Pyogenic Infection after Tatoo
Answer: D
In a recent survey, 25% of 18- to 50-year-olds in the U.S. had at least one tattoo. 12.5% of those responding developed some medical condition within 2 weeks of tattooing. Although this survey likely suffers from sampling and recall bias, it underscores an increasing population of patients seeking advice and/or care in the ED for a recent tattoo.
The most commonly reported symptoms and signs of normal effects of tattooing include fluid discharge, crusting, bleeding, swelling, scarring, itching, and sun sensitivity. The EP should become familiar with the aforementioned benign and expected signs and symptoms as well as those associated with increased morbidity.
Acute aseptic inflammatory reaction refers to the immediate erythema, edema, and induration after the tattoo needle repeatedly causes microtrauma to the dermis (A). On exam, the skin is warm and tender and the reaction closely follows the lines of the tattoo. Patients may report that “it feels like a sunburn”; the epidermis later peels away in the coming weeks. As this is the natural history of a normal tattoo, many experienced individuals do not seek emergency care for this.
Edema of the involved extremity may be marked, but also is to be expected. It can be distinguished form cellulitis in the absence of fever, chills, local inflammation, lymphangitis, local lymphadenopathy and normal WBC and CRP (if obtained).
Due to the inherently traumatic nature of tattooing, petechiae, purpura, and/or hematoma may be present. The tattoo artist typically wraps the tattoo in shrink wrap to wear overnight to help with the edema and bleeding. In profuse bleeding, an undiagnosed dyscrasia may be considered (e.g. von Willebrand disorder).
Below is an example of (normal) blood suffusion through needle puncture sites:
In a recent survey, 25% of 18- to 50-year-olds in the U.S. had at least one tattoo. 12.5% of those responding developed some medical condition within 2 weeks of tattooing. Although this survey likely suffers from sampling and recall bias, it underscores an increasing population of patients seeking advice and/or care in the ED for a recent tattoo.
The most commonly reported symptoms and signs of normal effects of tattooing include fluid discharge, crusting, bleeding, swelling, scarring, itching, and sun sensitivity. The EP should become familiar with the aforementioned benign and expected signs and symptoms as well as those associated with increased morbidity.
Acute aseptic inflammatory reaction refers to the immediate erythema, edema, and induration after the tattoo needle repeatedly causes microtrauma to the dermis (A). On exam, the skin is warm and tender and the reaction closely follows the lines of the tattoo. Patients may report that “it feels like a sunburn”; the epidermis later peels away in the coming weeks. As this is the natural history of a normal tattoo, many experienced individuals do not seek emergency care for this.
Edema of the involved extremity may be marked, but also is to be expected. It can be distinguished form cellulitis in the absence of fever, chills, local inflammation, lymphangitis, local lymphadenopathy and normal WBC and CRP (if obtained).
Due to the inherently traumatic nature of tattooing, petechiae, purpura, and/or hematoma may be present. The tattoo artist typically wraps the tattoo in shrink wrap to wear overnight to help with the edema and bleeding. In profuse bleeding, an undiagnosed dyscrasia may be considered (e.g. von Willebrand disorder).
Below is an example of (normal) blood suffusion through needle puncture sites:
A forearm with localized purpura/hematoma adjacent to the tattoo:
Subcutaneous ink diffusion – also called “tattoo blow out” – refers to a bluish or dark “blurry halo” of ink driven too deep, into the hypodermis, and subsequent migration of pigment (B). It may be misdiagnosed as a hematoma or purpura:
Contact dermatitis may be seen with the application of various disinfectants, creams, ointments, or oils used to facilitate healing. An acute, pruritic, vesicular rash from tattoo disinfectant:
Despite better equipment, improved training, and increasing certification of tattoo parlors, early local infection remains a source of morbity. Risk increases with unlicensed or amateur tattooists (“scratchers” or “backyard tattooists”). Staphylococcus aureus is the main culprit, causing the spectrum of folliculitis, pustules, abscesses, and cellulitis. Several states have reported community-acquired MRSA in these infections. Management is identical to any superficial simple skin infection.
