Tattoo-Associated Uveitis
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Tattoo-Associated Uveitis
TRUCIAN A. OSTHEIMER, BRYN M. BURKHOLDER, THERESA G. LEUNG, NICHOLAS J. BUTLER,
JAMES P. DUNN, AND JENNIFER E. THORNE
PURPOSE: To describe the clinical presentation of uve- of systemic sarcoidosis.1 This was followed, in 1969, by the
itis with coincident onset of raised and indurated tattooed first case series to describe bilateral intraocular inflamma-
skin. tion with the simultaneous development of tattoo granu-
DESIGN: Case series. lomas in 3 patients felt to have no evidence of systemic
METHODS: Seven consecutive patients were evaluated sarcoidosis at the time of presentation.2 The pathologic
at a tertiary ophthalmologic facility with coincident uve- hallmark of sarcoidosis is the noncaseating granuloma;
itis and cutaneous tattoo induration over an 18-month however, it remains a diagnosis of exclusion because of its
period. All subjects underwent complete ophthalmic lack of pathognomonic histopathology, imaging, or sero-
examination and a focused systemic medical evaluation logic studies.3 Among patients with sarcoidosis, anywhere
including serologic testing and imaging studies. Two par- from 25% to 80% may suffer from ocular or adnexal
ticipants underwent biopsy of their tattoos. The patients’ involvement,4 and approximately 25%–35% of patients
clinical courses and responses to treatment over a follow- develop cutaneous findings.3 Anterior uveitis is the most
up period of 1–20 months are reported (mean follow- common ocular manifestation of sarcoidosis, occurring in
up [ 9 months). Main outcome measures included degree 65% of patients with ophthalmic involvement.3
of intraocular inflammation, ocular complications, visual We present 7 patients with no prior diagnosis of sarcoid-
acuity, clinically observable tattooed skin changes, and osis who developed bilateral uveitis in temporal association
biopsy results. with inflammation of tattooed skin.
RESULTS: Five of 7 patients had bilateral nongranulom-
atous anterior uveitis: 4 with chronic and 1 with recurrent
disease. The remaining 2 patients had bilateral chronic
granulomatous panuveitis. Biopsies of raised and indurated METHODS
tattoos were performed in 2 patients and demonstrated
A RETROSPECTIVE REVIEW OF 7 CONSECUTIVE PATIENTS
noncaseating granulomatous inflammation surrounding
with bilateral uveitis and associated cutaneous changes sug-
tattoo ink in the dermis. The skin changes resolved in all
gestive of tattoo inflammation evaluated over a 20-month
patients, with a faster response noted in those treated
period was conducted at the Division of Ocular Immu-
with high-dose oral prednisone for intraocular inflamma-
nology, Wilmer Eye Institute. The study was approved by
tion. Five patients subsequently experienced recurrent
the Johns Hopkins School of Medicine Institutional
flares of intraocular inflammation in conjunction with
Review Board and adhered to all tenets of the Declaration
the recurrence of raised and indurated tattoos.
CONCLUSIONS: These cases represent a subset of
of Helsinki. All patient data were handled in accordance
with the Health Information Portability and Account-
patients in whom skin tattooing may have incited an
ability Act.
immune response leading to simultaneous inflammation
All patients underwent a complete ophthalmologic
of the eyes and tattooed skin. (Am J Ophthalmol
examination and received a medical evaluation (Table)
2014;158:637–643. Ó 2014 by Elsevier Inc. All rights
in an attempt to rule out syphilis (fluorescent treponemal
reserved.)
antibody-absorption [FTA-ABS] and rapid plasma reagin
testing [RPR]) and sarcoidosis (chest x-ray and/or
computed tomography [CT] chest, serum angiotensin-
I
N 1952, LUBECK AND EPSTEIN PUBLISHED THE FIRST
report of a patient with bilateral intraocular inflamma- converting enzyme [ACE] and/or serum lysozyme). Testing
tion and simultaneous tattoo granulomas in the setting for HLA-B27 positivity and infectious etiologies such as
Mycobacterium tuberculosis, Toxoplasma gondii, Bartonella
henselae, and Borrelia burdorferi was performed in selected
Accepted for publication May 16, 2014. patients. Two of the 7 patients underwent biopsy of their
From Wilmer Eye Institute, Johns Hopkins University School of inflamed tattoos. The patients’ clinical courses and
Medicine (T.A.O., B.M.B., T.G.L., N.J.B., J.P.D., J.E.T.); and
Department of Epidemiology, Bloomberg School of Public Health, Johns responses to treatment were reviewed over a follow-up
Hopkins University (J.E.T.), Baltimore, Maryland. period of 1–20 months.
