In August 2009, a healthy 44-year-old man (patient 1) received a tattoo on his left forearm at a commercial tattoo parlor. Three days later, a painless rash developed at the tattoo site. He applied antibacterial ointment, but the rash did not resolve; 12 days after rash onset, he sought care from his health care provider. The patient denied fever and other focal or constitutional symptoms. Erythematous nodules of 3–5 mm diameter in the region of the tattoo were noted, and the patient was given ceftriaxone and trimethoprim/sulfamethoxazole for presumed pyogenic infection. Two weeks later, the lesions were unimproved. Aerobic culture of the lesions was conducted and clindamycin was prescribed; no organisms grew from the culture. In mid-September, the patient again visited his health care provider because the nodules remained unimproved. Ceftriaxone was administered, and oral cephalexin was prescribed; an aerobic bacterial culture was repeated. Two weeks later, the numerous nodular pustules confined to the tattoo region remained ().
Pustular rash caused by Mycobacterium haemophilum confined to the tattooed region of the forearm. Photograph taken in October 2009, two months after tattooing.
Test results for hepatitis B and C viruses and HIV were negative. A swab of purulent material from 2 pustules was submitted for aerobic bacterial and fungal culture, an acid-fast bacilli (AFB) culture and smear, and a varicella-zoster virus direct fluorescent antibody assay and culture; clindamycin was prescribed. Samples were spread onto Middlebrook and chocolate agar plates and incubated at 30°C and onto Middlebrook agar plates and incubated at 37°C. After 3 weeks, AFB were recovered from only the plates incubated at 30°C. Using 16S rRNA gene sequencing, we identified the isolates as M. haemophilum.
The organism was sensitive to clarithromycin (<
15 µg/mL), rifampin (<
1 µg/mL), trimethoprim/sulfamethoxazole (<
0.5/9.5 µg/mL), amikacin (<
12 µg/mL), linezolid (<
6 µg/mL), ciprofloxacin (<
2 µg/mL), and moxifloxacin (<
5 µg/mL) (10
In December 2009, treatment with rifampin, ciprofloxacin, and clarithromycin was initiated. In February 2010, the rash had improved, although healing papules and erythema were still present. In March 2010, the patient discontinued treatment because of nausea. By May 2010, the lesions had healed.
In mid-October 2009, the same health care provider evaluated a healthy 35-year-old man (patient 2) with a pustulo-nodular skin infection confined to shaded areas in a tattoo received in August 2009 at the same tattoo parlor. During November–December 2009, standard aerobic bacterial or mycobacterial cultures from this patient’s lesions were performed, but no organisms were recovered. We considered this to be a suspected case.
During December 2009, both patients were interviewed; no other potential epidemiologic links were identified. Each patient denied exposure to recreational water, aquarium water, water with rusty sediment, or any other potential skin irritants.
To identify additional M. haemophilum cases, Public Health–Seattle and King County asked physicians to report atypical skin infections that developed after receipt of tattoos performed during June 1–December 1, 2009, and asked clinical laboratories to report atypical mycobacterial species recovered during the same period. No additional cases were identified.
During an investigation of the tattoo parlor on December 10, 2009, the operator reported having used similar procedures to tattoo each patient. No deviations from Washington State safety and sanitation standards were recognized (11
). Municipal water was used in a rinse solution applied during and after tattooing and to dilute ink for shading. Eleven environmental samples collected during the site visit included ink (1.5 L); tap water (1.5 L); liquid soap (1 L); petroleum jelly; and swabs of equipment, the soap dispenser port, and the tip of a reusable black-ink container. All samples were submitted to the Centers for Disease Control and Prevention (Atlanta, GA, USA) for mycobacterial culture; no mycobacteria were recovered. The tattoo parlor operator was instructed to use only sterile water for rinse solutions and dilution of tattoo dye.