title: The lady with the dragon tattoo.
abstract: BACKGROUND
  Though the skin is affected in sarcoidosis in about one-third of cases, granulomatous tattoo reactions are an unusual manifestation of the disease. It is important phenomenon to recognize, as it frequently leads to the diagnosis of systemic sarcoidosis.
  
  
  METHODS
  A 35-year-old Caucasian female with multiple tattoos presented with a 5-week history of tenderness of the black dye in a tattoo depicting a dragon. She also described a 15-month history of fatigue, polyarthralgia, and mild dyspnea. Skin biopsy demonstrated multiple dermal non-caseating granulomata with associated tattoo ink. Further investigation revealed the presence of systemic sarcoidosis. Her symptoms and skin changes improved with conservative management.
  
  
  CONCLUSIONS
  Sarcoidal tattoo reactions in those without systemic sarcoidosis are a rare occurrence, and their presence should prompt a search for systemic involvement. The accurate identification of skin involvement in sarcoidosis is important, as it tends to occur early in the course of disease, and the skin is a readily accessible site for biopsy, allowing for prompt diagnosis.
authors.affiliation: Department of Medicine, St Vincent's University Hospital and University College Dublin (UCD), Elm Park, Dublin 4, Ireland. sarahobeirne@gmail.com.
authors.forename: S L
authors.initials: SL
authors.lastname: O'Beirne
authors.affiliation: Department of Medicine, St Vincent's University Hospital and University College Dublin (UCD), Elm Park, Dublin 4, Ireland.
authors.forename: D N
authors.initials: DN
authors.lastname: O'Dwyer
authors.affiliation: Department of Medicine, St Vincent's University Hospital and University College Dublin (UCD), Elm Park, Dublin 4, Ireland.
authors.forename: S M
authors.initials: SM
authors.lastname: Walsh
authors.affiliation: Department of Radiology, St Vincent's University Hospital and University College Dublin (UCD), Elm Park, Dublin 4, Ireland.
authors.forename: J D
authors.initials: JD
authors.lastname: Dodd
authors.affiliation: Department of Pathology, St Vincent's University Hospital and University College Dublin (UCD), Elm Park, Dublin 4, Ireland.
authors.forename: T B
authors.initials: TB
authors.lastname: Crotty
authors.affiliation: Department of Medicine, St Vincent's University Hospital and University College Dublin (UCD), Elm Park, Dublin 4, Ireland.
authors.forename: S C
authors.initials: SC
authors.lastname: Donnelly
mesh_terms: D000328:Adult; D001706:Biopsy; D005260:Female; D006099:Granuloma / Q000473:pathology; D006801:Humans; D012507:Sarcoidosis / Q000175:diagnosis*; D012867:Skin / Q000473:pathology; D012871:Skin Diseases / Q000473:pathology*; D013653:Tattooing
keywords: Granuloma; Hypersensitivity; Immune Dysregulation; Sarcoidosis