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Kassirer S, Marini L, Zachary CB, Sarnoff DS, Landau M. Esthetic and medical tattooing: Part I: Tattooing techniques, implications, and adverse effects in healthy populations and special groups. J Am Acad Dermatol 2024:S0190-9622(24)00964-2. [PMID: 38980248 DOI: 10.1016/j.jaad.2024.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 07/10/2024]
Abstract
Tattooing, the introduction of exogenous pigments into the skin, has a rich history spanning thousands of years, with cultural, cosmetic, and medical significance. With the increasing prevalence of tattoos, understanding their potential complications and contraindications is of growing importance. The most common complications are hypersensitivity reactions, which may vary in morphology and timing. Infectious complications are often due to inadequate aseptic and hygienic practices during the tattooing process or healing period. Tattoo pigment can present diagnostic challenges, affecting cancer diagnosis and imaging. This CME article explores the history, cultural significance, epidemiology, chemistry, technique, contraindications, and complications of tattoos. Appreciating these factors can help individuals considering tattoos understand the safety and potential risks of their body art, and provide physicians with a thorough understanding of tattooing if consulted.
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Affiliation(s)
- Samuel Kassirer
- American Medical Program, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Leonardo Marini
- Diplomate General Surgery and Dermatology, Medical and Scientific Director, SDC The Skin Doctors Center, Trieste, Italy
| | | | - Deborah S Sarnoff
- Clinical Professor, Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine, New York, New York
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2
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Ghafari G, Newcomer J, Rigali S, Liszewski W. Permanent makeup: A review of its technique, regulation, and complications. J Am Acad Dermatol 2024:S0190-9622(24)00848-X. [PMID: 38901732 DOI: 10.1016/j.jaad.2024.01.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/19/2023] [Accepted: 01/05/2024] [Indexed: 06/22/2024]
Abstract
Permanent makeup (PMU) is a popular form of tattooing used to replace or enhance the use of daily makeup. The purpose of this literature review is to provide an overview of PMU, with a particular focus on its use, regulation, and potential complications reported in the literature. In the United States, there is significant variation in the regulation and training required to perform PMU. Adverse outcomes of PMU include infectious, allergic, and inflammatory complications. These complications may be more common if proper hygiene and aftercare practices are not followed. Cosmetically, PMU may shift or have an altered appearance if the underlying skin is treated with cosmetic fillers or local anesthetics. Given the popularity of PMU and its cosmetic uses, dermatologists should be aware of the PMU industry, potential complications, and how best to manage complications.
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Affiliation(s)
- Ghazal Ghafari
- Department of Dermatology, Northwestern University, Chicago, Illinois
| | - Jack Newcomer
- Department of Dermatology, Northwestern University, Chicago, Illinois.
| | - Sarah Rigali
- Department of Dermatology, Northwestern University, Chicago, Illinois
| | - Walter Liszewski
- Department of Dermatology, Northwestern University, Chicago, Illinois; Division of Cancer Epidemiology and Prevention, Department of Preventative Medicine, Northwestern University, Chicago, Illinois
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3
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Nontuberculous mycobacterial skin and soft tissue infection in Hawai'i. BMC Infect Dis 2022; 22:360. [PMID: 35410188 PMCID: PMC9004129 DOI: 10.1186/s12879-022-07345-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/31/2022] [Indexed: 11/27/2022] Open
Abstract
Background Hawaiʻi has the highest nontuberculous mycobacterial (NTM) lung infection prevalence in the United States. Limited data regarding skin and soft tissue infections (SSTI) due to NTM in Hawaiʻi exists. This study describes patient demographics, clinical courses of infection, treatment patterns, and clinical outcomes of NTM SSTIs in Hawaiʻi.
Methods A retrospective chart review (n = 50) of patients diagnosed and treated at Hawaiʻi Pacific Health facilities for NTM SSTIs between January 2010 and July 2021 was conducted. Patient demographics, clinical course, and treatment data were collected from electronic medical records.
Results Half of the patient population consisted of females, and the average age of patients during infection was 49 years (SD = 25.6). The majority of cases (80%) were caused by rapidly growing mycobacteria (RGM), most commonly Mycobacterium abscessus. NTM SSTI by race were Asian (48%), White (28%), and Native Hawaiian and Other Pacific Islanders (16%). Almost all Asian patients with NTM SSTI were Filipino or Japanese. Diagnosis was frequently delayed. The average time to diagnosis was 116 days. Most patients achieved complete resolution (72%) following a prolonged course of antimicrobial treatment (mean = 196 days) with surgical debridement. Conclusion Increased awareness among physicians and the community of non-mycobacterial skin infections is essential in Hawaiʻi due to the high prevalence of NTM and the high percentage of predisposed populations. Increased awareness of NTM could reduce delayed diagnosis and improve patient care. Further studies are required to inform optimal treatment and diagnostic strategies, improve patient outcomes, and aid public health surveillance efforts.
