Granulomatous Reaction Confined to Two Blue-ink Tattoos after H1N1 Influenza Vaccine

Abstract

A 33-year-old white female presented to dermatology clinic with a three-month history of swelling and itching of blue-ink tattoos over each of her deltoid muscles. These symptoms began within one week of receiving intramuscular H1N1 vaccine (Sanofi-Pasteur, multidose vial containing 0.01% thimerosal, lot number UP005AA with expiration date March 15th 2011) into the right deltoid muscle superior to the tattoo on the right deltoid. These tattoos were placed eight years prior at different tattoo parlors. The patient denied past cutaneous eruptions or history of sarcoidosis or other vaccines or tattoos during this period. Past medical history included depression treated with depakote and haloperidol; hysterectomy with right oophorectomy and obesity. No medications had changed in the previous four months. Social history included occasional alcohol use but no tobacco or intravenous drug abuse. Physical examination showed induration confined to the blue-ink containing skin of two tattoos over the patient's deltoid muscles ( Figure 1). Other tattoos containing black, red and yellow ink were not affected.Histology of the punch biopsy specimen revealed noncaseating granulomas containing fine black granules (Figure 2). Staining revealed no evidence of acid-fast bacilli or fungi. Pathohistological differential diagnosis was sarcoidosis versus granulomatous reaction to pigment granules.Workup for sarcoidosis included chest X-rays, pulmonary function testing, ophthalmological examination and angiotensin converting enzyme serum levels. All studies were within normal limits except for pulmonary function testing which revealed a moderate restrictive lung defect. The patient declined further workup, as well as referral to a pulmonologist. A diagnosis was made of granulomatous reaction confined to blue-ink tattoos possibly triggered by H1N1 vaccine. After failing a trial of clobetasol ointment twice daily the patient is currently well-controlled with intralesional injections of triamcinolone acetonide. CommentNoncaseating granulomas in patients with edema and pruritus of tattoos have been attributed to both sarcoidosis and delayed type hypersensitivity reactions.1 Sarcoidosis cannot be excluded even if foreign pigment is found in a biopsy site [1].Sarcoidosis is a common disorder of the lungs and skin with AbstractNoncaseating granulomas occur due to a hypersensitivity reaction to an exogenous antigen. The introduction of the H1N1 vaccine has been successful in disease prevention but we expand the current literature on possible adverse reactions to the vaccine to include granulomatous reactions.

Sarcoid Uveitis

“…The fact that granulomatous skin and ocular inflammation closely followed influenza vaccination in the patients with tattoo-associated uveitis reported by Psaltis et al in this issue of OII, 22 and by Handler et al in a previous publication, 33 supports the notion that environmental triggers may be important to the pathogenesis of both systemic and ocular sarcoidosis. 35 …”

“…Handler et al reported a similar case following H1N1 influenza vaccine, but limited to blue dye areas. 33 Psaltis et al provided a detailed summary of over 30 previously reported cases of granulomatous reaction to various tattoo dye colors, approximately one-third of which were associated with uveitis. Ostheimer et al recently reported tattoo-associated uveitis in a series of seven patients seen at The Wilmer Eye Institute over an 18-month period.…”

Systemic Sarcoidosis and Red Dye Granulomatous Tattoo Inflammation after Influenza Vaccination: A Case Report and Review of Literature

“…Handler et al 34 reported a case of granulomatous inflammation confined to the blue areas of a patient's tattoo 1 week following injection of an H1N1 vaccine containing 0.01% thimerosal preservative. The injection was administered directly superior to the tattoo on the right deltoid, which was placed 8 years prior.…”

“…The patient underwent a sarcoidosis workup that was unremarkable with exception of a moderate restrictive lung defect on PFT. Handler et al 34 theorized the release of the tattoo pigment into extracellular space during the patient's immunization initiated the granulomatous reaction. The Handler et al 34 case differs from our case because our patient received his vaccination in the arm contralateral to the tattooed arm.…”

“…Handler et al 34 theorized the release of the tattoo pigment into extracellular space during the patient's immunization initiated the granulomatous reaction. The Handler et al 34 case differs from our case because our patient received his vaccination in the arm contralateral to the tattooed arm. Therefore, the theory of Handler et al of the release of the tattoo pigment would not apply to our case.…”