Life-threatening cellulitis after traditional Samoan tattooing

Necrotizing Fasciitis Occurring After a Conventional Tattoo

A 34-year-old patient presented to the emergency department after getting a tattoo from a licensed tattoo artist at home. The patient was in septic shock with renal failure, and the clinical examination revealed a skin infection at the tattoo site. Suspecting necrotizing fasciitis, the patient underwent fasciotomy with deep tissue sampling and vacuum-assisted closure therapy. Broad-spectrum antibiotic therapy was initiated and later adjusted based on bacterial culture results. The patient quickly recovered and was discharged from the intensive care unit. We report the first case of post-conventional tattoo necrotizing fasciitis in Belgium. The tattoo was performed by a professional licensed tattoo artist, equipped as required by Western legislation. Previously reported cases highlighted necrotizing fasciitis occurring after Samoan or Samoan-style tattoos, an ancestral practice with handmade tools. In our case, the tattoo was done in a conventional way with modern tools and techniques. It is the lack of hygiene precautions that we can attribute to the development of this serious pathology.

Adverse effects related to tattoos in the community setting: a systematic review

BACKGROUND

Tattoos were historically associated with deviant behaviours or religious and other social purposes, but in the last decades, they have gained increasing popularity and have become a mainstream. The aim of this systematic review is to assess the literature evidence about decorative tattoos complications, considering both infective and non-infective risks.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We searched the following electronic bibliographic databases: PubMed, Scopus and Web of Science (science and social science citation index).

RESULTS

The literature search resulted in 6473 studies. A total of 207 full articles were considered potentially relevant and were reviewed independently by researchers. After full-text evaluation, 152 of 207 articles were excluded, as they did not meet selection criteria. The remaining 55 studies were included in the systematic review and their quality assessment was performed. Ten studies reported microbiological complications, 37 reported non-microbiological effects and eight reported either microbiological and non-microbiological complications.

CONCLUSIONS

Several well-known and uncommon risks are associated with tattooing and tattoo after-care. Public health authorities could take into account health education programmes for tattooists and customers in order to prevent health complications in people with tattoos.

PROSPERO REGISTRATION NUMBER

CRD42020177972.

Systemic infections associated with tattoos or permanent makeup: A systematic review

INTRODUCTION

The aim of this article is to summarize published information on systemic infective complications of tattoos to gain an update of the current picture.

METHODS

A literature search was performed in PubMed database (2009-2019), and compared with a search without year restriction. Eligibility criteria were studies on systemic tattoo-related infections, including case reports, case series, outbreak investigations, reviews, and systematic reviews.

RESULTS

We identified 17 manuscripts with systemic infections between 2009 and 2019, with one reported fatality. In contrast to the historical records, no reports of systemic tuberculosis, syphilis or viral (hepatitis or HIV) infections were reported within the study period. A few sporadic cases or Mycobacterium leprae (India) or regional lymphadenopathy associated with skin lesions in non-tuberculosis mycobacteria were identified. Persistent fever with rigour was common in bacterial bloodstream infections. One episode of staphylococcal toxic shock syndrome and several episodes of septic shock were reported, associated with cellulitis or necrotizing fasciitis within two weeks of the procedure, predominantly caused by pyogenic bacteria (S. aureus or streptococcus). Identification of lung or systemic embolisms in the absence of local symptoms, was indicative of (right or left) infective endocarditis.

CONCLUSIONS

Bacterial bloodstream infections should be considered in subjects developing fever and rigour after tattoos, regardless of local symptoms. A shift in causative organisms has been documented, when comparing with historical reports. NTM are emerging organisms causing lymphadenopathy. Strict hygiene conditions are essential when performing a tattoo.

Legal Tattoo Complicated by Sepsis and Necrotizing Fasciitis Requiring Acute Surgery

A previously healthy 26-year-old male was referred to our hospital for fever occurring after getting a tattoo on the left leg. At the emergency department, he was promptly diagnosed with sepsis and necrotizing fasciitis of the left leg. The patient was empirically treated with vancomycin and piperacillin/tazobactam. Blood cultures identified Streptococcus pyogenes. Necrotizing fasciitis required acute surgery. The patient survived as a result of an early clinical diagnosis and surgical intervention. We report the first case of sepsis and severe soft tissue infection, after legal tattooing, which required fasciotomy. All previously reported cases have been about necrotizing fasciitis in young males who received traditional Samoan tattooing, a practice usually realized with handmade tools. In our patient, the tattoo, created in Samoan style, was performed in an authorized center by a professional tattooist using contemporary sanitary techniques.

