sarcoidosis that arise with additional cutaneous manifestations of the disease, as is observed in our case report, although parallels do exist [12]. The mutable nature of the tattoo granulomas, as seen in our patient, has been described in other patients in the literature [8].

Several theories for the development of sarcoidal tattoo reactions exist. The Koebner reaction has been implicated, yet so many of the tattoo reactions occur years after tattoo placement [13, 14]. This observation contrasts with the days-to-weeks delay typically noted in the Koebner reaction of other conditions, such as lichen planus and psoriasis [15]. On the other hand, these tattoo granulomas simply may represent scar sarcoidosis, which is a recognized phenomenon that is a consequence of scar formation around tattoo pigments [4]. An immunologic reaction to one or more tattoo pigments has been implicated and is predicted in sarcoidal granulomas without systemic sarcoidosis [8]. However, this would not explain, at least fully, the manifestation in systemic sarcoidosis [8].

Tattoo granulomas remain an uncommon feature of systemic sarcoidosis, yet may prove informative in the pathogenesis of systemic sarcoidosis. They raise questions for the role of environmental antigens in the pathogenesis of sarcoidosis. Chronic, mild, antigenic stimulation, such as from tattoo pigment, might lead to a systematized, granulomatous hypersensitivity in genetically predisposed individuals [4].


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