Tattoo Granulomas With Uveitis

Abstract

Bilateral intraocular inflammation and simultaneous development of tattoo granulomas has been described in several case reports. The pathophysiology of this process is poorly understood, and it has been hypothesized that it could be a similar mechanism to systemic sarcoidosis versus a delayed hypersensitivity response. Granulomatous tattoo reaction with associated uveitis can manifest with or without evidence of systemic sarcoidosis, and it is usually responsive to immunosuppression and/or tattoo removal. We present a patient with no prior diagnosis of sarcoidosis who developed bilateral panuveitis and tattoo changes suggestive of tattoo granulomas with uveitis (TAGU). The patient was initially managed with intraocular steroids and systemic steroids with minimal improvement of symptoms. The patient later required steroid sparing therapy with a tumor factor inhibitor to achieve remission. There is a growing prevalence of tattooing among the general population and a low reported rate of tattooing complications. Granulomatous tattoo reaction with associated uveitis should be a consideration in patients with tattoos presenting with "idiopathic" uveitis.

Keywords: granuloma; panuveitis; tattooing; tumor necrosis factor-α; uveitis.

Figure 1.

(A) Inflammation and induration of a large black ink tattoo over right arm and chest; tattoo was inked 1 year prior to presentation. (B) Resolution of inflammation after systemic steroid use.

Figure 2.

(A/B) Unaffected tattoos performed 10 years prior to presentation.

Figure 3.

(A) Slit lamp examination of the left eye revealing iris synechia (head arrow). (B) Optical coherence tomography of the left eye macula showing macular edema (asterisks).

Figure 4.

Histology from punch biopsies of the affected skin (hematoxylin and eosin stain at ×4 [A] and ×20 [B] power) showing evidence of granulomatous inflammation (arrows) with associated tattoo ink deposition (asterisks) consistent with foreign body-type granulomatous reaction.