Annals of Internal Medicine LETTERS

OBSERVATION: CASE REPORT Figure 1. Enlarged, black axillary lymph node that was
surgically excised.

Tattoo Pigment–Induced Granulomatous Lymphadenopathy

Mimicking Lymphoma
Background: Decorative tattooing is associated with
acute complications, such as pain, infection, and hypersensi-
tivity. Delayed reactions also occur, including regional lymph-
adenopathy that may masquerade as malignant disease (1–3).
Objective: To describe a case of tattoo pigment–induced
lymphadenopathy that mimicked the clinical and radiologic
features of lymphoma.
Case Report: A 30-year-old woman presented to our
clinic reporting a 2-week history of bilateral axillary lumps
noted on self-examination. She had no fever, night sweats,
weight loss, or pulmonary symptoms. She had a history of
cluster headaches and had previously had breast augmenta-
tion surgery at age 19 years. Her only medication was an oral
contraceptive pill. She was a nonsmoker with no relevant fam-
ily history. On examination, numerous rubbery nontethered
nodes up to 1.5 cm in diameter were felt in both axillae, with
no other palpable lymphadenopathy. Her chest was clear to
auscultation, and no hepatosplenomegaly was present. A
large black-ink tattoo that had been present for 15 years cov-
ered her back. Another black-ink tattoo on her left shoulder
was 2.5 years old.
Blood tests included a complete blood count and serum
tests of electrolytes, renal and liver function, autoimmune
antibodies, protein electrophoresis, C-reactive protein, and
angiotensin-converting enzyme. All results were within normal
ranges. Her erythrocyte sedimentation rate was mildly ele-
vated at 18 mm/h. She had no risk factors for tuberculosis,
and results of the interferon-␥ release assay were negative.
Her chest radiograph showed no abnormalities. Positron
emission tomography– computed tomography (PET-CT) re- Discussion: Decorative tattooing is common, with almost
vealed multiple enlarged lymph nodes in the axillary, hilar, 15% of Australians aged 16 to 64 years reporting having a
and mediastinal areas, with a peak standardized uptake tattoo (4). In the acute setting, tattoo pigment elicits an inflam-
value of 17.7 (markedly glucose-avid) and maximal size of matory reaction in the epidermis and dermis, occasionally
13 × 23 mm. We interpreted these findings as consistent with leading to reactive local lymphadenopathy (1). Some cases of
lymphoma. delayed lymphadenopathy caused by tattoo pigment have
Fine-needle aspiration was nondiagnostic. Subsequent been reported, including one that occurred 30 years after
excisional biopsy of a left axillary node with a standardized tattooing (2). In these reports, lymphadenopathy was initially
uptake value of 16 revealed an enlarged, black node mistaken for malignant disease, particularly for melanoma,
(28 × 17 × 13 mm) (Figure 1). Microscopically, the nodal ar- which also causes pigmented nodes (1–3). The histology
chitecture was replaced by well-formed epithelioid granulo- described ranges from normal node architecture (1) to reac-
mas with scattered multinucleate giant cells. Collections of tive nodes with follicular hyperplasia (2, 3), with the dark
black pigment–laden macrophages were noted within the tattoo pigment deposited both extracellularly and within
paracortex (Figure 2). Stains for mycobacteria and fungi and macrophages.
immunohistochemistry for malignant disorders were negative. Granulomatous reactions to tattoo pigment are well-
Flow cytometry did not detect an abnormal lymphoid popu- described and histologically can be foreign-body type, sarcoi-
lation. We concluded that the diagnosis was granulomatous dal, or necrobiotic. Sarcoidal granulomas usually involve the
lymphadenitis, which was probably a hypersensitivity reaction tattooed skin and may represent a localized reaction or the
to tattoo pigment. The patient recalled that her tattoos be- first presentation of systemic sarcoidosis (5). The case we de-
came transiently pruritic and raised in areas for a few days scribe is unique in that there was no skin reaction, only gran-
each month. She has been monitored for 10 months, and ulomatous change within the lymph nodes. In addition, no
the previously palpable axillary lymph nodes are no longer cutaneous, pulmonary, or systemic symptoms were observed
evident. to suggest systemic sarcoidosis.

This article was published at Annals.org on 3 October 2017.

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 LETTERS

Figure 2. Lymph node showing epithelioid granulomas Elizabeth Robbins, BM

Royal Prince Alfred Hospital
and pigment-laden macrophages.
Sydney, Australia

Edmund M. Lau, BSc, MBBS, PhD

Royal Prince Alfred Hospital
Sydney, Australia

Cindy Mak, MBBS

Chris O’Brien Lifehouse
Sydney, Australia

Christian Bryant, BSc, MBBS, PhD

Royal Prince Alfred Hospital
Sydney, Australia

Disclosures: Disclosures can be viewed at www.acponline.org

/authors/icmje/ConflictOfInterestForms.do?msNum=L17-0424.

doi:10.7326/L17-0424

Hematoxylin– eosin stain; original magnification, ×20.
We report a case of tattoo pigment hypersensitivity caus-
ing widespread lymphadenopathy 15 years after the tattoo
was initially inked. To the best of our knowledge, the PET-CT
findings of markedly glucose-avid nodes in multiple areas
have not previously been described. This feature in combina-
tion with the clinical findings mimicked lymphoma. We be-
lieve that this case highlights the importance of a careful tat-
too history and physical examination.
Jad Othman, MBBS
Royal Prince Alfred Hospital
Sydney, Australia
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