James P. Dunn is currently employed at the Wills Eye Institute, Phila-
delphia, Pennsylvania.
Inquiries to Trucian A. Ostheimer, Wilmer Eye Institute, 600 N Wolfe SELECTED CASE REPORT: PATIENT 1: Patient 1 was a 20-
St, Woods 476, Baltimore, MD 21287; e-mail: tosthei1@jhmi.edu year-old African-American man who initially presented for
0002-9394/$36.00 Ó 2014 BY ELSEVIER INC. ALL RIGHTS RESERVED. 637
http://dx.doi.org/10.1016/j.ajo.2014.05.019
638
TABLE. Patient Demographics and Findings in Tattoo-Associated Uveitis
Intraocular Sarcoidosis Follow-up
Patients Demographics Initial VA Inflammation Uveitic Evaluationa Evaluationa Tattoo Findings Tattoo Biopsy Ocular Complications Treatment Duration
1 20yo AAM OD(sc): 20/100, OS(sc): Bilateral RPR, FTA-ABS, HLA- ACE, chest Elevation/induration of Noncaseating OU: posterior Mycophenolate mofetil, 13 months
20/400; PHNI OU granulomatous B27, IGRA, Lyme x-ray (32) skin tattooed with granulomatous synechiae, oral prednisone,
chronic panuveitis serology, black pigment reaction associated glaucoma s/p topical
Toxoplasma IgG, (predominantly with tattoo ink Baerveldt glaucoma corticosteroids, and
CMP, CBC black tattoos on implants IOP-lowering drops
arms, chest, and
abdomen)
2 31yo WM OU(sc): 20/25; PHNI Bilateral RPR, FTA-ABS, HLA- ACE, lysozyme, Elevation/induration of Noncaseating OU: steroid-associated Topical corticosteroids, 17 months
OU nongranulomatous B27, PPD, CMP, chest x-ray, CT skin tattooed with granulomatous ocular hypertension IOP-lowering drop
recurrent anterior CBC chest, lymph black pigment reaction associated
AMERICAN JOURNAL OF OPHTHALMOLOGY
uveitis node biopsyb (multicolored, with tattoo ink
extensive tattoos on
both arms)
3 32yo AAM OU(sc): 20/25-2; PHNI Bilateral RPR, FTA-ABS, HLA- ACE, chest x-ray Elevation/induration of Not performed OU: pupillary Methotrexate, oral 20 months
OU nongranulomatous B27, Lyme serology, skin tattooed with mebranes, prednisone, topical
chronic anterior CMP, CBC black pigment on cataracts, CME corticosteroids,
uveitis both arms (black OD: posterior IOP-lowering drops
tattoos on chest synechiae
never involved) OS: iris bombe, uveitic
glaucoma
4 23yo AAF OD(sc): 20/40, OS(sc): Bilateral RPR, FTA-ABS, HLA- Lysozyme, Elevation, induration, Not performed OU: posterior Mycophenolate mofetil, 7 months
20/200-2; PHNI OU nongranulomatous B27, Lyme serology, chest x-ray and scaling of synechiae, pupillary oral prednisone,
chronic anterior CMP, CBC tattoos with black membranes, iris topical
uveitis ink (multicolored bombe, severe CME corticosteroids,
tattoos on face, OS: uveitic glaucoma IOP-lowering drops
neck, torso, back,
and all limbs)
5 23yo AAM OD(sc): 20/25, OS(sc): Bilateral RPR, FTA-ABS, HLA- ACE, chest x-ray Elevation/induration of Not performed OS: posterior Topical corticosteroids 4 months
20/20þ1; PHNI OU nongranulomatous B27, Lyme serology, skin tattooed with synechiae
chronic anterior black pigment (black
uveitis tattoos on arms/
chest)
6 21yo AAF OD(sc): 20/100, OS(sc): Bilateral RPR, FTA-ABS, HLA- ACE,b chest x-ray Elevation/induration of Not performed OU: severe optic nerve Oral prednisone, 2 months
20/40; PH 20/80 OD, nongranulomatous B27, PPD, Lyme skin tattooed with elevation and topical
PHNI OS chronic panuveitis serology, Bartonella black pigment hyperemia with corticosteroids
with hypopyon antibody panel, (multicolored tattoos papillomacular
CMP, CBC on back) exudates, ERM
OD: subfoveal RPE
SEPTEMBER 2014
detachment
Continued on next page
evaluation of a 1-week history of blurred vision, photo-
phobia, and pain in both eyes. He had experienced similar
1 month (lost to
Patient 2 underwent biopsy of an enlarged axillary lymph node, which displayed a noncaseating granulomatous reaction. Patient 6 had an elevated ACE value of 85 (reference range: 9–67 U/L).
