Page 112 - Journal of Special Operations Medicine - Summer 2016

changing gloves between clients, hand hygiene, skin tiguous United States come at higher risk for cutaneous
antiseptics, and disinfection of equipment and surfaces, NTM infections.
these measures were not practiced. 2
In NTM infections, pulmonary involvement is most
Although outbreaks of skin infections such as commu- common and cutaneous disease is more likely in the im-
nity-acquired MRSA have been reported in military munocompromised patient; in fact, the presence of cu-
personnel previously, infections within tattoos have taneous disease likely indicates disseminated disease. 12,13
4
rarely been studied. In a study by Armstrong et al. that Cutaneous M. kansasii is almost exclusively seen in HIV-
questioned 1,835 basic recruits and advanced training infected patients, second only to M. avium-intracellulare.
students, it was determined that almost half (48%) of M. haemophilum is another atypical mycobacterial in-
Servicemembers were serious to very serious about fection that most commonly presents in immunocom-
getting a tattoo. At the time of the study, 36% of the promised patients with cutaneous findings of painful,
6
Servicemembers were already tattooed, of whom 22% erythematous skin nodules as well as arthralgias. 12,13
already possessed three or more tattoos. These data
point to a high incidence of tattooed Servicemembers For the healthy patients and immunocompromised pa-
and evidence for an enduring goal to obtain one or more tients, such NTM infections are most typically obtained
tattoos, consistent with sectors of military culture. More from skin abrasions or penetrating trauma (e.g., pierc-
than three-fourths of tattooed Soldiers partaking in the ing, tattoos, acupuncture, and injections). Cutaneous
8
questionnaire reported procedural bleeding from obtain- trauma creates a port of entry for atypical mycobac-
ing a tattoo, which further raises the risk of blood-borne teria. Incubation periods are variable, ranging from a
disease transmission should the tattoo facility not follow few weeks to longer than 1 year. Both M. fortuitum
10
local county health department regulations. Addition- and M. chelonae are abundant worldwide and clinically
2,6
ally, the CDC has gathered a plethora of data on the will present with pustular or nodular lesions. M. chelo-
person-to-person transmission of S. aureus from drain- nae outbreaks have been associated with commercially
ing lesions secondary to obtaining a tattoo. 2 obtained prediluted gray ink and linked to dilution of
black ink with nonsterile water to obtain desired shades
Secondary infections, hypertrophic scar, and keloid of gray. 14,15 The lesions, as with most NTM skin and
formation are common reactions after Servicemembers soft tissue infections, vary in morphology. Common
13
acquire tattoos. Additional skin reactions such as ec- features include red papules, pustules, lichenoid pap-
zematous dermatitis to red ink or IgE-mediated ink al- ules, and plaques. M. szulgai is another NTM that can
lergy have been documented. However, should initial present as cutaneous lesions in an immunocompromised
3,7
treatments not improve symptoms, as in our case, due host. Of note, all mycobacteria are acid fast, which
to the unique patient population, the differential diag- means that after staining with carbol-fuchsin or aura-
nosis of persistent lesions within a tattoo should spark mine-rhodamine, they do not decolorize with acidified
further workup for more uncommon etiologies. It has alcohol. Therefore, the title of AFB is effectively identi-
been reported in the United States that nontuberculosis cal to mycobacteria. 13
mycobacterial (NTM) contamination of inks can occur
during manufacturing due to contaminated ingredients, In general, tattoo ink reactions can be classified as acute
poor manufacturing practices, or even when inks are di- inflammatory reactions (infectious or noninfectious), al-
luted with nonsterile water. The US Food and Drug lergic hypersensitivity, and granulomatous, lichenoid,
8,9
Administration (FDA) does not have a regulation that and pseudolymphomatous types. Of these other skin re-
3
explicitly requires tattoo inks to be sterile. Estimates actions, a temporary eczematous dermatitis can usually
10
of the true burden of NTM in younger populations have manifest as dry, xerotic skin with associated flaking and
not been documented, partially because these infections pruritus. Treatment with a low-potency topical steroid
can be asymptomatic, they are not communicable, and such as hydrocortisone 2.5% or desonide 0.05% along
reporting is not required in the United States or many with antihistamines would be indicated unless the lesion
other countries, though overall the prevalence appears to is draining or has other evidence of infection. For moder-
be increased with time, likely due to enhanced detection. ate symptoms (including excoriations and erythema with
skin thickening and/or disturbed sleep), treatment with
In the active duty population, deployment particularly medium-potency topical steroid would be indicated,
increases risk of exposure to NTM infections, particu- such as triamcinolone 0.1%. However, initial therapy
larly Mycobacterium fortuitum, M. chelonae, and M. should always begin with a low-potency steroid.
abscessus. Most commonly, these organisms are found
in water and soil organic matter and are not spread via Additional skin reactions can include acquired hyper-
person to person. Therefore, it would not be unreason- sensitivity reactions to the tattoo pigment. Tattoo pig-
11
able to presume that tattoos obtained outside the con- ments are not FDA approved for intradermal use and the

98 Journal of Special Operations Medicine Volume 16, Edition 2/Summer 2016