Tattoo-associated uveitis

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Disease Entity

Tattoo-associated uveitis is a rare condition in which patients may present with uveitis and non-caseating granulomatous inflammation of tattoos. The entity was first described in a case series in 1952 by Lubeck and Epstein.[1] In general, cases present with noncaseating granulomas and uveitis (especially bilateral anterior uveitis or bilateral panuveitis). In a 2018 review, Kluger suggests that cases may be divided into three categories: presentations associated with sarcoidosis, presentations​ with no evidence of systemic manifestations of sarcoidosis​, and possible presentations without apparent tattoo involvement. [2] Tattoo-associated uveitis appears to be a rare condition based on the scarcity of reported cases, however literature review indicates that reports are increasing, possibly due to the increasing prevalence of tattoos. Some estimates suggest that ​approximately 25% of adults age 18-50 in the United States have tattoos​.[3]

Etiology

Although the etiology is unknown, it is speculated that the condition may represent a delayed hypersensitivity reaction to tattoo pigments, or possibly a limited form of sarcoidosis​.[2]

Risk Factors

The main risk factor for this condition is the presence of tattoos. Certain colors of tattoo inks have been implicated in reports, however tattoo inks are unregulated and therefore the composition of tattoo inks is not standardized.[4][5]

Histopathology

Biopsy of inflamed tattoos may reveal non-caseating granulomas, including granulomas that contain tattoo pigment. It is difficult to distinguish between foreign body granulomas and the granulomas of sarcoidosis.[6]

Diagnosis

History

All uveitis patients should be questioned about the presence of tattoos and any prior episodes of tattoo inflammation. Additional history should be obtained regarding risk factors for infectious etiologies of uveitis, and personal and family history of autoimmune diseases.

Physical examination

If patients report the presence of tattoos, it is prudent to examine the tattoos for signs of inflammation​. A complete ophthalmic examination including dilated fundus examination is warranted to look for evidence of all forms of uveitis.

Signs

Signs of tattoo-associated uveitis vary depending on the type of uveitis present. In general, tattoos may present with typical signs of inflammation including erythema, edema, induration, pain, warmth, or desquamation. Ocular signs may include conjunctival or scleral injection, tenderness, anterior chamber cell and flare, keratic precipitates including granulomatous precipitates, posterior synechiae, increased or decreased intraocular pressure, vitreous cell, snowballs or snowbanks, vasculitis, and choroiditis including choroidal granulomas.

Symptoms

Symptoms of uveitis may include pain, redness, sensitivity to light, floaters, and decreased visual acuity.

Clinical diagnosis

The diagnosis of tattoo-associated uveitis is based on the presence of both tattoos (especially inflamed tattoos) and uveitis. Diagnosis also generally requires the exclusion of other potential etiologies, especially sarcoidosis.

Diagnostic procedures

All patients with tattoo granulomas and uveitis should have an extensive workup performed to look for evidence of sarcoidosis. Chest radiograph and electrocardiogram (EKG) are recommended. If the chest radiograph is abnormal, or if the patient reports cough or dyspnea, then a high-resolution computed tomography (CT) scan of the chest is indicated to further evaluate for pulmonary sarcoidosis. Additional diagnostic procedures may be indicated depending on the history and physical examination.

Laboratory tests

As above, all patients with tattoo granulomas and uveitis should have an extensive workup performed to look for evidence of sarcoidosis. Laboratory testing should include a complete blood count with differential, a comprehensive metabolic panel, testing for tuberculosis (e.g. Quantiferon or similar test), screening for syphilis. Some physicians will also obtain serum ACE and/or lysozyme levels as part of the evaluation for sarcoidosis. Additional laboratory tests may be indicated depending on the history and physical examination.

Differential diagnosis

The differential diagnosis of uveitis is extensive, however given the typical presentations of tattoo-associated uveitis consideration may be given to infections or inflammatory etiologies. Potential infectious etiologies may include tuberculosis or syphilis. Less likely infectious etiologies may include leptospirosis, toxoplasmosis, toxocariasis, bartonellosis, or Lyme​ disease. Inflammatory etiologies include most likely sarcoidosis​, or less likely Behcet's, VKH or HLA-B27-associated uveitis.

