Dejection: a novel cause of rejection?

A 51-year-old man presented with non-healing ulceration at the site of a tattoo on his right leg. Some 8 years previously, in celebration of the victory of his favourite team, Carlton, in the Australian Football League Grand Final, he and a friend both had a picture of a stylised Carlton footballer tattooed on one of their legs. The tattooist did not have a navy blue pigment (the team’s colour) to tint the jersey, but improvised with another source of pigment.

The patient reported that about a year before presentation he had developed painful ulceration at the site of the tattoo. The ulcer had progressed and showed no signs of healing. Curiously, the ulceration had occurred at precisely the time when the club was undergoing a dramatic deterioration in its fortunes, as scandal and poor on-field performances saw the team fall to the bottom of the AFL ladder. My patient was just one of the many Carlton supporters who had become very disillusioned.

At presentation, there was a granulating ulcer within the tattoo that corresponded to the navy blue areas of the figure (Box), with mild surrounding inflammation. After discussion with the patient, it was decided to excise the ulcer and perform a skin graft. The graft suffered partial loss, associated with a Pseudomonas infection. The wound eventually healed, although at 1 year follow-up the patient complained of occasional itch and mild swelling in the graft.

Histology of the excised ulcer showed a dense lymphocytic infiltrate and multinucleated giant cells forming occasional granulomas, consistent with an immune response to the pigment. Black and yellow pigment was seen throughout the dermis and in histiocytes.