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Traditional Samoan tattoos, or tatau, are created by master tattooists, or tufuga ta tatau, and their assistants using multi-pointed handmade tools. These tools are used to tap tattoo pigment into the skin, usually over several days. This traditional process is considered an honor to the one receiving the tatau. Unfortunately, as it is typically practiced according to cultural traditions, the sanitary practices are less than ideal. There have been several reported cases of severe infection, sepsis, shock, and even death as a result of traditional Samoan tattoos. Although Hawai'i is the home of the second largest Samoan population in the United States, short of only American Samoa, literature review found no published case reports in this state. Presented is a case of a 46-year-old man, who, after undergoing a modified version of traditional Samoan tattooing for 5 days, was admitted to the intensive care unit with severe septic shock due to poly-microbial bacteremia with Group A Streptococcus and Methicillin-sensitive Staphylococcus Aureus. In addition, we will discuss the previously reported cases, mainly documented in New Zealand, and review some of the mandatory sanitary standards put into place there.
Traditional Samoan tattooing is an ancient process in practice for over two thousand years with strong ties to its culture. The traditional tattoo is referred to as pe‘a for men and malu for women. The tattoo, or tatau, is created by tools composed of shell, tooth and wood.1 A pe‘a is only done the traditional way by tapping of the tattoo pigment into the skin, usually under cultural ceremony or ritual. The design is typically geometric, covering the body from torso to knees and consisting mainly of straight lines with larger areas of solid dye. Originally, the tatau process took several months up to one year to complete. This process allowed the individual time to heal between sessions before continuing. Additionally, prior to each session the tools were boiled in water, which may explain the infrequency of complications arising from traditional tatau.1 This process is extremely painful and even in modern times, when done in stages, can take weeks to complete; in extreme cases, tattoos may be completed over a matter of days if there are no complications and the pain is tolerable.2
There are well known descriptions of medical complications arising from tattoos in general. These complications are divided into five categories: aseptic inflammation and pyogenic infections (such as impetigo, furunculosis, and cellulitis), non-pyogenic infections (to include syphilis, leprosy, and viral hepatitis), cutaneous diseases that localize in tattoos (such as vaccinia, psoriasis, and chronic discoid lupus erythematosus), acquired sensitivity to tattoo pigments, and miscellany (ie, keloids, erythema multiforme, or lymphadenopathy).3
The most serious complications are septicemia and local gangrene from deep seeded bacterial infections that can result in death.4 Although rare, life-threatening complications are more prevalent with homemade tattoos. The process of traditional Samoan tattooing has changed very little over time and as a result has led to a series of case reports linking infectious complications to Samoan tattooing in New Zealand and Australia. We present a case of a young Samoan man that developed a deep skin infection leading to bacteremia and severe sepsis after 5 consecutive days of extensive Samoan tattooing.
A previously healthy 46-year-old Samoan man presented to the emergency department after a pre-syncopal episode and 3 days of fevers, chills, and night sweats. Along with several other Samoan men receiving tattoos, a shark's tooth was used to create a pe‘a extending from his torso to lower extremities during the prior 5 days, each session lasting more than 5 hours. The tatau process was performed at the residence of a tufuga ta tatau. The patient noted increasing erythema, edema, and purulent exudate along several areas of the tattooed skin on his abdomen and right thigh since the third day of receiving his tattoos.
On admission, he was febrile, hypotensive, and tachycardic with subsequent decompensation requiring mechanical ventilation and vasopressor support for presumed septicemia from cellulitis. Laboratory studies revealed a profound leukocytosis (white cell count, 31.9×109/L), anemia (hemoglobin 9.7 g/dL, hematocrit 29.2%), mild hepatocellular injury (aspartate aminotransferase 101 units/L, alanine aminotransferase 48 units/L), acute renal failure (creatinine 1.75mg/dL) with hyperkalemia (5.9 mmol/L), myocardial infarction from toxic-metabolic supply demand mismatch with an elevated troponin of 6.170 ng/mL, C-reactive protein 40 mg/dL, pro-calcitonin 29.28 ng/mL, and an anion gap metabolic acidosis with a lactate of 5mmol/L. The patient's nares were positive for Methicillin Resistant Staphylococcus Aureus (MRSA) colonization.