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4
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Oyen EMM, Maijer KI, van der Bent SAS, Prins JM, Janssen S, Kuipers S, De Vries HJC. Spontaneous resolution of multidrug-resistant Mycobacterium abscessus infection in tattoo. J Eur Acad Dermatol Venereol 2021; 35:e328-e330. [PMID: 33290589 DOI: 10.1111/jdv.17072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Affiliation(s)
- E M M Oyen
- Academic Tattoo Clinic Amsterdam, Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - K I Maijer
- Academic Tattoo Clinic Amsterdam, Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S A S van der Bent
- Academic Tattoo Clinic Amsterdam, Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - S Janssen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - S Kuipers
- Department of Medical Microbiology, Radboud UMC, Radboud University, Nijmegen, The Netherlands
| | - H J C De Vries
- Amsterdam Institute for Infection and Immunity (AI&II), Department of dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,STI Outpatient Clinic, Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, The Netherlands
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5
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Investigation of Two Mycobacterium abscessus Outbreaks in Quebec Using Whole Genome Sequencing. BIOMED RESEARCH INTERNATIONAL 2020. [DOI: 10.1155/2020/7092053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
In recent decades, nontuberculous mycobacteria (NTM) infections are of emerging public health concern and have contributed towards significant clinical and economic burden globally. One such rapid growing mycobacteria, Mycobacterium abscessus, can cause clonal outbreaks, and these bacteria exhibit a highly resistant antimicrobial susceptibility profile. Here, we present an investigation of two small outbreaks of M. abscessus: first in a pediatric clinic setting and second in a tattoo parlour from Quebec. Two whole genome sequencing approaches were utilized for genotyping: MAB-MLST, a multilocus sequencing typing scheme containing housekeeping, identification, and antimicrobial resistance genes, and SNVPhyl that uses phylogenetics to determine single nucleotide variations between strains. MAB-MLST results showed that the pediatric outbreak strains had two distinct sequence types, demonstrating that one strain did not belong to the outbreak, while all tattoo outbreak isolates belonged to the same sequence type. SNVPhyl results were similar to MAB-MLST results and showed that the pediatric outbreak strains tightly clustered together with 0-1 SNVs between isolates, a sharp contrast between unrelated strains used as controls. Similar results were seen for tattoo outbreak cases with 3-11 SNVs between isolates. NTM infections can be difficult to identify, and outbreak investigations can be complicated. Thus, WGS tools can be used in public health outbreak investigations as they provide high discriminatory power.
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Griffin I, Schmitz A, Oliver C, Pritchard S, Zhang G, Rico E, Davenport E, Llau A, Moore E, Fernandez D, Mejia-Echeverry A, Suarez J, Noya-Chaveco P, Elmir S, Jean R, Pettengill JB, Hollinger KA, Chou K, Williams-Hill D, Zaki S, Muehlenbachs A, Keating MK, Bhatnagar J, Rowlinson MC, Chiribau C, Rivera L. Outbreak of Tattoo-associated Nontuberculous Mycobacterial Skin Infections. Clin Infect Dis 2020; 69:949-955. [PMID: 30452604 DOI: 10.1093/cid/ciy979] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/13/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND On 29 April 2015, the Florida Department of Health in Miami-Dade County (DOH Miami-Dade) was notified by a local dermatologist of 3 patients with suspected nontuberculous mycobacterial (NTM) infection after receiving tattoos at a local tattoo studio. METHODS DOH Miami-Dade conducted interviews and offered testing, described below, to tattoo studio clients reporting rashes. Culture of clinical isolates and identification were performed at the Florida Bureau of Public Health Laboratories. Characterization of NTM was performed by the Centers for Disease Control and Prevention and the US Food and Drug Administration (FDA), respectively. Whole-genome sequencing (WGS) and single-nucleotide polymorphism (SNP) analyses were used to construct a phylogeny among 21 Mycobacterium isolates at the FDA. RESULTS Thirty-eight of 226 interviewed clients were identified as outbreak-associated cases. Multivariate logistic regression revealed that individuals who reported gray tattoo ink in their tattoos were 8.2 times as likely to report a rash (95% confidence interval, 3.1-22.1). Multiple NTM species were identified in clinical and environmental specimens. Phylogenetic results from environmental samples and skin biopsies indicated that 2 Mycobacterium fortuitum isolates (graywash ink and a skin biopsy) and 11 Mycobacterium abscessus isolates (5 from the implicated bottle of graywash tattoo ink, 2 from tap water, and 4 from skin biopsies) were indistinguishable. In addition, Mycobacterium chelonae was isolated from 5 unopened bottles of graywash ink provided by 2 other tattoo studios in Miami-Dade County. CONCLUSIONS WGS and SNP analyses identified the tap water and the bottle of graywash tattoo ink as the sources of the NTM infections.
