Sarcoidosis presenting with multiple tattoo granulomata.

Case report The patient, a 32-year-old male unemployed gardener, had been tattooed whilst in the Army some 13 years previously. For the last 18 months he had noticed non-itchy lumps appearing in many of the tattoos, together with a swelling of the left ring finger, right thumb, left third toe and right second toe. More recently he had also developed swelling behind the left knee. On examination, the salient clinical features were multiple granulomata present in many differing tattoos. These granulomata were observed in brown (iron), green (chromium) and red (mercury) areas of different tattoos (Fig. 1). He also showed fusiform swelling of the right thumb, left ring finger, left third and right second toes (Fig. 2). There was also an effusion of the left knee with a popliteal cyst. Investigations showed a normal full blood count, urea, electrolytes, uric acid, serum proteins and liver function tests. The RA latex, DAT and ANF were negative. The Mantoux reaction was negative down to the dilution of 1/100. Chest X-ray showed bilateral hilar lymphadenopathy. X-rays of hands and feet showed abnormal trabeculation with cysts in the phalanges of the affected fingers in keeping with a diagnosis of sarcoid osteitis. Twenty millilitres of turbid yellow fluid was aspirated from the left knee. This contained 400 red cells/mm3 and 220 white cells, .( ... .....