Management

Treatment of tattoo-associated uveitis generally includes topical steroids, and often includes systemic steroids​. Systemic immunosuppression may be required. ​For an isolated small tattoo that shows evidence of inflammation, excision could be discussed with the patient as some reports describe resolution after excision.[7][8] Laser tattoo removal is not be advisable, as this could expose additional pigment to the immune system and promote further inflammation. [9][10][11][12]

Some physicians may counsel these patients against obtaining additional tattoos given the possibility that additional exposure to tattoo ink could worsen or provoke additional ocular inflammation.[13]

Complications

As with all forms of uveitis, complications of ocular inflammation and steroid treatment of ocular inflammation include peripheral anterior synechiae, posterior synechiae, secondary glaucoma, cataract, retinal detachment, and chorioretinal scarring.

Prognosis

The prognosis of tattoo-associated uveitis is variable, with many patients improving on topical and/or systemic steroids, and some patients requiring systemic immunosuppression. Some patients may require lifelong immunosuppression for severe or recurrent disease.

Additional Resources

  1. Watch for Tattoo-Related Uveitis: An Emerging Concern. https://www.aao.org/eyenet/article/watch-for-tattoo-related-uveitis

References

  1. Lubeck G, Epstein E. Complications of tattooing. Calif Med. 1952 Feb;76(2):83-5. PMID: 14905289; PMCID: PMC1521348.
  2. 2.0 2.1 Kluger, N. (2018). Tattoo‐associated uveitis with or without systemic sarcoidosis: A comparative review of the literature. Journal of the European Academy of Dermatology and Venereology, 32(11), 1852-1861. doi:10.1111/jdv.15070
  3. Laumann AE, Derick AJ. Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol. 2006 Sep;55(3):413-21. doi: 10.1016/j.jaad.2006.03.026. Epub 2006 Jun 16. PMID: 16908345.
  4. Ostheimer, T. A., Burkholder, B. M., Leung, T. G., Butler, N. J., Dunn, J. P., & Thorne, J. E. (2014). Tattoo-Associated Uveitis. American Journal of Ophthalmology, 158(3). doi:10.1016/j.ajo.2014.05.019
  5. Think Before You Ink: Are Tattoos Safe? Retrieved on November 10, 2020 from https://www.fda.gov/consumers/consumer-updates/think-you-ink-are-tattoos-safe.
  6. Saliba, N., Owen, M. & Beare, N. Tattoo-associated uveitis. Eye 24, 1406 (2010). https://doi.org/10.1038/eye.2010.17
  7. Rorsman H, Brehmer-Andersson E, Dahlquist I et al. Tattoo granuloma and uveitis. Lancet 1969; 2:27–28.
  8. Barabasi Z, Kiss E, Balaton G, Vajo Z. Cutaneous granuloma and uveitis caused by a tattoo. Wien Klin Wochenschr 2008; 120: 18.
  9. Hibler BP, Rossi AM. A case of delayed anaphylaxis after laser tattoo removal. JAAD Case Rep 2015;1:80-1.
  10. Zemtsov A, Wilson LA. Case study of a systemic allergic reaction following CO2 laser tattoo removal. Dermatitis. 1997;8:64.
  11. Izikson L, Avram M, Anderson RR. Transient immunoreactivity after laser tattoo removal: Report of two cases. Lasers Surg Med 2008;40:231-2.
  12. Meesters AA, De Rie MA, Wolkerstorfer A. Generalized eczematous reaction after fractional carbon dioxide laser therapy for tattoo allergy. J Cosmet Laser Ther 2016;18:456-8.
  13. Morales-Callaghan AM Jr, Aguilar-Bernier M Jr, Martinez-Garcia G, Miranda-Romero A. Sarcoid granuloma on black tattoo. J Am Acad Dermatol. 2006;55(5 Suppl):S71-73.