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Affiliation(s)
- Isabel Griffin
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Ann Schmitz
- Bureau of Epidemiology, Florida Department of Health, Tallahassee.,Office of Public Health Preparedness and Response, Division of State and Local Readiness, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Christine Oliver
- Environmental Health, Florida Department of Health in Miami-Dade County
| | - Scott Pritchard
- Bureau of Epidemiology, Florida Department of Health, Tallahassee
| | - Guoyan Zhang
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Edhelene Rico
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Emily Davenport
- Center for State, Tribal, Local, and Territorial Support, CDC, Atlanta, Georgia
| | - Anthoni Llau
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Emily Moore
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Danielle Fernandez
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Alvaro Mejia-Echeverry
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Juan Suarez
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Pedro Noya-Chaveco
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | - Samir Elmir
- Environmental Health, Florida Department of Health in Miami-Dade County
| | - Reynald Jean
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
| | | | | | - Kyson Chou
- US Food and Drug Administration, Silver Spring, Maryland
| | | | - Sherif Zaki
- Infectious Disease Pathology Branch, CDC, Atlanta, Georgia
| | | | | | - Julu Bhatnagar
- Infectious Disease Pathology Branch, CDC, Atlanta, Georgia
| | - Marie-Claire Rowlinson
- Division of Disease Control and Health Protection, Bureau of Public Health Laboratories, Jacksonville, Florida
| | - Calin Chiribau
- Division of Disease Control and Health Protection, Bureau of Public Health Laboratories, Jacksonville, Florida
| | - Lillian Rivera
- Epidemiology, Disease Control, and Immunization Services, Florida Department of Health in Miami-Dade County, Tallahassee
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Abstract
Pathogen-related skin infections are a common problem in the dermatological practice. Apart from culturing and serological detection methods, a skin biopsy is a possible diagnostic procedure, especially when the clinical picture is unspecific and other non-infectious skin diseases are considered as possible differential diagnoses. Some organisms can already be detected by routine staining methods (hematoxylin & eosin, e. g., yeasts, Leishmania), for others numerous histochemical and immunohistochemical stains are available, e. g. periodic acid-Schiff reaction (PAS) and Grocott for hyphae and spores, Ziehl-Neelson and Fite-Faraco for Mycobacteria or specific antibodies for Treponema pallidum or herpesviruses. In other instances, an infectious disease may not be diagnosed with certainty in a histological section but the pattern of inflammatory infiltrates is highly suggestive of an infectious cause. Based on such reaction patterns, the dermatopathologist can advise the clinician to perform cultures or serological investigations or additional molecular biological techniques can be applied to the biopsy specimen in order to identify the pathogens. This article presents skin infections with their histopathological features and highlights diseases that can be diagnosed with certainty in a biopsy and those in which a biopsy is helpful to exclude differential diagnoses or to perform molecular diagnostics on the specimen.
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Affiliation(s)
- A Böer-Auer
- Klinik für Hautkrankheiten, Universitätsklinikum Münster, Von-Esmarch-Str. 58, 48149, Münster, Deutschland.
- Dermatologikum Hamburg, Stephansplatz 5, 20354, Hamburg, Deutschland.
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8
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Chung J, Ince D, Ford BA, Wanat KA. Cutaneous Infections Due to Nontuberculosis Mycobacterium: Recognition and Management. Am J Clin Dermatol 2018; 19:867-878. [PMID: 30168084 DOI: 10.1007/s40257-018-0382-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Nontuberculous mycobacteria (NTM) are a diverse group of organisms that are ubiquitous in the environment, and the incidence of cutaneous infections due to NTM has been steadily increasing. Cutaneous infections due to NTM can be difficult to diagnose, due to their wide spectrum of clinical presentations and histopathological findings that are often nonspecific. A variety of modalities including tissue culture and polymerase chain reaction (PCR) assays may be necessary to identify the organism. Treatment can also be challenging, as it can depend on multiple factors, including the causative organism, the patient's immunological status, and the extent of disease involvement. In this review, we discuss the common presentations of cutaneous NTM infections, diagnostic tools, and treatment recommendations. A multi-disciplinary approach that involves good communication between the clinician, the histopathologist, the microbiologist, and infectious disease specialists can help lead to successful diagnosis and management.
