Mycobacteria Infections Associated With Tattooing

William R. Jarvis, MD


September 27, 2012


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Today I want to talk about a recent outbreak associated with tattooing. In this outbreak, a patient became infected with Mycobacterium chelonae.

The patient presented with a red papular rash in the area of grey in his tattoo. After an appropriate work-up, the patient was found to have M chelonae. Subsequently, the local health department, together with the state health department and Centers for Disease Control and Prevention (CDC), conducted an investigation.[1] They ultimately identified 19 persons who had this persistent raised erythematous rash in the tattoo area. The rashes occurred about 3 weeks after these patients received their tattoos. The tattoos were traced to an artist who used premixed grey ink.

Skin biopsies, performed on 17 of these patients, were abnormal histologically for all of the patients. M chelonae was isolated in 14 of the 17. This was confirmed by DNA sequencing, and subsequently pulsed-field gel electrophoresis was conducted of 11 clinical isolates and 1 isolate obtained from the ink dye. These were all indistinguishable by pulsed-field gel electrophoresis. In fact, the M chelonae was identified from both opened and unopened premixed grey ink.

Eighteen of the 19 individuals were treated with antimicrobials, and after varying durations, they recovered. The artist had been using this premixed dye since about May 2011. He used a new hand-blended diluted blue dye called "grey wash" that contains pigment, distilled water, witch hazel, and glycerin. It was provided by a company in Arizona. The dye is used for portrait and photography tattooing, which is becoming increasingly popular.

The health department evaluated this tattoo parlor and could identify no environmental health issues. The Arizona manufacturer subsequently conducted a voluntary recall of this dye. The organisms were found to be susceptible to both macrolides and doxycycline, and the patients were treated with either one or both of those agents.

It is important to keep in mind that other outbreaks of nontuberculous mycobacteria have been associated with tattoo parlors, and in follow-up to this investigation, other outbreaks in other tattoo parlors in other states identified a variety of nontuberculous mycobacteria, including M fortuitum, M chelonae, and M abscessus.

In this case, the premixed ink called "grey wash" was intrinsically contaminated at the time of manufacture. Other outbreaks of this are associated with intrinsic and extrinsic contamination, keeping in mind that mycobacteria, particularly nontuberculous mycobacteria, can easily survive even in distilled water.

This is an important outbreak that raises our concern about the potential for such nontuberculous mycobacteria infections associated with tattooing. Thank you.