An unusual case of tattoo pigments and systemic lymphadenopathy

ARTICLE

Auteur(s) : Anusha Hennedige¹, Leena Joseph², Asaid Zeiton

¹Nightingale Centre, Wythenshawe Hospital, Southmoor Road, M23 9LT Manchester, UK
²Histopathology, Wythenshawe Hospital, Southmoor Road, M23 9LT Manchester, UK

The term “tattooing” originates from a Tahitian term (Ta tatau, meaning “to mark something”) [1], and describes the implantation of pigment in the skin. Tattooing has been practised worldwide since ancient times. Despite some taboos, the art continues to be popular in many parts of the world. In Western societies today, there is an increase of body art and tattooing [2, 3]. As well as leaving a permanent imprint on the skin, tattooing comes with its own set of risks [4], some more life-threatening than others.

We present a patient with systemic lymphadenopathy secondary to the enthusiastic use of body tattooing. Increased awareness of the adverse effects of body tattooing is necessary to avoid over-investigation and prevent the alteration of an operative plan without first obtaining a nodal histological confirmation.

A 22-year-old female was referred to our Breast Unit with axillary lymphadenopathy. She reported a history of non-tender lumps in her axilla, groin and occipital region. These had not changed in size apart from a left axillary lymph node which had enlarged. There were no associated skin changes. She was otherwise asymptomatic with no significant past medical or family history.

Clinical breast examination was normal. She had large decorative and colourful body tattooing on her trunk (figures 1A, B) which she had had for 2 years. Axillary palpation revealed bilateral lymphadenopathy with particular emphasis on a larger left axillary lymph node. Ultrasound scanning of the left axilla revealed an irregular lymph node measuring 24 × 13 × 6 mm, which was recorded as abnormal with indeterminate significance. An ultrasound-guided fine needle aspiration revealed a relatively low cellularity bloodstained specimen containing lymphoid cells, consistent with a lymph node aspirate, with no evidence of metastatic carcinoma or high grade lymphoma.

Excision biopsy revealed a lobulated lymph node measuring 35 × 25 × 15 mm. Microscopic examination (figure 1C) showed preservation of the nodal architecture with scattered reactive follicles of varying sizes. There was a prominent deposition of dark granular pigment, consistent with tattoo pigment, associated with a marked expansion of the paracortex by cells with a pale eosinophilic cytoplasm and ovoid vesicular nuclei. The appearance was of a dermatopathic lymphadenopathy.

Tattooing involves piercing the skin with injections of pigmentation. The natural processes which occur involve sloughing of the overlying epidermis, dermal inflammation and assimilation of pigment into macrophages [5]. Tattoo-associated dermatoses are increasingly recognised by dermatologists but systemic complications occur as a delayed reaction, as most of the pigment finds its way to the lymph channels, leading to nodal hyperplasia.

Reactions to tattoos may present as granulomatous, lichenoid, or pseudolymphomatous reactions [6]. Intolerance reactions are recognised, however, most reactions present with a delay of a few months to several years. Malignant tumours are known to arise within tattoos [1]. When tattoo pigments are phagocytosed by macrophages and transferred to regional lymph nodes, pigments can be mixed up with metastatic changes. When present in sufficient quantity, they can mimic calcification on mammography [5]. In a similar patient over the age of 35, a mammogram in parallel with an ultrasound of the axilla would have been performed which could have revealed calcified lymph nodes [5]. This illustrates the importance of meticulous histological confirmation before proceeding with more radical surgery.

The incidence of systemic lymphadenopathy has not been reported in the literature. A Medline search for articles failed to reveal any such cases. Understanding the pathway and implications of body tattooing on a cellular basis assists in accurately predicting the potential outcomes of such a procedure. The public and medical practitioners should be made more aware of body tattooing and its potential risks so that appropriate management can be swiftly implemented.

Acknowledgements

References

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