Clinical Images: Hidden in plain sight: a case of tattoo‐associated sarcoidosis

A 33-year-old man presented with a one-month history of left retro-orbital pain, blurred vision, dry cough, low-grade fever, weight loss, and a pruritic rash. His symptoms began following house renovations, during which he was exposed to mold and water leaks. Physical examination revealed bilateral chorioretinitis, anterior uveitis in the left eye, right supraclavicular and left epitrochlear lymphadenopathy, and an erythematous, scaly, desquamative rash strictly confined to long-standing (>10-year-old) tattoos on his upper extremities and torso. Laboratory tests showed elevated erythrocyte sedimentation rate levels (36 mm/hr; reference, 0–40 mm/hr), C-reactive protein levels (37 mg/L; reference, 4–10 mg/L), and calcium levels (10.3 mg/dL; reference, 8.7–10.2 mg/dL); low total 25-hydroxyvitamin D levels (13 ng/mL; reference, 30–100ng/mL); normal 1,25-dihydroxyvitamin D3 levels (43.1 pg/mL; reference, 24.8–81.5pg/mL) and angiotensin-converting enzyme levels (56 U/L; reference, 14–82 U/L), and a positive antinuclear antibody test. Comprehensive tests for infectious etiologies and a lymphoma panel were negative. Chest computed tomography imaging revealed no pulmonary involvement. Punch biopsies of two tattooed sites revealed nonnecrotizing granulomas containing pigment, confirming extrapulmonary sarcoidosis. The patient received 60 mg intravenous methylprednisolone followed by an oral prednisone taper alongside hydroxychloroquine 400 mg daily and azathioprine 1.2 mg/kg/day, with rapid resolution of ocular inflammation and cutaneous lesions. This case highlights the diagnostic challenge of tattoo-associated sarcoidosis, often misdiagnosed as infections or allergic reactions to tattoo ink, leading to inappropriate treatments. Our patient reported using Eternal Ink, which contains nickel and cobalt; prior spectrophotometric studies suggest these metals may trigger chronic antigenic stimulation in genetically predisposed individuals.1-3 Prompt recognition enables timely and effective treatment with glucocorticoids and immunosuppressants, improving outcomes. Tattoo-associated sarcoidosis is a distinct manifestation of sarcoidosis. With tattoos becoming popular, clinicians should consider sarcoidosis in their differential diagnoses in patients with systemic symptoms and skin changes at tattoo sites, regardless of how long ago the tattoos were applied. Disclosure Form: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.