Mycobacteria introduced by tattoosBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e8331 (Published 12 December 2012) Cite this as: BMJ 2012;345:e8331
All rapid responses
In the 15 December 2012 issue of the British Medical Journal (BMJ) Scott-Lang and colleagues report a case of Mycobacterium chelonae infection following cosmetic skin tattooing(1). In the same week’s issue of the New England Journal of Medicine (NEJM) Schwartzman reports an identical dermal infection after tattooing in Los Angeles, USA(2) . His correspondence was in response to research, published in the NEJM in September 2012, reporting an outbreak of M. chelonae infection in frequenters of a tattoo parlour in New York(3) . In this case the organism was isolated for unopened ink vials from a distributor in Arizona, USA. Following the outbreak, the USA Food and Drug Administration Agency (FDA) engaged in an inclusive drive to raise awareness amongst health care providers, public health officials, consumers, and the tattoo industry in order to effectively combat tattoo-related disease . The FDA in collaboration with the Centers for Disease Control and Prevention (CDC) started a nationwide investigation which identified similar outbreaks in other states of the USA. The CDC also issued a nationwide alert on the outbreak.
Scott-Lang and colleagues suggest that the source of the infection, in the BMJ Minerva report, was the fact the tattooists mixed ink with non-sterile water, which was also used to sterilise utensils. However given the findings in New York and the USA, it is important to entertain the possibility that the inks vials were pre-contaminated with the pathogen and hence to trace the origin of the vials. The accompanying NEJM editorial warns clinicians to be alert to the possibility of ink contamination prior to distribution(4). Hogsberg and collaborators, in their January 2013 paper (published online initially), observed that 11% (6/58) of original unopened tattoo inks were contaminated with an infective pathogens(5). M. chelonae, however, was not isolated in their study. They concluded that in the Eurozone, the Europe Council resolution that tattoo ink should be sterile, was not being respected . They also note that tattoo ink vials in the Eurozone are frequently imported from both the US and the UK.
M chelonae is not a notifiable disease neither in the UK (including Scotland) nor the USA(6,7,8) in spite of the significant public health ramifications. Given this transatlantic coincidence of synchronous transatlantic tattoo-related M. chelonae infection, there may be merit in transatlantic collaboration to determine if there is an international common origin. In addition Kennedy and co-workers in the NEJM advocate greater oversight of not just tattooing but also the of the ink manufacturing process, which may also be pertinent for both the UK and the USA.
1. Scott-Lang VE, Holme A. Mycobacteria introduced by tattoos. BMJ 2012;345:e8331
2. Schwartzman WA. Mycobacterium chelonae Illnesses Associated with Tattoo Ink N Engl J Med 2012; 367:2356-2358
3. Kennedy BS, Bedard B, Younge M, et al. Outbreak of Mycobacterium chelonae infection associated with tattoo ink. N Engl J Med 2012;367:1020-1024
4. LeBlanc PM, Hollinger KA, Klontz KC. Tattoo Ink–Related Infections — Awareness, Diagnosis, Reporting, and Prevention N Engl J Med 2012; 367:985-987
5. Høgsberg T, Saunte DM, Frimodt-Møller N, Serup J. Microbial status and product labelling of 58 original tattoo inks. J Eur Acad Dermatol Venereol. 2013 Jan;27(1):73-80
Competing interests: No competing interests