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Affiliation(s)
- Jina Chung
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Dilek Ince
- Division of Infectious Disease, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Bradley A Ford
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Karolyn A Wanat
- Department of Dermatology, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
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9
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Combalia A, Morgado-Carrasco D, Fustà-Novell X, Mascaró-Galy JM. Abdominal violaceous skin lesions of a 47-year-old woman following a geometric pattern. Enferm Infecc Microbiol Clin 2018; 36:598-599. [DOI: 10.1016/j.eimc.2017.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/08/2017] [Accepted: 10/10/2017] [Indexed: 11/25/2022]
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10
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Wahid B, Saleem K, Rasool N, Rafique S, Ali A, Waqar M, Idrees M. Tattooing trend: major cause of HCV transmission among youngsters. Infect Dis (Lond) 2018; 50:871-873. [PMID: 30317901 DOI: 10.1080/23744235.2018.1518586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Braira Wahid
- a Department of Life Sciences, School of Science , University of Management and Technology , Lahore , Pakistan
| | - Komal Saleem
- b Genome Centre for Molecular Based Diagnostics and Research Centre , Lahore , Pakistan.,c Centre for Applied Molecular Biology (CAMB), University of the Punjab , Lahore , Pakistan
| | - Nouman Rasool
- d Department of Life Sciences, School of Science , University of Management and Technology , Lahore , Pakistan
| | - Shazia Rafique
- e Division of Molecular Virology and Diagnostics Center of Excellence in Molecular Biology (CEMB) , University of the Punjab , Lahore , Pakistan
| | - Amjad Ali
- f Centre for Applied Molecular Biology (CAMB), University of the Punjab , Lahore , Pakistan
| | - Muhammad Waqar
- g Genome Centre for Molecular Based Diagnostics and Research Centre , Lahore , Pakistan
| | - Muhammad Idrees
- h Genome Centre for Molecular Based Diagnostics and Research Centre , Lahore , Pakistan.,i Centre for Applied Molecular Biology (CAMB), University of the Punjab , Lahore , Pakistan.,j Division of Molecular Virology and Diagnostics Center of Excellence in Molecular Biology (CEMB) , University of the Punjab , Lahore , Pakistan.,k Hazara University, Mansehra , Pakistan
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11
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Dickison P, Howard V, O'Kane G, Smith SD. Mycobacterium abscessus infection following penetrations through wetsuits. Australas J Dermatol 2018; 60:57-59. [PMID: 30175424 DOI: 10.1111/ajd.12915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 07/23/2018] [Indexed: 11/30/2022]
Abstract
Mycobacterium abscessus is a rapidly growing mycobacterium which is reportedly increasing in prevalence. Infection of the skin and soft tissue with M. abscessus is rare but typically associated with trauma. We present two cases of M. abscessus infection linked by penetration through wetsuits.
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Affiliation(s)
- Philippa Dickison
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Vicki Howard
- Department of Histopathology, Douglas Hanly Moir Pathology, North Ryde, New South Wales, Australia
| | - Gabrielle O'Kane
- Department of Microbiology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Saxon D Smith
- Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Dermatology, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,The Dermatology and Skin Cancer Centre, Gosford, New South Wales, Australia
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12
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Affiliation(s)
- Jordan Keeley
- University of Mississippi Medical School, Jackson, Mississippi
| | - Thy Huynh
- Department of Dermatology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Robert T Brodell
- Department of Dermatology, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi.,Department of Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, New York
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13
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Nho S, Kim S, Kweon O, Howard P, Moon M, Sadrieh N, Cerniglia C. Microbiological survey of commercial tattoo and permanent makeup inks available in the United States. J Appl Microbiol 2018; 124:1294-1302. [DOI: 10.1111/jam.13713] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/09/2018] [Accepted: 01/16/2018] [Indexed: 12/15/2022]
Affiliation(s)
- S.W. Nho
- Division of Microbiology National Center for Toxicological Research US FDA Jefferson AR USA
| | - S.‐J. Kim
- Division of Microbiology National Center for Toxicological Research US FDA Jefferson AR USA
| | - O. Kweon
- Division of Microbiology National Center for Toxicological Research US FDA Jefferson AR USA
| | - P.C. Howard
- Office of Scientific Coordination National Center for Toxicological Research US FDA Jefferson AR USA
| | - M.S. Moon
- Office of Cosmetics and Colors Center for Food Safety and Applied Nutrition US FDA College Park MD USA
| | - N.K. Sadrieh
- Office of Cosmetics and Colors Center for Food Safety and Applied Nutrition US FDA College Park MD USA
| | - C.E. Cerniglia
- Division of Microbiology National Center for Toxicological Research US FDA Jefferson AR USA
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14
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Velez L, Harb J, Anuszewski S, Wesson S. Cutaneous Mycobacterium massiliense infection from tattooing: a common yet under-reported and persistent epidemic hazard for dermatologists. BMJ Case Rep 2018; 2018:bcr-2017-222762. [PMID: 29330276 DOI: 10.1136/bcr-2017-222762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Tattoo popularity continues to rise, with 3 in 10 Americans bearing at least one. Among tattoo complications, non-tuberculous mycobacteria (NTM) has emerged as a global public health concern. NTM infections associated with tattooing of immunocompetent individuals have occurred as sporadic cases and community outbreaks. Water sources are considered the major pathogenic reservoirs. Tattoo-related inoculation has been linked to contamination of ink, either during the manufacturing process or during dilution of black ink using non-sterile water. NTM infections have also been documented in a number of cosmetic and surgical procedures, including cutaneous surgery, Mohs micrographic surgery, mesotherapy, liposuction and laser resurfacing. NTM inoculation through exposure to contaminated water or non-sterile instruments remains a challenge for dermatologists and risk to patients. We reported a case of cutaneous Mycobacterium massiliense infection following tattoo placement. This report underscores the importance of clinicians to consider NTM infections in the differential diagnosis of procedure-related reactions.
