Tattoo-Associated Nontuberculous Mycobacterial Skin Infections

Multiple States, 2011-2012

Brenden Bedard, MPH; Byron Kennedy, MD; Vincent Escuyer, PhD; Kara Mitchell, PhD; Jeffrey S. Duchin, MD; Paul Pottinger, MD; Stanley Hurst, MD; Ken Sharp, MPA; Timothy Wickham, MPH; Sarah Jackson, MPH; Wendy Bamberg, MD; Pamela LeBlanc, MPH; Linda M. Katz, MD; Taranisia MacCannell, PhD; Judith Noble-Wang, PhD; Heather O'Connell, PhD; Alexander Kallen, MD; Bette Jensen, MMSc; Duc B. Nguyen, MD; Michael H. Kinzer, MD

Disclosures

Morbidity and Mortality Weekly Report. 2012;61(33):653-656. 

In This Article

Abstract and Introduction

Introduction

Permanent tattoos have become increasingly common, with 21% of adults in the United States reporting having at least one tattoo.[1] On rare occasions, outbreaks of nontuberculous mycobacterial (NTM) skin infections have been reported after tattooing.[2,3] In January 2012, public health officials in New York received reports of Mycobacterium chelonae skin infections in 14 New York residents who received tattoos during September–December 2011. All infections were associated with use of the same nationally distributed, prediluted gray ink manufactured by company A. CDC disseminated an Epi-X public health alert to identify additional tattoo-associated NTM skin infections; previously identified cases were reported from three states (Washington, Iowa, and Colorado). Public health investigations by CDC, state and local health departments, and the Food and Drug Administration (FDA) found NTM contamination in tattoo inks used in two of five identified clusters. All infected persons were exposed to one of four different brands of ink. NTM contamination of inks can occur during the manufacturing process as a result of using contaminated ingredients or poor manufacturing practices, or when inks are diluted with nonsterile water by tattoo artists. No specific FDA regulatory requirement explicitly provides that tattoo inks must be sterile. However, CDC recommends that ink manufacturers ensure ink is sterile and that tattoo artists avoid contamination of ink through dilution with nonsterile water. Consumers also should be aware of the health risks associated with getting an intradermal tattoo.

On January 4, 2012, the Monroe County (New York) Department of Public Health began an outbreak investigation after receiving a report of a person with a persistent papular rash beginning 1 week after being tattooed by an artist in October 2011; M. chelonae was isolated from a skin biopsy. Since May 2011, the artist had been using company A prediluted gray ink. Using a list of customers provided by the artist, a total of 19 infections were identified, including 14 confirmed with M. chelonae.

All infected persons had been tattooed with company A prediluted gray ink. The tattoo artist said he had not diluted the ink before use, and a review of his practices did not reveal other potential sources of contamination. M. chelonae was isolated from tissue specimens, and from one opened and one unopened bottle of company A prediluted gray ink. Pulsed-field gel electrophoresis (PFGE) patterns of 11 available patient isolates and an unopened bottle of company A prediluted gray ink were indistinguishable; the M. chelonae isolate from the opened ink bottle showed ≥95% genetic relatedness to the other isolates. Water and environmental samples collected at the manufacturing company and tattoo parlor were negative for M. chelonae.

Company A prediluted gray ink was a nationally distributed product. To identify additional tattoo-related NTM infections not limited to exposure to any particular brand of ink, case finding was initiated February 15, 2012, through Epi-X using the following case definitions: 1) a possible case was defined as persistent inflammatory reaction (i.e., redness, swelling, or nodules) localized within the margins of a new tattoo on a person between May 1, 2011, and February 10, 2012; 2) a probable case was defined as a possible case with evidence of an NTM infection by histopathology or clinical response to treatment; 3) a confirmed case was defined as a possible case with NTM cultured from a wound or skin biopsy. The New York cluster included 14 confirmed and four probable cases, and one possible case. An investigation by Public Health – Seattle & King County, Washington, identified five confirmed and 26 possible cases. Confirmed cases also were reported from Iowa (two) and Colorado (one) (Table). Among 22 confirmed cases, 63.6% involved men, and the median age of persons in the 22 cases was 33.5 years (range: 20–48 years).

Cases identified in Washington were associated with two clusters, and the initial two cases from patients with recent tattoos were reported by clinicians to local public health authorities. The first, Washington cluster 1, had three confirmed Mycobacterium abscessus cases and 24 possible cases in persons tattooed with black ink from company B. Water and environmental samples collected from company B did not grow NTM, but the company reported receiving complaints of unusually long-lasting skin reactions in clients tattooed with company B black ink from 35 customers in 19 states between August 2011 and March 2012. Customer identifiers were not available to CDC for follow-up. Two M. abscessus clinical isolates from Washington cluster 1 were indistinguishable by PFGE, but NTM was not recovered from samples of brand B ink. The second Washington cluster had two confirmed cases of M. chelonae and two possible cases associated with company C gray ink. One clinical isolate from Washington cluster 2 was available for testing. A sample from an opened bottle of company C gray ink grew M. chelonae, which was unrelated to the Washington cluster 2 clinical isolate and was unrelated to New York isolates, based on PFGE patterns. Reviews of tattoo practices at the parlors associated with the clusters did not reveal other potential sources of contamination.

The Iowa Department of Public Health reported two confirmed M. chelonae cases. Patients were tattooed with black ink from company C. PFGE testing showed that two clinical isolates from Iowa and the clinical isolate from Washington cluster 2 were indistinguishable from each other, but unrelated to New York isolates. Ink and environmental samples were not available for testing.

The Colorado Department of Public Health and Environment reported one confirmed case of M. chelonae infection. PFGE testing showed that this strain was unrelated to any of the clinical and ink isolates identified in other clusters. Artists at the Colorado tattoo parlor reported using distilled or reverse osmosis water to dilute company D black ink. Although used for tattooing, the ink was labeled as a drawing ink, and specified as not indicated for tattooing. The artist rinsed needles with distilled or reverse osmosis water when switching colors of ink on the same client. An unopened bottle of company D black drawing ink, reverse osmosis water samples, and environmental samples were tested, but NTM were not recovered.

In March and April 2012, FDA conducted inspections of company A and company B ink manufacturing sites. Ingredients used in the manufacture of tattoo inks at those sites included a wide range of pigments, carrier solutions, and diluents, including distilled water in some formulations. Samples of unopened ink bottles, ink ingredients, environmental samples, distilled water, and tap water were tested at CDC and did not yield NTM.

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