Pulmonary sarcoidosis presenting as a granulomatous tattoo reaction

A 29-year-old man presented with nodular skin lesions localized to areas of navy-blue pigmentation within a tattoo. Light microscopy demonstrated well-defined epithelioid granulomata in close relation to blue and black pigment. Although the patient was asymptomatic, a chest X-ray showed bilateral pulmonary shadowing, and histology of a transbronchial biopsy specimen showed features compatible with a diagnosis of sarcoidosis. X-ray energy dispersive spectroscopy identified copper and titanium in the tattoo pigment. These elements were not found in tissue from the lung biopsy. The cutaneous eruption resolved with oral steroid therapy. Our observations suggest that the granulomatous reaction in the tattoo was a manifestation of sarcoidosis, rather than a specific reaction to pigment.