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Affiliation(s)
- Lymaries Velez
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jennifer Harb
- Department of Dermatology, University of Florida, Gainesville, Florida, USA
| | | | - Stanton Wesson
- Department of Dermatology, University of Florida, Gainesville, Florida, USA
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15
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Dal Molin M, Gut M, Rominski A, Haldimann K, Becker K, Sander P. Molecular Mechanisms of Intrinsic Streptomycin Resistance in Mycobacterium abscessus. Antimicrob Agents Chemother 2018; 62:e01427-17. [PMID: 29061744 PMCID: PMC5740355 DOI: 10.1128/aac.01427-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/17/2017] [Indexed: 12/29/2022] Open
Abstract
Streptomycin, the first drug used for the treatment of tuberculosis, shows limited activity against the highly resistant pathogen Mycobacterium abscessus We recently identified two aminoglycoside-acetylating genes [aac(2') and eis2] which, however, do not affect susceptibility to streptomycin. This suggests the existence of a discrete mechanism of streptomycin resistance. M. abscessus BLASTP analysis identified MAB_2385 as a close homologue of the 3″-O-phosphotransferase [APH(3″)] from the opportunistic pathogen Mycobacterium fortuitum as a putative streptomycin resistance determinant. Heterologous expression of MAB_2385 in Mycobacterium smegmatis increased the streptomycin MIC, while the gene deletion mutant M. abscessus ΔMAB_2385 showed increased streptomycin susceptibility. The MICs of other aminoglycosides were not altered in M. abscessus ΔMAB_2385. This demonstrates that MAB_2385 encodes a specific and prime innate streptomycin resistance determinant in M. abscessus We further explored the feasibility of applying rpsL-based streptomycin counterselection to generate gene deletion mutants in M. abscessus Spontaneous streptomycin-resistant mutants of M. abscessus ΔMAB_2385 were selected, and we demonstrated that the wild-type rpsL is dominant over the mutated rpsLK43R in merodiploid strains. In a proof of concept study, we exploited this phenotype for construction of a targeted deletion mutant, thereby establishing an rpsL-based counterselection method in M. abscessus.
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Affiliation(s)
- Michael Dal Molin
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Myriam Gut
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Anna Rominski
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Klara Haldimann
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Katja Becker
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
| | - Peter Sander
- Institut für Medizinische Mikrobiologie, Universität Zürich, Zürich, Switzerland
- Nationales Zentrum für Mykobakterien, Zürich, Switzerland
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16
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Breuner CC, Levine DA, Breuner CC, Alderman EM, Garofalo R, Grubb LK, Powers ME, Upadhya KK, Wallace SB. Adolescent and Young Adult Tattooing, Piercing, and Scarification. Pediatrics 2017; 140:peds.2017-1962. [PMID: 28924063 DOI: 10.1542/peds.2017-1962] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Tattoos, piercing, and scarification are now commonplace among adolescents and young adults. This first clinical report from the American Academy of Pediatrics on voluntary body modification will review the methods used to perform the modifications. Complications resulting from body modification methods, although not common, are discussed to provide the pediatrician with management information. Body modification will be contrasted with nonsuicidal self-injury. When available, information also is presented on societal perceptions of body modification.
