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JAMA Clinical Challenge
May 5, 2015

Tattoo Rash

Author Affiliations
  • 1Department of Medicine, Georgia Regents University, Augusta
JAMA. 2015;313(17):1747-1748. doi:10.1001/jama.2015.0990

A previously healthy 32-year-old man presented with 27-kg weight loss over the course of 1 year, dyspnea, nonproductive cough, subjective fevers, night sweats, and painful hematuria. He had tattoos placed 3 years before presentation and noticed skin lesions confined to his tattoos 1 year ago. His medical history includes a 5-pack-year smoking history but no illicit drug or alcohol use, promiscuous sexual activity, or recent travel outside of the United States. He works with Mexican immigrants. Vital signs revealed temperature, 36.7°C; heart rate, 76/min; respiratory rate, 17/min; blood pressure, 128/82 mm Hg; and oxygen saturation, 99% on room air. Examination revealed a well-appearing patient with clear lungs bilaterally and numerous scattered red to violaceous macules and papules along his tattoos (Figure 1, left). Complete blood cell count showed hemoglobin level, 11.3 g/dL; white blood cell count, 4.5 ×103/mm3; and platelet count, 189 ×103/mm3. Results of a complete metabolic panel were normal except for elevated levels of blood urea nitrogen (33 mg/dL), creatinine (3.0 mg/dL), and ionized calcium (6.7 mg/dL). Urinalysis showed gross hematuria, with 10 to 20 red blood cells per high-power field and 0 to 5 white blood cells per high-power field. Chest radiography showed bilateral hilar lymphadenopathy without consolidations, nodules, or cavitary lesions (Figure 1, right). Computed tomography of the abdomen showed right-sided hydronephrosis with an obstructive stone.

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