AAF ¼ African-American female; AAM ¼ African-American male; ACE ¼ serum angiotensin-converting enzyme; CBC ¼ complete blood count; CME ¼ cystoid macular edema; CMP ¼ complete
G; IGRA ¼ interferon gamma release assay (QuantiFERON–TB Gold); IOP ¼ intraocular pressure; PH ¼ visual acuity measured with pinhole occluder; PHNI ¼ visual acuity measured with pinhole
occluder offered no improvement in vision; PPD ¼ tuberculosis purified protein derivative skin testing; RPE ¼ retinal pigment epithelium; RPR ¼ syphilis rapid plasma regain; sc ¼ without correction;
metabolic panel including liver function testing; CT ¼ computed tomography; ERM ¼ epiretinal membrane; FTA-ABS ¼ syphilis fluorescent treponemal antibody-absorption; IgG ¼ immunoglobulin
Follow-up
follow-up)
Duration symptoms 6 months earlier, which lasted approximately
1 month before spontaneously resolving. Review of systems
was notable for elevation and swelling of 8 tattoos on his
immunosuppression arms and chest that occurred in conjunction with his ocular
recommended symptoms on both occasions (Figure 1). All of his tattoos
Treatment
Oral prednisone;
were performed during a 1-year period, approximately
systemic
6 months prior to his initial ocular complaints.
Upon presentation, best-corrected visual acuity
(BCVA) was 20/100 in the right eye and 20/400 in the
Ocular Complications
retinal detachment
left eye, with an intraocular pressure (IOP) of 11 mm Hg
OD: neurosensory
OS: severe CME
in the right eye and 10 mm Hg in the left eye. Slit-lamp
OU: posterior
synechiae
examination revealed diffuse conjunctival injection, dense
mutton-fat keratic precipitates with overlying corneal
microcystic edema, and posterior synechiae bilaterally.
TABLE. Patient Demographics and Findings in Tattoo-Associated Uveitis (Continued )
Both eyes displayed anterior chamber inflammation of 3þ
Tattoo Biopsy
cells and 1þ flare, with 2þ anterior vitreous cells. Both
Not performed
optic nerves appeared hyperemic and edematous, but a
more detailed posterior segment examination, including
an assessment of vitreous haze, was limited by bilateral
corneal edema and posterior synechiae.
black pigment (arm)
Elevation/induration of
An initial evaluation, consisting of FTA-ABS, RPR,
skin tattooed with
Patient 7 had an elevated lysozyme value of 32 (reference range: 9–17 mg/mL) and a normal serum ACE value of 47.
Tattoo Findings
QuantiFERON-TB Gold, chest x-ray, and Lyme antibody,
was unrevealing. He was initially treated with intensive
topical corticosteroids and cycloplegic drops. Three days
after presentation, BCVA improved to 20/50 in the right
eye and 20/60 in the left eye, with an IOP of 20 mm Hg
in the right eye and 22 mm Hg in the left eye. However,
chest x-ray, CT
Sarcoidosis
Evaluationa
ACE, lysozyme,b
his intraocular inflammation persisted and high-dose
(1 mg/kg/day) oral prednisone therapy was initiated. The
chest
bilateral anterior chamber inflammation and elevated tat-
toos resolved over the course of 3 weeks; however, his
IOP became elevated at this time (33 mm Hg in the right
Uveitic Evaluationa
FTA-ABS, HLA-B27,
eye and 27 mm Hg in the left eye). Topical IOP-lowering
CMP, CBC
therapy was initiated in a stepwise manner, which escalated
to maximal topical therapy. Topical prednisolone acetate
All results unremarkable/negative unless otherwise indicated.
