Abstract
Nontuberculous (atypical) mycobacteria rarely cause skin and soft tissue infections. Tattooing with contaminated gray ink has been implicated in previously reported outbreaks. We report the case of a 39-year-old Hispanic male who presented with a refractory, pruritic, papular eruption within the distribution of his tattoo with punch biopsy demonstrating papillary dermal granulomatous and suppurative inflammation surrounding small collections of acid-fast bacilli with associated superficial and deep dermal perivascular lymphatic inflammation, consistent with nontuberculous mycobacterial infection. Although uncommon, clinicians should consider nontuberculous mycobacterial infection in the differential diagnosis of refractory tattoo-associated skin eruptions.
Highlights
Nontuberculous mycobacteria (NTM), known as atypical mycobacteria, are acidfast bacilli (AFB) and are subcategorized by growth rate and pigment production
Though almost all NTM species have been associated with skin and soft tissue infections, rapidly-growing mycobacteria (RGM) species are most often responsible
Cutaneous NTM infection is rare with a reported incidence of approximately 0.9-2.0 cases per 100,000 persons; the incidence rate has risen threefold since 1980.1 NTM species are ubiquitous in the environment, with a recent study finding 78% of tap water samples positive for NTM.[3]
Summary
Nontuberculous mycobacteria (NTM), known as atypical mycobacteria, are acidfast bacilli (AFB) and are subcategorized by growth rate and pigment production. Lesions may spread in a sporotrichoid pattern along lymphatic vessels.[1,2] Due to overlapping and nonspecific clinical features, cutaneous NTM infections require a high index of suspicion for diagnosis and should be considered in patients who present after a surgical or cosmetic procedure and fail to respond to initial therapy. A 39-year-old Hispanic man with no significant past medical history presented for evaluation of a tender, pruritic, papular rash present for four days within the distribution of his new tattoo, which he had completed 2 days prior to rash onset. Histologic examination demonstrated a focal area of papillary dermal granulomatous and suppurative inflammation with associated superficial and deep perivascular lymphocytic infiltrate (Figure 2). Along with the clinical examination, the histologic findings supported a diagnosis of atypical mycobacterial infection in association with grey tattoo ink. Cutaneous NTM infection is rare with a reported incidence of approximately 0.9-2.0 cases per 100,000 persons; the incidence rate has risen threefold since 1980.1 NTM species are ubiquitous in the environment, with a recent study finding 78% of tap water samples positive for NTM.[3]
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