Three men aged 21–24 years presented to our dermatology clinic with a 2-week history of pruritic erythematosquamous papules coalescing into plaques within areas of recent tattooing. The tattoos were done in Thailand 4 weeks before presentation (Box, A–E). The lesions were concentrated in areas of black shading and overlapping colours, and did not involve non-tattooed skin. All patients were afebrile, systemically well with no palpable lymphadenopathy. Investigations, including a full blood count, biochemistry and inflammatory markers, returned results within the normal range. Serological tests for HIV, hepatitis B, hepatitis C and syphilis were negative. Skin biopsies were performed on all three patients. Histopathology showed a suppurative granulomatous reaction with lymphohistiocytic infiltrate in the upper and mid dermis (Box, F–H). Modified Ziehl–Neelsen staining was negative for acid-fast bacilli. However, cultures showed Mycobacterium mucogenicum in Patients 1 and 2, and M. fortuitum in Patient 3. Empiric antibiotic therapy was commenced with oral clarithromycin 500 mg twice a day for 4 weeks. Patients 1 and 2 required 7 days of intravenous amikacin 750 mg daily and cefoxitin 2 g four times a day for failure to respond based on tissue culture and sensitivities.
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