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Affiliation(s)
- Cora C. Breuner
- Adolescent Medicine Division, Department of Pediatrics, Orthopedics and Sports Medicine, Seattle Children’s Hospital, University of Washington, Seattle, Washington; and
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17
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Unusual Eruption on the Arm. Am J Dermatopathol 2017; 39:e102-e103. [PMID: 28727602 DOI: 10.1097/dad.0000000000000536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Wu CH, Thong HY, Huang CC, Chen PH. Report of two cases of cutaneous Mycobacterium abscessus infection complicating professional decorative tattoo. DERMATOL SIN 2017. [DOI: 10.1016/j.dsi.2016.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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19
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Abstract
ABSTRACT
Rapidly growing mycobacteria (RGM) compose approximately one-half of the currently validated mycobacterial species and are divided into six major groups, including the
Mycobacterium fortuitum
group,
M. chelonae/M. abscessus
complex,
M. smegmatis
group,
M. mucogenicum
group,
M. mageritense
/
M. wolinskyi
, and the pigmented RGM. This review discusses each group and highlights the major types of infections associated with each group. Additionally, phenotypic and molecular laboratory identification methods, including gene sequencing, mass spectrometry, and the newly emerging whole-genome sequencing, are detailed, along with a discussion of the current antimicrobial susceptibility methods and patterns of the most common pathogenic species.
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20
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Bø K, Skullerud KH, Mengshoel AT, Eldholm V, Brantsæter AB. [Tattooed norwegian tourist with fever and rashes]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:205-207. [PMID: 28181759 DOI: 10.4045/tidsskr.16.0710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Kristine Bø
- Seksjon for hudsykdommer Oslo universitetssykehus, Rikshospitalet
| | - Kristin Helene Skullerud
- Seksjon for hudsykdommer Oslo universitetssykehus, Rikshospitalet * Nåværende adresser: K.H. Skullerud, Olafiaklinikken, Seksjon for venerologi Oslo universitetssykehus
| | - Anne Torunn Mengshoel
- Avdeling for mikrobiologi Oslo universitetssykehus A.T. Mengshoel, Nasjonalt referanselaboratorium for mykobakterier Folkehelseinstituttet
| | | | - Arne Broch Brantsæter
- Infeksjonsmedisinsk avdeling Oslo universitetssykehus, Ullevål og Nasjonal behandlingstjeneste for CBRNE-medisin Oslo universitetssykehus
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21
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Sousa PPD, Cruz RCDS, Schettini APM, Westphal DC. Mycobacterium abscessus skin infection after tattooing--Case report. An Bras Dermatol 2016; 90:741-3. [PMID: 26560222 PMCID: PMC4631242 DOI: 10.1590/abd1806-4841.20153362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/27/2014] [Indexed: 11/23/2022] Open
Abstract
Mycobacterium abscessus is a rapidly growing mycobacterium that has
been affecting people undergoing invasive procedures, such as videosurgery and
mesotherapy. This bacterium has global distribution, being found in numerous niches.
The frequency of published reports of infection by rapidly growing mycobacteria
associated with tattooing procedures has increased in recent years. However, in
Brazil there were no case reports of M. abscessus after tattooing in the literature
until now. In this paper, we describe the case of a patient with a nine-month history
of lesion on a tattoo site. The diagnosis of infection with Mycobacterium
abscessus was established by correlation between dermatological and
histopathological aspects, culture and molecular biology techniques. The patient had
significant improvement of symptoms with the use of clarithromycin monotherapy.
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22
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Islam PS, Chang C, Selmi C, Generali E, Huntley A, Teuber SS, Gershwin ME. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol 2016; 50:273-86. [DOI: 10.1007/s12016-016-8532-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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23
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Pescitelli L, Galeone M, Tripo L, Prignano F. Cutaneous Non-Tuberculous Mycobacterial Infections: Clinical Clues and Treatment Options. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2015. [DOI: 10.1007/s40506-015-0064-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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24
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Important to recognize and manage complications of decorative tattoos. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-015-0210-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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25
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Abstract
Decorative tattoo is a popular practice that is generally safe when performed in the professional setting but can be associated with a variety of inflammatory, infectious, and neoplastic complications, risks that may be increased with current trends in home tattooing. Modern tattoo inks contain azo dyes and are often of unknown composition and not currently regulated for content or purity. Biopsy of most (if not all) tattoo reactions presenting to the dermatologist is recommended, given recent clusters of nontuberculous mycobacterial infections occurring within tattoo, as well as associations between tattoo reactions and systemic diseases such as sarcoidosis.
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Affiliation(s)
- Michi M Shinohara
- Divisions of Dermatology and Dermatopathology, University of Washington School of Medicine, Seattle, Washington.
