A 45-year-old male with a history of asthma and diabetes presented to a New York hospital complaining of fevers, night sweats, dyspnea with non-productive cough and bilateral joint pains for two days. The patient was hospitalized two weeks prior for an asthma exacerbation and community acquired pneumonia, at which time he was treated with antibiotics and steroids. Physical exam was significant for bilateral wrist, knee and ankle joint swelling with point tenderness, right lower lobe rales and a left shoulder black tattoo with firm subcutaneous papules and nodules overlying the pigment. The patient was afebrile during the hospitalization. Chest x-ray revealed a right lower lobe infiltrate that was decreased from the prior admission. CT scan of the chest showed patchy consolidations and ground glass nodules in the right upper lobe, right middle lobe and both lower lobes that have markedly improved since the prior examination. Laboratory studies were only significant for a c-reactive protein of 9.74 mg/dL and an erythrocyte sedimentation rate of 111 mm/hr. A skin biopsy at the tattoo site revealed non-caseating granulomas consistent with cutaneous sarcoidosis. His joint pains were controlled with Naprosyn and he was discharged on a Prednisone taper for his sarcoidosis flare.
Sarcoidosis is a granulomatous disease that can affect any organ. Patients with sarcoidosis who become acutely symptomatic (such as fevers, night sweats, weight loss and fatigue) are more likely to have extrapulmonary involvement. Granulomatous skin lesions are seen in about one-third of patients with sarcoidosis. These lesions are prone to developing over sites of prior skin tissue injury, such as in areas with tattoos. The majority of skin biopsies from tattoo sites that are consistent with non-caseating granulomas also contain amorphous and crystallized foreign material within the biopsied specimen. In fact, one study has shown that foreign body dermatitis was seen in 38% of patients who had tattoo alterations. Reactions to the various metallic compounds found in specific tattoo dye pigments have been linked to the development of cutaneous sarcoidosis at these sites. As seen in our patient, a positive skin biopsy for granulomas over a tattoo yielded clues to a systemic disease process. First-line treatment for pulmonary sarcoidosis with extrapulmonary manifestations remains oral corticosteroids.
Granulomatous skin lesions are common in patients with sarcoidosis. A thorough skin examination can be the first diagnostic clue to a systemic disease process. Although patients may present with symptoms of a common disease such as pneumonia, a clinician must be careful not to ignore concurrent skin findings and arthritis. It is the constellation of signs and symptoms in the appropriate clinical setting that allows the whole mosaic to come together.
To cite this abstract:Bodner S, Makhnevich A. The Clue Is in the Tattoo: A Case of Cutaneous Sarcoidosis. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 459. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/the-clue-is-in-the-tattoo-a-case-of-cutaneous-sarcoidosis/. Accessed April 4, 2020.