DERMATOLOGICA SINICA 35 (2017) 40e43

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CASE REPORT

Report of two cases of cutaneous Mycobacterium abscessus infection

complicating professional decorative tattoo
Chia-Hua Wu 1, Haw-Yueh Thong 1, Chieh-Chen Huang 1, Po-Hua Chen 1, 2, *
1
Department of Dermatology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
2
Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: Two healthy middle-aged men presented with extensive skin eruptions of erythematous papules and
Received: Feb 17, 2016 plaques associated with tattoo pigments of multiple colors. Diagnosis of cutaneous Mycobacterium
Revised: Jun 28, 2016 abscessus infection was made based on the clinical and histological findings and culture results. Both of
Accepted: Jul 5, 2016
the patients were successfully treated with clarithromycin. In addition to the two patients, nine other
clients in the same tattoo parlor also suffered from similar symptoms. A local outbreak of M. abscessus
Keywords:
infection after tattooing in Taiwan was suspected. We report two cases of M. abscessus infection after
Mycobacterium abscessus
tattooing and review the literature.
rapidly growing mycobacterium
tattoo
Copyright © 2016, Taiwanese Dermatological Association.
Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction tattoo pigment for about 1 month. He was previously diagnosed

Tattooing has been practiced for thousands of years for religious
and cosmetic purposes or as a common custom in different cul-
tures. During the procedure, tattoo artists use an electric needle to
introduce particles of pigment into the dermis. Complications
resulting from tattoos are rare, but the incidence is increasing due
to the increased popularity and efficient identification, including
inflammatory dermatoses, infections, and neoplasms.1 Although
there are increasing case reports about nontuberculosis mycobac-
terium (NTM) infection after tattooing, not all cases are caused by
Mycobacterium abscessus infection, and only six cases of definitive
M. abscessus infection following tattooing were identified in the
literature review. Thus far, there is no report of such a condition in
Taiwan. We present two cases of cutaneous M. abscessus infection
during professional tattooing.
Case Report
Case 1
A previously healthy 44-year-old man presented with extensively
involved itching and painful erythematous papules overlying the
and treated for folliculitis and allergic dermatitis using oral clin-
damycin, topical sulfur preparations, and topical and oral cortico-
steroids, but the condition did not show significant clinical
improvement. On review of his past history, 2 months prior to his
skin eruption, he underwent tattooing by a professional tattoo ar-
tist. On skin examination, there were extensive colorful totems of
yellowish, red, green, blue, and black tattoo on the patient’s arms,
shoulders, back, and chest wall. Many firm erythematous papules
were located on the black tattoo area. Some of the green-colored
zones were also involved (Figure 1A). He denied fever, chills,
cough, or other discomfort. Incisional biopsy and tissue culture of
representative lesions were performed. Histology showed granu-
lomatous inflammation mainly located in the upper dermis, with
neutrophil infiltration and focal microabscess formation
(Figure 1B). Special stain identified acid-fast bacilli in the upper
dermis (Figure 1C). Tissue culture for bacteria and fungus were
negative. M. abscessus was isolated from the tissue culture in 10
days. Plain film of chest X-ray was normal. Cutaneous M. abscessus
infection caused by direct inoculation during the tattoo procedure
was diagnosed based on the patient’s clinical history, histopatho-
logical findings, and culture results. He was treated with oral clar-
ithromycin 500 mg twice daily. Significant clinical improvement
was achieved after 6 weeks treatment (Figures 1D and 1E).

Conflict of interest: The authors declare that they have no financial or non-financial
conflicts of interest related to the subject matter or materials discussed in this article.
* Corresponding author. Department of Dermatology, National Taiwan University
Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan.
E-mail address: walile0425@gmail.com (P.-H. Chen).
Case 2
A 37-year-old man without underlying disorder, presented with a
1-month history of extensive erythematous papules on tattoo

http://dx.doi.org/10.1016/j.dsi.2016.06.006
1027-8117/Copyright © 2016, Taiwanese Dermatological Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 C.-H. Wu et al. / Dermatologica Sinica 35 (2017) 40e43 41

Figure 1 (A) Extensive firm erythematous papules and confluent plaques on the tattoo pigment; (B) in lower-powered field, there is a vague granulomatous inflammation mainly
located in the upper dermis as well as foci of microabscess (hematoxylin and eosin, 40); (C) positive stain for acid-fast bacilli (acid-fast stain, 400). Significant clinical
improvement after 6 weeks treatment with clarithromycin: before treatment (D); and after treatment (E); and (F) erythematous papules on tattoo pigments of multiple colors,
including black, red, and yellow zones.