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26
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Mikkelsen CS, Holmgren HR, Arvesen KB, Jarjis RD, Gunnarsson GL. Severe scratcher-reaction: an unknown health hazard? Dermatol Reports 2015; 7:5816. [PMID: 25918618 PMCID: PMC4387333 DOI: 10.4081/dr.2015.5816] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 12/23/2022] Open
Abstract
Tattoos are well known to cause skin problems and the number of reported adverse reactions after tattooing has increased. Illegally imported tattoo ink is unrestrained and can contain unknown ingredients and contamination thereby posing a serious health hazard. We present a case illustrating the risk of pronounced phototoxic allergic reaction and other severe complications after using home kit tattoo ink.
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Affiliation(s)
| | | | | | - Reem Dina Jarjis
- Department of Plastic Surgery, Aalborg University Hospital , Denmark
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27
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Yun JH, Sung H, Kim T, Hong SI, Chong YP, Kim SH, Choi SH, Kim YS, Woo JH, Lee SO. Comparison of the clinical characteristics of Mycobacterium tuberculosis and nontuberculous mycobacteria patients with joint involvement. Infection 2015; 43:207-9. [PMID: 25623639 DOI: 10.1007/s15010-015-0731-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/14/2015] [Indexed: 01/15/2023]
Abstract
Nontuberculous mycobacteria (NTM) joint involvement is rare. However, the incidence of NTM disease is increasing and it is difficult to distinguish NTM from Mycobacterium tuberculosis (MTB). Here, the clinical characteristics of NTM joint involvement were compared with those of MTB. Distal joint involvement and precipitating factors were significantly more frequent for NTM joint infections. Because pathologic findings of NTM and MTB were similar, microbiological investigations are needed.
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Affiliation(s)
- J H Yun
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
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28
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Dubée V, Bernut A, Cortes M, Lesne T, Dorchene D, Lefebvre AL, Hugonnet JE, Gutmann L, Mainardi JL, Herrmann JL, Gaillard JL, Kremer L, Arthur M. β-Lactamase inhibition by avibactam in Mycobacterium abscessus. J Antimicrob Chemother 2014; 70:1051-8. [PMID: 25525201 DOI: 10.1093/jac/dku510] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Two β-lactams, cefoxitin and imipenem, are part of the reference treatment for pulmonary infections with Mycobacterium abscessus. M. abscessus has recently been shown to produce a broad-spectrum β-lactamase, BlaMab, indicating that the combination of β-lactams with a BlaMab inhibitor may improve treatment efficacy. The objectives of this study were to evaluate the impact of BlaMab production on the efficacy of β-lactams in vitro and to assess the benefit of BlaMab inhibition on the activity of β-lactams intracellularly and in an animal model. METHODS We analysed the mechanism and kinetics of BlaMab inactivation by avibactam, a non-β-lactam β-lactamase inhibitor currently in Phase III of development, in combination with ceftazidime for the treatment of serious infections due to Gram-negative bacteria. We then deleted the gene encoding BlaMab to assess the extent of BlaMab inhibition by avibactam based on a comparison of the impact of chemical and genetic inactivation. Finally, the efficacy of amoxicillin in combination with avibactam was evaluated in cultured human macrophages and in a zebrafish model of M. abscessus infection. RESULTS We showed that avibactam efficiently inactivated BlaMab via the reversible formation of a covalent adduct. An inhibition of BlaMab by avibactam was observed in both infected macrophages and zebrafish. CONCLUSIONS Our data identify avibactam as the first efficient inhibitor of BlaMab and strongly suggest that β-lactamase inhibition should be evaluated to provide improved therapeutic options for M. abscessus infections.
