A CASE OF TATTOO SARCOIDOSIS

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Sarcoidosis is a multisystem granulomatous disease that commonly affects the lungs and intrathoracic lymph nodes. In rare cases, it can present as localized hypersensitive reaction to a pre-existing chemical irritant with symptoms limited to areas of granuloma formation. When it affects the lungs and mediastinal lymph nodes, as seen in over 90% of patients, it causes lymphadenopathy associated with cough, dyspnea, and interstitial lung disease. Here we present a case of Sarcoidosis diagnosed in the setting of hypersensitive reaction to a pre-existing tattoo. CASE PRESENTATION: A 61-year-old Caucasian woman presented to dermatologist for evaluation of gradually worsening eyebrow redness, swelling, and pruritus. On physical exam, she was noted to have small, scattered <1 cm areas of raised non-blanching macules limited to where she had received a cosmetic eyebrow tattoo about four years prior to presentation. A skin biopsy of the affected area showed mixed inflammatory infiltrate with numerous epithelloid histiocytes, multinucleated foreign body giant cells, lymphocytes, plasma cells, and a few eosinophils intermixed with tattoo particulate deposition. Skin biopsy was negative for fungal and acid fast bacilli. She was referred to Pulmonology, who she saw four months later, with complaints of fatigue, dry cough and dyspnea on exertion. She denied any chest tightness, wheezing, palpitations, fever, chills or unexpected weight loss. Chest X-ray and CT Chest w/o contrast showed mediastinal bilateral hilar lymphadenopathy and peribronchovascular bundle nodules. She had ACE level 85 IU/L and ESR 25 mm/h. PFTs showed moderate obstructive defect with FEV-1 of 68%. She had no history of COPD or asthma. She was started on long course of Prednisone with taper. At one-month follow-up visit, the patient reported improvement with resolution of shortness of breath and skin changes including eyebrow redness and swelling. DISCUSSION: As this case illustrates, sarcoidal reaction within a pre-existing tattoo can be the sole presenting symptom leading to the diagnosis of systemic sarcoidosis. Other associated findings of dyspnea, hilar lymphadenopathy on CT were seen later in time. It has been proposed that exposure to foreign antigens triggers dysregulated TH-1 inflammatory response activating the CD4 T-helper cells and macrophages. The latent period can range anywhere from months to ten years and it is unknown if tattoo removal affects the progression of the disease. CONCLUSIONS: Sarcoidosis is a diagnosis of exclusion and requires clinical and radiographic findings compatible with histological confirmation of noncaseating granulomas. With the increasing popularity of cosmetic tattoos and techniques to enhance the appearance of eyebrows via addition of pigment to skin, a simple hypersensitivity reaction with supporting pathological and radiologic evidence can lead to the diagnosis of this multisystem disease. Reference #1: Marcoval J, Mañá J, Moreno A, Gallego I, Fortuño Y, Peyrí J. Foreign Bodies in Granulomatous Cutaneous Lesions of Patients With Systemic Sarcoidosis. Arch Dermatol. 2001;137(4):427–430. doi: 10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-137-4-dst0038 Reference #2: Antonovich D.D., Callen J.P. Development of sarcoidosis in cosmetic tattoos. Arch Dermatol. 2005;141:869–872 Reference #3: P. P. Papageorgiou, W. Hongcharu, A. C. Chu. Systemic sarcoidosis presenting with multiple tattoo granulomas and an extra-tattoo cutaneous granuloma. J Eur Acad Dermatol Venereol. 1999 Jan; 12(1): 51–53 DISCLOSURES: No relevant relationships by Mudher Al Shathir, source=Web Response No relevant relationships by Himani Bhasin, source=Web Response No relevant relationships by Kenneth DSouza, source=Web Response