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Monroe County Health DepartmentAn uncommon skin infection led to a doctor's investigation into tainted tattoo ink. The reddish-purple rash, seemingly woven into the tattoo on a 20-year-old New Yorker's forearm, was strange enough to have doctors scratching their heads.
Doctors initially treated the man's arm with topical steroids, thinking that the rash was allergic-contact dermatitis.
For the patient, the finding meant a trip to an infectious disease specialist to start up to a full year of treatment.
An article published Wednesday in the New England Journal of Medicine describes how this one dermatologist helped connect the dots in an outbreak of tattoo-related atypical skin infections. Mycobacterium chelonae is a rapidly growing bug found in soil, dust, water, animals, hospitals, and contaminated pharmaceuticals.
The finding sent Kennedy and his associates to the tattoo parlor where the patient had been inked. The ingredients of the ink -- pigment, witch hazel, glycerin, and distilled water -- seemed innocuous enough.
The finding raised a number of questions -- not the least of which was how the bottles of premixed ink passed U.S. While the pigments are subject to FDA monitoring, "no specific FDA regulatory requirement explicitly provides that tattoo inks must be sterile," they said.

Local jurisdictions can further regulate the practice of tattooing, with Los Angeles County cited by the CDC as an area where only sterile water is allowed for use with tattoo ink.
In a perspective article published Wednesday in the New England Journal, Pamela LeBlanc of the FDA comments on this.
The CDC urges consumers to be vigilant about ensuring hygienic practices at their tattoo parlor of choice, and to alert health care providers at any sign of infection or rash. Doctors, meanwhile, are urged to report suspected or confirmed cases to FDA's MedWatch program. What he saw was startling: the sample was riddled with a wormlike bacterium related to tuberculosis. Byron Kennedy, public health specialist at Monroe County Department of Public Health, took over the case from Goldgeier. This family of bacteria does not commonly affect healthy individuals, but in patients with suppressed immune systems -- like those with HIV or on chemotherapy -- these bacteria can cause serious disease, often resulting in death.
Everything in the clinic was sterile, which made it unlikely that the infection had arisen there. But further examination revealed that the distilled water in the pigment was the likely culprit of the contamination. Centers for Disease Control and Prevention acknowledged this gap in regulations Wednesday in its Morbidity and Mortality Weekly report.

CDC testing revealed that 1 out of 3 unopened bottles of the gray ink from the original distributor in Arizona contained mycobacterium chelonae. But the tattoo artist, they learned, had been using a new gray premixed ink purchased in Arizona in April 2011; he used the ink between May and December 2011. Kennedy then instructed nearby pathology labs to notify the county health department of any reported cases of this same infection.
The CDC then issued a national alert for local health officials to be on the lookout for tattoo-related infections caused by this bacteria. But with this burden of ink comes increased need for monitoring of safe practices and tattoo-related complications -- especially skin infections.
Once again, tendrils of mycobacterium chelonae, a type of tuberculosis-related skin bacteria, showed up in the sample. Due to these combined efforts, 19 cases of this atypical and difficult-to-treat skin infection were identified and treated, all from the same tattoo parlor.

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