It’s Terrifying To Think About It: Can A Tattoo Be Infected Like This? ? ?

Hey guys, there are about 50 different species of mycobacteria that can cause disease in humans, several of which belong to the nontuberculous mycobacteria (NTM). Mycobacterium fortuitum, Mycobacterium chelonae, and Mycobacterium abscessus can be further classified as rapidly growing mycobacteria (RGMs). This class of mycobacteria can be found in a variety of places such as surface water, tap water, soil, domestic and wild animals, milk, and food. They can also cause surgical site infections after exposure to unsterilized tap water. Unique clinical symptoms include lung disease, lymphadenitis, disseminated disease, and skin and soft tissue infections. However, they can also exist on body surfaces or in secretions without causing disease, which makes them difficult to diagnose clinically.

 

• Specifically, M. fortuitum infects the skin and soft tissues via direct inoculation and typically presents as a single lesion. Mycobacteria share the common description of acid-fast bacilli, so further testing is required to differentiate between the different microorganisms. Biopsy and culture followed by polymerase chain reaction (PCR) and nucleic acid-specific testing are used to determine the presence and type of RGM, but treatment may vary between specific types. M. fortuitum can exhibit resistance to certain macrolide antibiotics via the erm resistance gene, and the best drugs for treatment include amikacin, ciprofloxacin, levofloxacin, moxifloxacin, sulfonamides, and imipenem.

Figure: Mycobacterium abscessus infection after mesodermal injection

• Today we study a series of eight patients infected with Mycobacterium fortuitum. The infections were associated with a single tattoo administration facility. Each patient was unique in terms of clinical presentation and laboratory test results, but what they all had in common was infection with Mycobacterium fortuitum.

Case Showcase

Index Case



On February 11, 2011, a 41-year-old Caucasian male received a tattoo on his right forearm containing red; yellow; and finally gray inks. Three days after receiving the black ink, he developed redness, swelling, painful bleeding, small pustules, and crusting primarily in the area tattooed with black ink (Figure 1A). After symptoms persisted for two months, he presented to the emergency department on March 7, 2011, and was treated with anti-inflammatory, oral antibiotics, and topical treatments. These treatments temporarily relieved symptoms; however, exacerbations subsequently occurred. On March 11, 2011, due to lack of improvement, he returned to the emergency department and was subsequently admitted to the hospital and treated with intravenous clindamycin, topical clobetasol ointment, and a 12-day course of tapered prednisone. He was discharged with instructions to continue oral antibiotics, prednisone, and topical clobetasol ointment. He subsequently visited his personal dermatologist, where he underwent a biopsy (Figure 1B) and tissue culture. Acid-fast staining was positive (Figure 1C), and the presence of mycobacteria was confirmed by tissue culture (Figure 1D). After the M. fortuitum infection was confirmed, he was treated with ciprofloxacin and linezolid for at least 3 to 4 months.

Figure 1
a) Clinical presentation as nodular and edematous plaques covered with scales and pustules confined to the area of ​​gray tattoo ink; b) Hematoxylin and eosin staining showing hyperkeratotic and granulomatous dermatitis with necrosis and neutrophils; c) Positive Fette's acid-fast stain (modified acid-fast stain) showing acid-fast bacilli; d) Mycobacterium fortuitum on Middlebrook 7H10 agar

Other cases

The authors then reviewed the medical records of eight patients who had an isolated M. fortuitum infection between December 15, 2010, and January 28, 2011. The clinical course, biopsy results, and culture results were reviewed. Once public health officials confirmed the tattoo association, all eight cases were linked to a single tattoo parlor and a single tattoo artist.

 

This series consisted of eight patients, including seven male patients and one female patient. All patients received tattoos from a single tattoo artist in a tattoo parlor between December 2010 and January 2011. The clinical presentation of their lesions varied from small skin papules to edema and indurated plaques, all of which were confined to the black and gray areas of the tattoo ink. All cases were first presented between January and February 2011. Six patients were initially treated with topical steroids and antibiotics, while two patients were initially treated with topical steroids alone. Two patients required hospitalization, while the remaining six patients were treated on an outpatient basis.

The patient characteristics of each case in this series are summarized in Table 1

Table 1: Patient characteristics

Discussion

Nontuberculous mycobacteria are known to be the culprits of tattoo-associated infections. The etiology of the outbreak was reported to be gray ink diluted with contaminated water. It is known that this contamination occurs at both the manufacturer and the artist level. In this report, the authors focus on NTM infections associated with tattoos that primarily involve skin and soft tissue, surgical wounds, and catheter-related infections via direct inoculation. Although none of the patients in this group were immunosuppressed, the rate of NTM-associated infections is higher in immunosuppressed populations. The nonspecific clinical presentation of fortuitous mycobacterium infections is a diagnostic and therapeutic challenge. This case series shows how the nonspecific presentation of this infection can lead to delayed diagnosis, which unfortunately led to hospitalization of the two patients discussed here. Because the diagnosis may or may not be confirmed by culture, it must be emphasized that a biopsy is required in addition to culture to aid in the diagnosis. One should consider that infection is present when a patient presents with signs and symptoms of inflammation in a tattoo, especially when the lesions are confined to the area of ​​the gray ink tattoo.

Figure: NTM infection

Regarding treatment, a variety of antibiotic sensitivities have been described in the literature. For infections limited to the skin and soft tissue, current recommendations state that two of the following antibacterial drugs should be taken orally for at least four months: trimethoprim-sulfamethoxazole, doxycycline, levofloxacin, and clarithromycin or azithromycin. For more extensive skin and soft tissue disease, parenteral treatment with at least two of the following drugs for 2-6 weeks is recommended: aminoglycosides (amikacin or tobramycin), cefoxitin, imipenem and levofloxacin. This should be followed by 6 to 12 months of oral treatment with any of the previously mentioned medications. The authors' case series has three notable limitations, including the inability to confirm that gray ink was the source of infection because samples were not available; because one case did not have an associated biopsy; and, once cultures were obtained, most patients had already been treated with antibiotics.

 

References 1. Schlesinger TE, Wilson AE, Trivedi L, Latham PJ, Ball R. A Series of Tattoo-associated Mycobacterium Fortuitum Infections. J Clin Aesthet Dermatol. 2021 Apr;14(4)：38-40. Epub 2021 Apr 1. PMID：34055187; PMCID：PMC8142829.