He was empirically treated with intravenous Vancomycin, Pipercillin-Tazobactam, and Levofloxacin to cover for MRSA, other gram positive organisms present in skin flora, as well as gram negative and anaerobic organisms that could be introduced by unsanitary practices. On day 2 of hospitalization, blood cultures grew Methicillin-Sensitive Staphylococcus Aureus (MSSA) and Group A Streptococcus, prompting a change in his antibiotic regimen to intravenous Nafcillin and Clindamycin. Magnetic resonance imaging was performed because of concern for necrotizing fasciitis of his lower extremities and the findings were concerning for potential necrotizing extension of his skin and soft tissue infection. Surgical consultation was obtained and, after examination, it was felt the patient did not have clinical evidence to support a diagnosis of necrotizing fasciitis. He was stabilized over the course of 72 hours in the medical intensive care unit with aggressive fluid resuscitation, intravenous antibiotics, vasopressor, and inotropic support. The hospital course was complicated by the development of multiple subcutaneous abscesses in his left lower extremity requiring surgical drainage and wound debridement. He was transferred to an acute care rehabilitation center on hospital day 18 to complete a 4-week antibiotic course.
Tattoos are permanent imprints on the skin created by deposition of ink into the dermis through a series of punctures using a sharp object.5 The art of tattooing has been in practice for hundreds of years by many cultures across each continent that can be dated back to 4000 B.C. The English term tattoo has its origins from the Polynesian language and is thought to be most directly derived from the Samoan word tatau.2
Samoa is an archipelago in the South Pacific roughly halfway between Hawai‘i and New Zealand. The Samoan natives are steeped in custom and have been practicing the art of tattooing since 1500 B.C.6 These creations are more than symbols of beautification as they signify respect for a man's courage and transition through manhood — a symbol of high social status and a prerequisite to receiving a Chief title. Despite early missionary attempts to outlaw this practice, the tradition has thrived in Polynesia and continues today as it was in the past.2
When a needle pierces the outer layer of the skin, the dye is carried along the surface through the wound tract in the upper and middle aspects of the dermis.7 An inflammatory process is stimulated causing superficial epidermal sloughing and influx of inflammatory cells, exposing the basilar layers. In the dermis, most of the pigments aggregate within the papillary and reticular layer. Eventually, there is gradual assimilation of the pigment into macrophages. The majority of these macrophages migrate to regional lymph nodes, while the remaining population forms the permanent tattoo.4
The most common adverse effect from tattooing is a local bacterial infection, occasionally severe enough to cause necrosis, amputation, or even death.4 This was reported as early as the 19th century among French sailors receiving tattoos. Such complications were not surprising given the general lack of sterility, use of contaminated needles, and application of substances such as urine or saliva during the tattoo process. Today, these complications are rare in the professional tattoo community with the adoptation of sterilization, standardization of equipment, and the availability of antibiotics in the event of a cutaneous infection.3
With the emigration of Samoans throughout the Pacific basin, traditional tattooing has followed. These tattoos are a popular means of connecting to their homeland and its heritage. The sense of pride in receiving a tattoo in the traditional manner may lead to acceptance of poor antiseptic techniques involved in the tatau process.8 A strong desire to preserve this traditional process has frequently discouraged young Samoan men from using antibiotics or painkillers during the tatau process.9 Unlike Western tattooing techniques that only penetrate through the upper layers of the skin, tapping of the instrument in Samoan tradition requires some force. This primitive technique usually drives the teeth of the instrument through several layers of skin causing more injury and exposure to the outside environment.
Surprisingly, there are only a few reported cases of life threatening complications linked to traditional tattooing. The earliest report was documented by Korman of Australia in 1994.10 The traditional technique involved use of a sharpened boar's teeth and application of paste consisting of kerosene and turmeric over the tattooed areas of a Samoan male. After developing thigh inflammation, the man presented one week later with acute illness and was found to have polymicrobial septicemia with Pseudomonas aeruginosa and Streptococcus pyogenes.
In Auckland, New Zealand there has been a resurgence of traditional tattooing performed by resident tufuga ta tatau. In 2003, Porter, et al, described two cases of necrotizing fasciitis and cellulitis, one resulting in death, following traditional tattooing.11 An investigation of the two cases had similar causal themes to include improper sanitary conditions and late presentation of infectious complications because of unwillingness to access medical services as an expectation of tradition and a misunderstanding of the presenting symptoms.