Infection prevention in personal services settings: Evidence, gaps and the way forward

Background

Personal services is a continuously evolving industry that encompasses a variety of aesthetic treatments and personal enhancement services. Personal services are an important public health concern because delivery of service may pose potential health risks for both clients and workers. To date, there is a lack of evidence on the specific infection risks involved with personal services and the magnitude of these risks. While guidance and regulation of personal services settings do exist, they appear in varying degrees and complexity across Canada.

Objectives

To summarize relevant literature on the risk of infections related to personal services; conduct an environmental scan of current provincial and territorial guidance and regulations; identify key risk mitigation measures; and summarize gaps and challenges.

Methods

A working group of national experts in the field was established for consultation on key issues. A narrative literature review was conducted to summarize findings from relevant articles. Key questions and a literature search strategy were developed and articles were screened and critically appraised for eligibility. An environmental scan of key guidelines was also conducted to identify relevant legislation and guidance. Findings from both the narrative review and environmental scan were summarized to inform guidance and identify gaps.

Findings

The review of the literature identified factors associated with increased risk of infection including inadequate training of personal services workers and non-compliance with established infection prevention principles. The environmental scan demonstrated that some guidelines have been developed by provincial/territorial ministries of health utilizing basic, generally accepted infection prevention principles. The established body of evidence that informs infection prevention and control recommendations is valid for health care settings; however there are factors to consider in extracting and applying such guidance to personal services settings. Major gaps and challenges remain in supporting both the advancement of infection prevention guidance and the development of enhanced regulatory frameworks, applicable to personal services settings in Canada.

Conclusion

This review involved a comprehensive examination of relevant literature and provides a summary of issues addressing the risk of infection in personal services settings. There is a paucity of high quality evidence to support guidance, and findings reveal the need for further investigation and enhanced awareness of public health risks associated with personal services. Nonetheless, these findings can inform future research and the development of infection prevention and control guidelines and recommendations for such settings.

The Risk of Bacterial Infection After Tattooing

BACKGROUND

Tattooing is a globally growing trend. Overall prevalence among adults in industrialized countries is around 10-20%. Given the high and increasing numbers of tattooed people worldwide, medical and public health implications emerging from tattooing trends require greater attention not only by the public, but also by medical professionals and health policy makers.

METHODS

We performed a systematic review of the literature on tattooassociated bacterial infections and bacterial contamination of tattoo inks. Furthermore, we surveyed tattoo inks sampled during an international tattoo convention in Germany to study their microbial status.

RESULTS

Our systematic review identified 67 cases published between 1984 and 2015, mainly documenting serious bacterial infectious complications after intradermal deposition of tattoo inks. Both local skin infections (e.g. abscesses, necrotizing fasciitis) and systemic infections (e.g. endocarditis, septic shock) were reported. Published bacteriological surveys showed that opened as well as unopened tattoo ink bottles frequently contained clinically relevant levels of bacteria indicating that the manufactured tattoo product itself may be a source of infection. In our bacteriological survey, two of 39 colorants were contaminated with aerobic mesophilic bacteria.

CONCLUSION

Inappropriate hygiene measures in tattoo parlors and non-medical wound care are major risk factors for tattoo-related infections. In addition, facultative pathogenic bacterial species can be isolated from tattoo inks in use, which may pose a serious health risk.

[Rose necrosis: Necrotizing granulomatous reaction with infected node at red pigment of a tattoo]

INTRODUCTION

Nowadays, necrotizing cutaneous reaction after a tattoo is rare especially with the sterile tattoo equipment and antisepsis rules. We report the rare case of a necrotizing reaction secondary to a granulomatous reaction after a red tattoo, with a satellite node.