1% was changed to loteprednol etabonate 0.5% approxi-
mately 8 weeks after presentation in an attempt to mini-
nongranulomatous
mize any steroid-response component; however, oral
chronic anterior
Inflammation
Intraocular
VA ¼ visual acuity; WM ¼ white male; yo ¼ year old.
acetazolamide was necessary. A prolonged attempt to taper
his oral prednisone led to a recurrence of intraocular
uveitis
Bilateral
inflammation and tattoo elevation, and 3 months after
his initial presentation he was referred for dermatologic
20/40; PHNI OD, PH
OD(sc): 20/20, OS(sc):
evaluation. His oral prednisone dose was tapered from
40 mg/day to 30 mg/day 6 days prior to this dermatology
Initial VA
appointment, and a biopsy was taken from an area of previ-
OS 20/32
ously affected skin on his chest. Histologic sections of this
biopsy displayed macrophages in clusters around the dermal
superficial vascular plexus that contained tattoo pigment
Patients Demographics
with surrounding granulomatous inflammation. A repeat
42yo AAM
chest x-ray, comprehensive chemistry panel, and serum
ACE were ordered by dermatology, with all results inter-
preted as normal. He then returned for routine follow-up
b
a
nearly 3 weeks later on 20 mg/day of prednisone, at which
7
time he was noted to have diffuse elevation of all tattoos
VOL. 158, NO. 3 TATTOO-ASSOCIATED UVEITIS 639FIGURE 1. Tattoo inflammation in a 20-year-old African-American male subject with simultaneous bilateral, chronic, granulomatous
panuveitis (Patient 1). (Upper left) Nodular elevation of focal areas of tattooed skin on the patient’s left shoulder. (Upper right) Diffuse
elevation of black tattoos on the chest, with involvement of adjacent nontattooed skin. Hematoxylin-eosin stain (original magnifica-
tion 3100) of biopsies from the chest and shoulder display a granulomatous reaction in the dermis with aggregates of epithelioid his-
tiocytes, giant cells, and a sparse mononuclear infiltrate (Bottom left); all granulomas contained tattoo pigment (inset, Bottom right).
containing black ink. Punch biopsies of the affected skin panuveitis. One patient with anterior uveitis had recurrent
were taken from his left shoulder and chest. Histology slides disease, while all other patients had chronic uveitis.
of these biopsy specimens revealed aggregates of epithelioid A medical examination was performed on all patients
histiocytes and giant cells containing pigment particles and interpreted as unremarkable, with the exception of a
with sparse mononuclear cell infiltrate (Figure 1). single elevated serum ACE (Patient 6) and lysozyme value
Ultimately, his refractory ocular hypertension resulting (Patient 7). Patient 4 presented with submandibular and
from a combination of uveitic and steroid response mecha- occipital lymphadenopathy not associated with overlying
nisms required placement of glaucoma drainage devices tattooing, though she did have extensive head and neck
4 months and 6 months after presentation in the right tattoos. Patient 2 developed an enlarged left axillary lymph
and left eye, respectively. The patient agreed to initiation node near the area of heavy tattooing on the same arm.
of immunosuppressive therapy with mycophenolate mofe- All patients denied abnormal cutaneous reactions imme-
til, which enabled successful tapering of oral prednisone. diately after tattooing, and all had their most recent tattoo
At the most recent examination, 13 months after presenta- placed at least 6 months prior to the onset of cutaneous and
tion, BCVA was 20/25 bilaterally with controlled IOP and intraocular symptoms. Five of the patients had extensive
intraocular inflammation on mycophenolate mofetil 1.5 g tattoos, all of which consisted entirely of only black
twice daily and prednisone 5 mg once daily. pigment or multicolored tattoos containing black ink.
The remaining 2 patients had more limited tattooing
(Patients 6 and 7). Only tattoos or portions of tattoos
containing black pigment were affected in all 7 patients.
RESULTS Involvement of the affected tattoos varied from focal
SELECTED CLINICAL CHARACTERISTICS OF ALL 7 PATIENTS nodular elevation in regions of black pigment to uniform
are summarized in the Table. Six patients were African elevation and induration of all portions of the tattoo
Americans, 4 of whom were male. The remaining patient containing black ink (Figure 2). In Patient 1, striking
was a white man. The age range of all patients was 20–42 elevation and induration of the surrounding skin was also
years at the time of presentation. Five patients presented observed. Five patients (Patient 1 and Patients 3–6) expe-
with bilateral nongranulomatous anterior uveitis, while rienced at least 1 recurrence of intraocular inflammation
the remaining 2 patients presented with granulomatous with simultaneous tattoo involvement.
