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Tattoo granulomas with uveitis rather than Vogt-Koyanagi-Harada disease after tattooing?

  • Nicolas Kluger
    Correspondence
    Correspondence to: Nicolas Kluger, MD, PhD
    Affiliations
    Department of Dermatology, Allergology and Venereology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland

    Tattoo Consultation, Department of Dermatology, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Published:January 15, 2019DOI:https://doi.org/10.1016/j.jcjo.2018.10.020
      Dear Editor:
      I read with interest the case by Gill et al. about a 32-year-old female who developed bilateral panuveitis associated with simultaneous tattoo.
      • Gill I.
      • Ziouzina O.
      • Kalisiak M.
      • Fielden M.
      Probable Vogt-Koyanagi-Harada disease with granulomatous tattoo-related dermatitis.
      The authors suggested that the patient had probable Vogt-Koyanagi-Harada disease (VKH). The patient did not disclose any of the other classical extraocular features of VKH. I wish to suggest another diagnosis alternative. Regarding the cutaneous symptoms, the article unfortunately lacks clinical pictures, and the authors did not specify whether the rash was restricted to black colour. The skin biopsy showed noncaseating foreign-body granulomas and black exogenous tattoo pigments in the dermis. Based on the anamnesis, the clinical and pathological findings, and the lack of sarcoidosis, I rather think that the patient may have tattoo granulomas with uveitis (TAGU).
      • Kluger N.
      Tattoo-associated uveitis with or without systemic sarcoidosis: a comparative review of the literature.
      TAGU is a recent acronym that I suggested after extensively reviewing cases of tattoo granulomas associated with uveitis from the literature.
      • Kluger N.
      Tattoo-associated uveitis with or without systemic sarcoidosis: a comparative review of the literature.
      TAGU is an exclusion diagnosis that encompasses patients for whom we fail to find any sarcoidosis or other causes after extensive investigation. The patients are mostly young males with a median age of 27 years who develop bilateral chronic anterior uveitis (81%) or panuveitis (19%). The delay of onset of uveitis varies from 6 months to 12 years after the last tattoo. Cutaneous symptoms present as infiltration, induration, and swelling within the tattoos, mainly on black tattoos (75%). In 70% of the cases, eye and skin symptoms occur almost simultaneously. As in the present case,
      • Gill I.
      • Ziouzina O.
      • Kalisiak M.
      • Fielden M.
      Probable Vogt-Koyanagi-Harada disease with granulomatous tattoo-related dermatitis.
      histology shows nonnecrotizing granulomas surrounding pigmented granules in the dermis. Patients with TAGU are more likely to receive immunosuppressive treatment because of the eye prognosis. The similarities between tattoo granulomas with uveitis and sarcoidosis raise the theoretical question of whether they represent variants of a single biological process. In practical terms, sarcoidosis should be extensively explored with laboratory tests, imaging investigations, and targeted biopsies. We recently informed French ophthalmologists about this rare cause of uveitis.

      Kluger N. Tattoo-associated uveitis. J Fr Ophtalmol. https://doi.org/10.1016/j.jfo.2018.04.008.

      As tattoo is more popular in North America than in Europe,
      • Shannon-Missal L.
      Tattoo Takeover: Three in Ten Americans Have Tattoos, and Most Don't Stop at Just One..
      we wish to raise awareness of this condition on the other side of the Atlantic.

      References

        • Gill I.
        • Ziouzina O.
        • Kalisiak M.
        • Fielden M.
        Probable Vogt-Koyanagi-Harada disease with granulomatous tattoo-related dermatitis.
        Can J Ophthalmol. 2018; 53: e179-e182
        • Kluger N.
        Tattoo-associated uveitis with or without systemic sarcoidosis: a comparative review of the literature.
        J Eur Acad Dermatol Venereol. 2018; 32: 1852-1861
      1. Kluger N. Tattoo-associated uveitis. J Fr Ophtalmol. https://doi.org/10.1016/j.jfo.2018.04.008.

        • Shannon-Missal L.
        Tattoo Takeover: Three in Ten Americans Have Tattoos, and Most Don't Stop at Just One..
        The Harris Poll, 2016 (February 10. Available from:)