pigments of multiple colors (Figure 1F). The skin rash developed 2
weeks after the tattoo procedure, which was performed in the same
professional tattoo parlor as for Case 1, by the same artist. In
contrast to the first case, dizziness, general weakness, and feeling of
chills accompanied his skin lesions. Incisional biopsy and tissue
culture were performed. Histology showed perivascular lympho-
histiocytic infiltration. Tissue culture for bacteria or fungi was
negative. M. abscessus was isolated from tissue culture in 8 days.
Remarkable improvement with clarithromycin was also reached
after diagnosis was confirmed.
While tracing the source of infection of our patients, we also
identified nine other clients who had developed similar symptoms
during the same period in the same parlor. Not every client who
had been tattooed with the same bottle of diluted ink developed
skin lesions, but the victims were all tattooed by the same artist. For
personal reasons and self-negligence, they refused further work-up
and management. As a result, we were unable to perform further
epidemiological survey.
Discussion
Decorative tattooing has gained more popularity in our era with
correspondingly increased adverse reactions. Approximately 2e6%
of patients who received tattooing developed complications such
as inflammatory dermatoses, infections and neoplasms.1 It is
imperative that medical practitioners recognize such conditions
and manage the complications timeously.
NTM species are a group of mycobacteria other than the Myco-
bacterium tuberculosis complex. They are free-living saprophytes in
the environment, including water, soil, dust, and aerosols. NTM
have been detected in 38% of 42 public drinking water distribution
systems in the USA and in 20.4% (10/49) of the samples of tap water
42 C.-H. Wu et al. / Dermatologica Sinica 35 (2017) 40e43

from a hospital in Taiwan.2,3 They are more tolerant to a wide range
of pH and temperature than other bacteria and can survive in water
containing trace amounts of nutrients.4 Failure to efficiently elim-
inate NTM in water treatment lines with chlorine has been
demonstrated.5 NTM resistant to aldehyde-based high-level disin-
fectant (glutaraldehyde or orthophthalaldehyde) has also been
identified, and may pose a potential threat to selection of the more
resistant strains of rapidly growing mycobacterium.6 In contrast to
M. tuberculosis, NTM are generally not considered as obligate hu-
man pathogens but may cause diseases under certain circum-
stances, such as skin injury, pulmonary or immune dysfunctions,
and chronic diseases.7
M. abscessus complex is a group of NTM, characterized by fast-
growing, nonchromogenic properties, and is notorious for multi-
drug resistance.8 M. abscessus was first isolated from a knee abscess
in 1952. Initially considered as a subspecies of Mycobacterium che-
lonae, M. abscessus was not classified as an individual species until
1992.9 It had been isolated in soft tissue infection associated with
surgery, cosmetic procedures (mesotherapy, abdominoplasty, breast
augmentation, and face lift), acupuncture, and body piercing, as well
as pulmonary disease, especially in vulnerable hosts with underlying
structural lung diseases, such as cystic fibrosis or bronchiectasis.
Systemic dissemination in immunocompromised hosts, including
persons with HIV had also been reported. Outbreaks of M. abscessus
soft tissue infections are related to contamination of laparoscopic
equipment, tap water, diluted glutaraldehyde solution, wading
pools, benzalkonium chloride, and soil from the vial lid.
There have been increasing reports of NTM infection after tat-
tooing in recent years. The majority of cases are related to
M. chelonae infection. M. abscessus infection after tattooing was
rarely reported in the literature, as summarized in Table 1.10e13
The route of cutaneous NTM infection during tattooing is clas-
sified into three categories. First, the contamination of tattoo inks
during the manufacturing or manipulating process, resulting as
failure to eliminate the pathogen in the finished product or dilution
of ink with nonsterile water at the point of use. Dilution also makes
the preservatives less effective. Second, inappropriate disinfection
prior to carrying out procedures. Lack of antiseptic practice or
inadequate disinfection technique may put the clients at risk of
mycobacterial infection. Third, contamination from the tools
introducing the pigment, such as tattoo machines or needles. In our
cases, contamination by tap water or ink was less likely, because
not every client using the same diluted ink was infected and the
lesions were located at different color zones in our patients. Hence,
it is speculated that improper disinfection or contamination of tools
was more likely to be the cause of this outbreak.
M. abscessus infection is particularly virulent and treatment is
challenging.8 Management is individualized and should consider
multimodality management such as surgical debridement, abscess
drainage, and systemic antibiotics, either singly or in combined
treatment regimens. Clarithromycin became the drug of choice in
the 1990s with therapeutic success for pulmonary infection.14
However, inducible macrolide resistance related to expression of
intrinsic erm gene has been demonstrated in M. abscessus subspecies
bulletii and abscessus.15 Besides, acquired mutations of rrl gene
encoding for the 23S rRNA have also been identified to cause mac-
rolide resistance.16 Because of the varied in vitro drug susceptibility
of M. abscessus, The Clinical and Laboratory Standards Institute
recommends testing M. abscessus for sensitivity to a panel of anti-
biotics, including clarithromycin, aminoglycosides, fluo-
roquinolones, imipenem, doxycycline, tigecycline, cefoxitin,
cotrimoxazole, and linezolid. Among these agents, clarithromycin
(83e99%), aminoglycoside (amikacin: 87e95%, isepamicin: 96%,
tobramycin: 36e95%), cefoxitin (11e99%) and tigecycline (100%)
have the best in vitro antimycobacterial activity. There was variable
susceptibility to imipenem (8e55%) and fluoroquinolones (10e73%).
Poor in vitro antimycobacterial activity was noted with tetracyclines
(5e10%), linezolid (23%), and sulfamethoxazole (1e12%).8,17,18
Monotherapy with clarithromycin could be considered for
localized cutaneous infection in immunocompetent patients.13 For
serious skin and soft tissue infection caused by M. abscessus,
combination treatment with clarithromycin and parenteral medi-
cations (amikacin, cefoxitin, or imipenem) is recommended.19
Consensus treatment guidelines regarding the treatment protocol
of cutaneous infection by rapid-growth mycobacteria are not well
established. The treatment duration is mainly based on the expert
opinion or the experiences in case series or case reports at present.
In a case review performed in Taiwan,20 30 patients with cuta-
neous, rapidly growing mycobacterial infection showed resolution
after antibiotic treatment for 4e12 months. According to expert
opinions,21 the recommended length of treatment for cutaneous
RGM infection is 4 months for mild disease and 6 months for
serious disease. In the updated statement of the American Thoracic
Society and Infectious Diseases Society of America,19 a minimum of
4 months of therapy is needed to provide a high likelihood of cure
for severe M. abscessus infection.
Effective disinfection before invasive procedures is necessary.
Alcohol, chlorhexidine gluconate (CHG), and povidoneeiodine
(PVI) are widely used disinfectants for skin preparation before
surgery. Alcohol has bactericidal, mycobactericidal, fungicidal, and
virucidal activity but does not destroy bacterial spores and has no
appreciable residual activity. CHG has antimicrobial activity against