640 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2014DISCUSSION
WE DESCRIBE A SERIES OF 7 CONSECUTIVE PATIENTS WHO
demonstrated simultaneous onset of bilateral uveitis and
tattoo elevation with induration. Five other cases
published in 3 articles reported similar findings and no
additional evidence of sarcoidosis on examination or chest
imaging (chest x-ray and/or CT studies) at the time of pre-
sentation.2,5,6 Similar to our series, these 5 patients
exhibited bilateral uveitis, ranging from iridocyclitis to
panuveitis. During observed follow-up, 1 patient developed
‘‘red infiltrates resembling erythema nodosum’’ on both
shins that were not associated with tattooed skin.2 In our
series, Patient 2 developed noncaseating granulomatous
inflammation of an axillary lymph node adjacent to an
area of dense tattooing, and Patient 3 developed subman-
dibular and occipital lymphadenopathy, which was suspi-
FIGURE 2. Tattoo elevation in a 23-year-old African- cious for sarcoidosis. Furthermore, there have been cases
American female subject with simultaneous bilateral, chronic, reported in the literature of patients with a diagnosis of sys-
nongranulomatous anterior uveitis (Patient 4). All areas of temic sarcoidosis at the time of presentation with bilateral
her abdominal tattoo containing black pigment were raised and uveitis and tattoo induration.1,7,8
indurated, and similar tattoo involvement was noted on her Each of the patients in our series had extensive areas of
head, neck, and back. tattooing that contained or consisted entirely of black
ink. Other published reports describe skin inflammation
associated with blue,2 red,5 and black ink.6–8 Tattoo size
Tattoo biopsies were performed on Patients 1 and 2. A and color varied, although 1 case report described a
tattoo biopsy on Patient 2 was performed 2 weeks prior patient with extensive black tattooing,6 which was similar
to presentation and displayed noncaseating granulomas to the patients in our series. All of our patients received the
composed of histiocytes surrounding black tattoo pigment majority of their tattoos over a relatively short period of
in the dermis. His enlarged axillary lymph node also was time—approximately 1 year or less—but none experienced
biopsied and displayed noncaseating granulomatous induration or inflammation of the tattoos at the time of
inflammation. Similar findings were demonstrated in the tattoo placement. In the majority of reports, the inflamma-
tattoo biopsies of Patient 1. Patients 4 and 5 were referred tion of tattooed skin coincided with the onset of uveitis
for biopsy of their tattoos and enlarged lymph nodes (Pa- except for 2 of 3 patients reported by Rorsman and associ-
tient 4) immediately after their initial evaluation, but ates, in whom tattoo inflammation occurred immediately
both failed to follow up with dermatology and had rapid after placement and did not correlate temporally with their
resolution of these findings following initiation of high- delayed ocular involvement.2
dose oral prednisone. The remaining patients (Patients 3, Of the 8 previously reported patients with tattoo-
6, and 7) were not sent for biopsy of their involved tattoos associated uveitis, 4 underwent complete excision of the
because they were immediately treated with high-dose oral affected tattoo(s).2,5 Interestingly, 3 of these 4 patients
prednisone, which coincided with rapid resolution of their were reported to have improvement in their intraocular
tattoo findings over the course of approximately 1 week. inflammation following tattoo excision, with 2 achieving
Owing to military service obligations requiring him to relo- complete resolution off of all medications. As with our
cate, Patient 7 was lost to follow-up after 2 visits. series, the follow-up periods in these cases were limited,
Five of 7 patients suffered potentially vision-threatening and it remains unclear whether tattoo excision had a role
ocular complications at some point during observation. Pa- in disease resolution or simply coincided with spontaneous
tients 3 and 4 presented with iris bombe, pupillary mem- disease remission. Unlike these previously reported cases,
branes, and cystoid macular edema, which subsequently tattoo excision was not offered to the patients we continue
required treatment with immunosuppressive therapy. to follow at our facility, as the percentage of body surface
Patient 7 presented to our institution with a neurosensory area encompassed by their involved tattoos was deemed
retinal detachment in the right eye and severe cystoid mac- too extensive for subsequent skin grafting.
