Severe infections as collateral damage of decorative tattoos - A literature survey

Tattooing is an ancient decorative cosmetic procedure with increasing popularity, but regulations concerning professional including hygienic practice are limited. Although mild inflammatory responses due to infections, for instance, are known complications, severe sequelae are beyond consideration. Here we summarize 40 cases of invasive and systemic infections as collateral damages of decorative tattooing. Reports from 14 countries revealed that most patients were male, with a median age of 28.5 years including a 6-week-old infant. Cases were categorized into deep abscesses and cellulitis, infective endocarditis, necrotizing soft-tissue infection, toxic shock syndrome, sepsis, and others. Overall, Gram-positive bacteria including Staphylococcus aureus and streptococci dominated as infectious agents. Thirty out of 40 patients were considered immunocompetent, 23 required surgical interventions alongside antimicrobial therapy, and five cases were fatal. Severe complications occurred due to soft-tissue destruction near the tattoo, hematogenous seeding to distant sites such as the heart valves, and toxin-mediated systemic responses; unregulated inadequate hygienic practices were risk factors for such collateral damages. In conclusion, severe tattoo-associated infections are rare events but can be fatal even in immunocompetent individuals. In cases of otherwise unexplained soft-tissue, systemic, or cardiac valve infections a tattooing history should be considered even if the tattoo site looks uninflamed.