Two additional cases in New Zealand were reported by McLean et al in 2010.12 The first suffered from extensive cellulitis and necrosis with wound cultures identifying Staphylococcus aureus and Group C Streptococcus. The other involved severe septic shock and multi-organ failure from necrotizing fasciitis with abdominal wound cultures demonstrating Group A Streptococcus and Pseudomonas aeruginosa. Both men were immune to Hepatitis B. Further investigation through survey of regional general practitioners and emergency departments revealed eight additional cases of cellulitis with varying degrees of severity. Five of these cases were linked to the same tattooist who was known as an experienced traditional Samoan practitioner that worked from his garage. Microbiology testing performed on his tools isolated the same strain of Group A streptococcus identified in the latter case. This tattooist voluntarily ceased practice and eventually resumed practice once he was able to demonstrate adequate infection control procedures to an infectious disease specialist.12
There are only two other recent cases identified in the literature relating to complications of Samoan tattoos, both published in New Zealand. These are unique cases linking traditional tattoos to Diphtheria,13 an acute bacterial illness caused by toxigenic strains of Corynebacterium diphtheria, and Sporotrichosis,14 a fungal infection caused by the dimorphic organism Sporothrix schenckii. Although Hawai‘i is the home of the largest Samoan population in the United States, our literature review revealed no published case reports in this state. Similar to the published cases we have just reviewed, the tatau process in our case was performed at the private residence of a local tufuga ta tatau. It is likely that bacterial pathogens were introduced through use of non-sterile instruments or improper sanitary techniques.
Given the resurgence of traditional tattoos in New Zealand and the series of related pyogenic infections, bylaws have been formulated by the Manukau City Council to specifically address these issues.15 These bylaws have been amended to include standards for cultural tattoo artists that aim to prevent transmission of diseases. According to these regulations, a tufuga ta tatau is required to obtain a permit to practice and demonstrate proper sanitation techniques before, during and after tattooing. In the state of Hawai‘i, the Department of Health has set forth minimum requirements for the safety and protection of public health.16 However, the licensing and sanitation requirements do not apply to culturally significant tattooing practices.
Traditional Samoan tattooing has been in existence for thousands of years, and remains in common practice today. There are inherent dangers with the traditional tatau techniques, mostly as a result of poor sanitation practices that have occasionally lead to serious medical complications, particularly in the modified traditional process practiced today where the pe‘as are completed in as little as 5 days to a week. In the literature review, patients present late in the course of their infectious process due to a strong desire to adhere to traditional practice without medical interference. In our case, the patient thought that his initial manifestations (erythema, induration, fevers, and even purulence) were typical inflammation for someone undergoing the tatau process. He did not seek medical care until he had systemic complications including pre-syncope and severe fatigue. This minimization of symptoms, in addition to the polymicrobial bacteremia, led to a complicated and difficult hospital course for the patient, who eventually recovered.
In addressing this public health risk, future priorities should focus on teaching of proper sanitary techniques to local tufuga ta tatau in conjunction with regulated adherence to these standards as have been established in New Zealand. However, the medical community should take caution in its approach to address the sanitation standards in order to balance the health concerns with cultural sensitivities and what may be interpreted as interference with a Samoan rite of passage. The incidence of this case, in conjunction with the documented complications in New Zealand, should provide the gateway for primary care manager (PCM) and patient discussion when a patient is going to get a tattoo. It is prudent on the part of the PCM to take thorough social history, to tease out the social roots of a patient and to ask about any cultural practices that a patient may plan to pursue. If a patient endorses desire or intent to have a tattoo, particularly a traditional style tattoo, then a PCM should take liberty to inform the patient of proper sanitation methods that the tufuga ta tatau should follow, and the Hawaiian medical community should strive to encourage our patients to seek medical treatment when they experience complications from the tatau process despite the cultural stigma that maybe associated with seeking help, as well as educating the patient population about the signs and symptoms of complications.
The views expressed in this abstract/manuscript are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.
None of the authors identify any conflict of interest. The authors have no financial interest in this paper. No financial support was provided for this paper.