Table 1 Summary of cutaneous Mycobacterium abscessus infection associated with tattooing in the literature review.

Refs Age Latency Skin finding Color of tattoo Probable Clustering Treatment Outcome
(y)/gender cause (2 cases)

Bechara et al10 (2009) 51/Male 10 d Numerous Grey Tap water No Clarithromycin (4 mo) Improved
papulopustular lesions
11
Ricciardo et al (2010) 23/Male 7e10 d Erythematous papules Grey Tap water Yes Minocycline (8 wk) and Improved
(1 confirmed, clarithromycin (20 wk)
1 suspected)
Falsey et al12 (2013) Unknown 7e21 d Erythematous papules Not mentioned Ink Yes Case 1: clarithromycin Improved
and pustules (3 confirmed, (2 mo)
24 suspected) Case 2: clarithromycin
(5 wk), Tigecycline
(14 d)
Case 3: not mentioned
Sousa et al13 (2015) 42/Female 15 mo Erythematous Green Unknown No Clarithromycin (5 mo) Improved
infiltrative plaques
Current study 44/Male & 1 mo & 2 wk Erythematous papules Multiple colors, Unknown Yes Clarithromycin Improved
37/Male and plaques mainly black (2 confirmed, (Ongoing, Dec 2015 to
9 suspected) present)
 C.-H. Wu et al. / Dermatologica Sinica 35 (2017) 40e43
bacteria, fungi, and enveloped viruses and shows a sustained effect
even in the presence of organic material. However, it inefficiently
kills mycobacteria and bacterial spores. PVI has the widest anti-
microbial spectrum, including bacteria, mycobacteria, spores, fungi,
and enveloped viruses, but loses effectiveness in the presence of
organic material. Both CHG and PVI are available as aqueous or
alcohol-based solutions. Many studies have been conducted
regarding preoperative antiseptics. Chlorhexidine may decrease
surgical site infection (SSI) rates compared with PVI.22 Alcohol-
based agents, either chlorhexidineealcohol or iodineealcohol are
likely superior to aqueous agents. Although not statistically sig-
nificant, there is a trend toward superiority for chlorhex-
idineealcohol over iodineealcohol in preventing SSI.23 PVI and
alcohol have an advantage over chlorhexidine for antimycobacterial
activity. PVI may be the most useful antiseptic for prevention of
mycobacterial infection, as nearly all strains of mycobacteria can be
eradicated within 30 seconds with 0.02% PVI,24 while a 1-minute
duration of disinfection with alcohol is suggested due to the
emergence of alcohol-resistant NTM.25 As a result, disinfection with
a combined regimen of chlorhexidineealcohol or iodineealcohol
for an adequate waiting period seems to be the most effective
method to prevent SSI and mycobacterial infection.
The practice of tattooing should be supervised by the govern-
ment. Regulations including the production of sterile ink, formal
personnel training in proper antiseptic practice during tattooing, and
using sterile water to dilute tattoo ink should be made mandatory.
To the best of our knowledge, this is the first case report and
small outbreak of M. abscessus cutaneous infection associated with
tattoos in Taiwan. We emphasize vigilance for healthcare providers
to include NTM infection in the differential diagnosis when seeing
patients with skin rashes after tattooing. We also suggest a need for
the Department of Health to establish regulations for safe tattoo
practices.
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