Deep or severe infections (as shown in question stem) may result from a previously superficial infection. However, there are many reports of polymicrobial cellulitis, necrotizing fasciitis, and septicemia in advanced presentations in patients who were recently tattooed. Some organisms isolated include S aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, Corynebacterium species, and Klebsiella species. These may be due to contaminated inks or contaminated water used to reconstitute the ink. Particularly unsanitary facilities have produced herpes compunctorum, or a tattoo inoculated with herpes simplex from a contaminated needle.
Our patient above shows signs of worsening cellulitis and systemic symptoms. Although he is young and relatively healthy, his ongoing smoking status will impede healing. He should be evaluated and monitored for the presence or development of necrotizing fasciitis during his hospitalization. Systemic complications of tattoo misadventures include hepatitis B and C, as well as HIV.
Other pearls:
References
Gupta D. Tattoo flash: consider "do not resuscitate". J Palliat Med. 2010 Sep;13(9):1155-6.
Hessert MJ, Devlin J. Ink sick: tattoo ink hypersensitivity vasculitis. Am J Emerg Med. 2011 Nov;29(9):1237.e3-4
Kluger N. Acute complications of tattooing presenting in the ED. Amer J Emerg Med. 2012; 30(9): 2055-2063.
MMWR. Methicillin-Resistant Staphylococcus aureus Skin Infections Among Tattoo Recipients --- Ohio, Kentucky, and Vermont, 2004—2005. June 23, 2006; 55(24):677-679
Deep or severe infections (as shown in question stem) may result from a previously superficial infection. However, there are many reports of polymicrobial cellulitis, necrotizing fasciitis, and septicemia in advanced presentations in patients who were recently tattooed. Some organisms isolated include S aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, Corynebacterium species, and Klebsiella species. These may be due to contaminated inks or contaminated water used to reconstitute the ink. Particularly unsanitary facilities have produced herpes compunctorum, or a tattoo inoculated with herpes simplex from a contaminated needle.
Our patient above shows signs of worsening cellulitis and systemic symptoms. Although he is young and relatively healthy, his ongoing smoking status will impede healing. He should be evaluated and monitored for the presence or development of necrotizing fasciitis during his hospitalization. Systemic complications of tattoo misadventures include hepatitis B and C, as well as HIV.
Other pearls:
- A recently tattooed patient with recurrent or persistent fevers should be evaluated for possible endocarditis.
- Back pain and/or neurologic findings in a recently tattooed patient may be the presentation of a spinal abcess caused by bacteremia from needle trauma.
- Systemic vasculitis can be triggered from tattoo pigment and can mimic an infectious process – always treat possible infection, but keep a systemic vasculitic reaction in the differential diagnosis of a patient who does not improve with conventional therapy.
- Pigments that contain higher levels of iron (black, brown, red) may cause a skin burn if the patient is taken to MRI. Fortunately this is usually non-life-threatening. Evaluate your patient’s “ink burden” before MRI and monitor him during the study.
- Some practitioners and centers are advocating that selected populations get tattooed with pertinent information about themselves: medically fragile children (often nonverbal/non-communicative, delayed, or with a life-threatening condition) with their chronic disease and allergies; and those with a “do not resuscitate” wish.
References
Gupta D. Tattoo flash: consider "do not resuscitate". J Palliat Med. 2010 Sep;13(9):1155-6.
Hessert MJ, Devlin J. Ink sick: tattoo ink hypersensitivity vasculitis. Am J Emerg Med. 2011 Nov;29(9):1237.e3-4
Kluger N. Acute complications of tattooing presenting in the ED. Amer J Emerg Med. 2012; 30(9): 2055-2063.
MMWR. Methicillin-Resistant Staphylococcus aureus Skin Infections Among Tattoo Recipients --- Ohio, Kentucky, and Vermont, 2004—2005. June 23, 2006; 55(24):677-679