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Affiliation(s)
- Vincent Dubée
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Audrey Bernut
- Laboratoire de Dynamique des Interactions Membranaires Normales et Pathologiques, Université de Montpellier 2 et 1, CNRS, UMR 5235, Montpellier, France INSERM, DIMNP, Montpellier, France
| | - Mélanie Cortes
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Tiffany Lesne
- Laboratoire de Dynamique des Interactions Membranaires Normales et Pathologiques, Université de Montpellier 2 et 1, CNRS, UMR 5235, Montpellier, France INSERM, DIMNP, Montpellier, France
| | - Delphine Dorchene
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Anne-Laure Lefebvre
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Jean-Emmanuel Hugonnet
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
| | - Laurent Gutmann
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Assistance Publique-Hôpitaux de Paris, Service de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Jean-Luc Mainardi
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Assistance Publique-Hôpitaux de Paris, Service de Microbiologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Jean-Louis Herrmann
- EA3647 - EPIM, Université de Versailles St-Quentin-en-Yvelines et UFR des Sciences de la Santé, Montigny-le-Bretonneux, France Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Microbiologie, Hôpital Raymond Poincaré, Garches, France
| | - Jean-Louis Gaillard
- EA3647 - EPIM, Université de Versailles St-Quentin-en-Yvelines et UFR des Sciences de la Santé, Montigny-le-Bretonneux, France Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Microbiologie, Hôpital Raymond Poincaré, Garches, France
| | - Laurent Kremer
- Laboratoire de Dynamique des Interactions Membranaires Normales et Pathologiques, Université de Montpellier 2 et 1, CNRS, UMR 5235, Montpellier, France INSERM, DIMNP, Montpellier, France
| | - Michel Arthur
- INSERM, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006, Paris, France Université Paris Descartes, Sorbonne Paris Cité, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1138, Centre de Recherche des Cordeliers, F-75006 Paris, France
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Simunovic C, Shinohara MM. Complications of decorative tattoos: recognition and management. Am J Clin Dermatol 2014; 15:525-36. [PMID: 25385257 DOI: 10.1007/s40257-014-0100-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Tattooing is an ancient practice that enjoys continued popularity. Although a modern, professionally performed tattoo is generally safe, complications can occur. A skin biopsy of all tattoo reactions is recommended as some tattoo reactions have systemic implications. Tattoo-related infections are seen days to decades after tattooing, and range from acute pyogenic infections to cutaneous tuberculosis. In particular, non-tuberculous mycobacterial infections happen in tattoos with increasing frequency and are introduced at the time of tattooing through contaminated ink or water used to dilute inks. Despite a transition in tattoo pigments from metal salts to industrial azo dyes, hypersensitivity reactions also persist, and include eczematous, granulomatous, lichenoid, and pseudoepitheliomatous patterns (among others). Granulomatous tattoo reactions can be a clue to cutaneous or systemic sarcoidosis, particularly in the setting of interferon use. Pseudoepitheliomatous tattoo reactions have substantial overlap with squamous cell carcinoma and keratoacanthoma, making diagnosis and management difficult. Other malignancies and their benign mimics can occur in tattoos, raising questions about the safety of tattoo ink and its role in carcinogenesis.
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Roukens AH, Mendels EJ, Verbeet NL, von dem Borne PA, Nicolae-Cristea AR, Bentvelsen RG, van Doorn R, de Boer MG. Disseminated Cutaneous Mycobacterium chelonae Infection in a Patient With Acute Myeloid Leukemia. Open Forum Infect Dis 2014; 1:ofu103. [PMID: 25734171 PMCID: PMC4324231 DOI: 10.1093/ofid/ofu103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 10/20/2014] [Indexed: 12/30/2022] Open
Abstract
We report a case of disseminated cutaneous Mycobacterium chelonae infection in a patient who was treated with chemotherapy for acute myeloid leukemia. We discuss the clinical manifestations, diagnosis, and treatment of this unusual infection in neutropenic patients.
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Abstract
PURPOSE OF REVIEW Skin and soft tissues infections (SSTIs) caused by nontuberculous mycobacteria (NTM) are underrecognized and difficult to treat. Controversies exist for optimal medical management and the role of surgery. Defining the epidemiology in the environment, in animals and in healthcare aids disease prevention. This review focuses on recent advances in epidemiology, risk factors, diagnostics and therapy. RECENT FINDINGS The increasing consumer appetite for cosmetic and body-modifying procedures (e.g. tattooing, mesotherapy, liposuction) has been associated with rises in sporadic cases and outbreaks of NTM SSTIs. In mainstream healthcare, recent epidemiological studies have helped to quantify the increased risk of NTM infection related to anti-tumour necrosis factor-α monoclonal antibody therapy. Cervicofacial lymphadenitis in children poses management dilemmas, but recent studies and resultant algorithms have simplified decision-making. Molecular studies have led to a better understanding of the epidemiology, therapy and course of Mycobacterium ulcerans infection (Buruli ulcer) that remains prevalent in many areas including sub-Saharan Africa and southeastern Australia. Apart from molecular methods, the widespread adoption of matrix-assisted laser desorption ionization-time of flight mass spectrometry by routine laboratories has potential to simplify and expedite the laboratory identification of NTMs. SUMMARY An improved understanding of the epidemiology of NTM SSTIs indicates a need to apply effective infection control and ensure regulation of cosmetic and related procedures associated with nonsterile fluids. Broader access to newer diagnostic methods will continue to improve recognition of NTM disease. Along with a paucity of therapeutic agents, there is need for more reliable methods to assess susceptibility and selection of effective combination therapy.
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