ular edema in the left eye. All patients treated with oral Various patterns of histologic reactions have been reported
prednisone (Patients 1, 3, 4, 6, and 7) displayed simulta- to occur in tattooed skin, and one of the more common find-
neous improvement in their ocular inflammation and reso- ings is granulomatous inflammation.9 Histologically, this can
lution of their tattoo findings. be classified as a foreign body or sarcoid-type reaction, and the
VOL. 158, NO. 3 TATTOO-ASSOCIATED UVEITIS 641differentiation of these 2 types of granulomas may be both exposure in lung cell lines13 and mice14 have shown
challenging and open to controversy.9,10 Allergic reactions that these particles ‘‘induce inflammation, oxidize
to tattoo pigment can also occur, which may exhibit a DNA, cause DNA strand breaks and increase the mutant
variety of histologic forms, some of which are also frequency following long-term exposure at a subcytotoxic
consistent with sarcoidosis.9 Granulomatous reactions concentration.’’15 All of our patients received the major-
confined to single tattoo colors typically represent a local ity of their tattoos over a relatively short period of
hypersensitivity reaction to specific components of tattoo time—approximately 1 year or less—which may have
pigment, but they may also represent a manifestation of conferred an increased risk of disease development as a
systemic sarcoidosis.9 Interestingly, reports of allergic reac- result of the relatively large antigenic and/or toxic
tions to black tattoo pigment are very rare.11 The histologic load. Interestingly, the US Food and Drug Administra-
appearance of tattoo biopsy specimens obtained from 2 of tion has not approved any tattoo pigments for injection
the 7 patients in our series were interpreted as noncaseating into the skin, and many pigments used in tattoo inks are
granulomatous inflammation in association with dermal industrial-grade colors suitable for printers’ ink or auto-
tattoo pigment, which is consistent with but not specific for mobile paint.16 Among adults 18–50 years of age in
sarcoidosis. this country, the prevalence of tattoos may be as high
Although the etiology of sarcoidosis remains unclear, it is as 24%.17
hypothesized that the disease process is initiated when a genet- Ultimately, the patients in our series seem to represent a
ically susceptible host is exposed to an inciting environmental subset of patients in whom some component of tattoo
antigen(s).3,10 In such an event, an exaggerated immune pigment initiated a localized cutaneous response that by
response characterized by the activation of macrophages some means also played a role in the simultaneous develop-
and CD4þ T lymphocytes occurs, resulting in cytokine ment of ocular inflammation. Whether the pathophysi-
production consistent with a TH1-type immune response, ology of this process is similar to systemic sarcoidosis, is
ultimately leading to granuloma formation.3,10 Considering the result of a hypersensitivity response, or is attributble
the multiple environmental risk factors reported to date, it to some other mechanism is not yet known. Continued
seems reasonable to conclude that the development of observation for the development of additional organ system
sarcoidosis is likely the end result of immune responses to a involvement consistent with sarcoidosis, and the potential
potentially large variety of environmental triggers.3,4 benefit of tattoo removal, if performed, may be useful
The production of black tattoo ink is based on soot, knowledge. Altogether, the clinical presentation of the
which may ‘‘contain toxic, mutagenic or carcinogenic patients collected for this series nearly equals the cumula-
compounds such as carbon black and polycyclic aromatic tive number of previously reported cases, suggesting that
hydrocarbons or phenol.’’12 Carbon black nanoparticle this association is likely underappreciated.
ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST.
Jennifer E. Thorne discloses the following: grant funding from the National Institutes of Health (Bethesda, Maryland, USA), Research to Prevent Blindness
Sybil B. Harrington Special Scholars Award (New York, New York, USA), Allergan (Irvine, California, USA); consultant for AbbVie (North Chicago,
Illinois, USA), Gilead (Foster City, California, USA), Navigant (Chicago, Illinois, USA), Xoma (Berkeley, California, USA). The authors indicate no
funding support. Contributions of authors: all listed authors made substantial contributions regarding (1) data acquisition (T.O., B.B., T.L., N.B., J.D., J.T.);
(2) drafting (T.O.) or revising the article (T.O., B.B., T.L., N.B., J.D., J.T.); and (3) approval of submitted version (T.O., B.B., T.L., N.B., J.D., J.T.).
Pathology consultation was provided by Gulsun Erdag, MD, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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VOL. 158, NO. 3 TATTOO-ASSOCIATED UVEITIS 643Biosketch Trucian Ostheimer, MD, graduated from the Ohio State University College of Medicine in 2008, and completed his ophthalmology residency at the Illinois Eye & Ear Infirmary in 2012. He is currently completing a two-year ocular immunology fellowship at the Wilmer Eye Institute, and has a special interest in birdshot chorioretinopathy. Dr Ostheimer will begin a fellowship in vitreoretinal surgery at the University of Washington in July, 2014. 643.e1 AMERICAN JOURNAL OF OPHTHALMOLOGY SEPTEMBER 2014
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