Tattoo-Induced Sarcoidosis Presenting as Hypertension, AKI, and Uveitis

Introduction: There can be overlapping features on kidney biopsy of tubulointerstitial nephritis (TIN) and sarcoidosis. Both can present with interstitial nephritis and uveitis. TIN can present with extrarenal manifestations and has multiple causes including medication-induced, infectious, autoimmune, vascular, and Tubulointerstitial Nephritis and Uveitis (TINU). Renal manifestations of sarcoidosis commonly include nephrocalcinosis and renal granulomas. Although tattoo-induced sarcoidosis has been reported, renal involvement has been rarely documented. Case Description: 20-year-old female with obesity, prediabetes and multi-drug resistant hypertension presented with weight loss, fatigue, AKI and left eye redness. Ultrasound raised suspicion for bilateral renal artery stenosis. Initial diagnoses were ARB-induced and dehydration-related AKI, and episcleritis with plan for outpatient angiogram. She had worsening eye pain, fatigue and dyspnea leading to re-admission and additional work up. Urine was negative for blood and protein with 6-10 WBC/HPF. ESR/CRP were elevated; rheumatologic work-up was negative. She also developed bilateral uveitis. Renal and aorta/neck angiogram were normal but did show axillary lymphadenopathy. Lymph node pathology showed non-necrotizing epithelioid sarcoid-like granulomas with black pigment consistent with tattoo ink. Renal biopsy showed severe granulomatous tubulointerstitial nephritis, eosinophil-rich. She was started on prednisone for suspected tattoo-induced sarcoidosis with granulomatous TIN and has had improving renal function and symptoms. Discussion: Differential for uveitis and co-occurring granulomatous, eosinophil-rich interstitial nephritis includes TINU and sarcoidosis. In TINU, 10-15% have granulomas and 1/3 have eosinophilic infiltrates. Several cases of sarcoidosis can have increased interstitial eosinophils. In this case, granulomas on lymph node biopsy favors a systemic granulomatous disease like sarcoidosis, and presence of black pigment ink suggests tattoo induced process. This patient’s unique presentation of pediatric hypertension with acute onset renal injury and eye symptoms highlights the importance of multi-disciplinary evaluation and collaboration in reaching diagnosis.