CASE REPORT

A 40-year-old patient suffering from a granulomatous reaction to red dye of a large pectoral tattoo, with cutaneous and sub-cutaneous necrosis, and an infected axillary node. This pectoral tattoo also triggered a necrotizing granulomatous reaction on red-pigmented areas of other older tattoos. Local treatments (dressings, antibiotics, repeated excisions of necrotizing tissues) did not stop the allergic reaction, and an infectious origin was eliminated. The patient asked for a complete excision of the pectoral tattoo. Black intramacrophagic pigment was found in the black lymph node analysed. We did not experience any complications and the patient is satisfied with the results.

DISCUSSION

Very few examples of cutaneous necrotizing secondary to a tattoo have been found in the literature. The hypothesis of a primitive infection that had secondarily led to necrosis is refuted by the lack of infective structures found in the analysed node, and most of all by the same reaction on other older tattoos on red-pigmented areas. This rare complication must be known by plastic surgeons, who will probably be called upon to take care of more and more tattooed patients.

CONCLUSION

Even if it's rare, necrosis with a granulomatous reaction to red pigment after a tattoo must be known. This case illustrates a very violent immune reaction where infection was not proved.

Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: a retrospective chart review

Background

The incidence and mortality from necrotizing fasciitis (NF) are increasing in New Zealand (NZ). Triggered by a media report that traditional Samoan tattooing was causing NF, we conducted a chart review to investigate the role of this and other predisposing and precipitating factors and to document NF microbiology, complications and interventions in NZ.

Methods

We conducted a retrospective review of 299 hospital charts of patients discharged with NF diagnosis codes in eight hospitals in NZ between 2000 and 2006. We documented and compared by ethnicity the prevalence of predisposing and precipitating conditions, bacteria isolated, complications and interventions used.

Results

Out of 299 charts, 247 fulfilled the case definition. NF was most common in elderly males. Diabetes was the most frequent co-morbid condition, followed by obesity. Nearly a quarter of patients were taking non-steroidal anti-inflammatory drugs (NSAID). Traditional Samoan tattooing was an uncommon cause. Streptococcus pyogenes and Staphylococcus aureus were the two commonly isolated bacteria. Methicillin-resistant Staphylococcus aureus was implicated in a relatively small number of cases. Shock, renal failure, coagulation abnormality and multi-organ dysfunction were common complications. More than 90% of patients underwent surgical debridement, 56% were admitted to an intensive care unit (ICU) and slightly less than half of all patients had blood product transfusion. One in six NF cases had amputations and 23.5% died.

Conclusion

This chart review found that the highest proportion of NF cases was elderly males with co-morbidities, particularly diabetes and obesity. Tattooing was an uncommon precipitating event. The role of NSAID needs further exploration. NF is a serious disease with severe complications, high case fatality and considerable use of health care resources.

Microbial status and product labelling of 58 original tattoo inks

BACKGROUND

European Council resolutions on tattoo ink introduce sterility and preservation of inks to protect customers. Inks used in Denmark are typically purchased over the internet from international suppliers and manufacturers from the US and the UK. In Denmark tattoo inks are regulated and labelled according to REACH as if they were plain chemicals.

OBJECTIVE

The objective of this study was to check the microbial product safety of unopened and opened tattoo ink stock bottles. Packaging, labelling, preservation, sterility and contamination with micro-organisms were studied.

METHODS

Physical inspection and culture of bacteria and fungi.

RESULTS

Six of 58 unopened stock bottles (10%) were contaminated with bacteria and one of six samples (17%) of previously used stock bottles was contaminated. The bacterial species represented bacteria considered pathogenic in humans as well as non-pathogenic environmental bacteria. Yeast or moulds were detected in none of the samples. A total of 31% of the manufacturers informed only about the brand name. No information about content, sterility, risks or expiry date was indicated on the label. A total of 42% claimed sterility of their inks. A total of 54% labelled a maximum period of durability of typically 2-3 years. The physical sealing was leaking in 28% of the products.

CONCLUSIONS

The European Council resolutions regarding safety of tattoo inks are not effective. Stock bottles of tattoo ink may contain bacteria pathogenic to humans and environmental bacteria, and packaging, labelling and preservation of inks are of inadequate quality. Claim of sterility can be erroneous.