A 20-year-old man in China may be anxiously reassessing his chances of eternal damnation after the cross he had tattooed on his neck inexplicably vanished after five months and was replaced by an aggressive necrotic ulcer and grave inflammation. The case is so strange that doctors say it "expands the spectrum of tattoo-associated pathology."
In an uncanny case report published Thursday in JAMA Otolaryngology–Head & Neck Surgery, the man's doctors noted the multiple ways in which his lesion was striking. First, they could find no trace of an infection. The pigment used for the tattoo, which was red, had disappeared from his skin, leaving just scarring behind in places not yet covered by the ulcer. This isn't entirely unusual; in normal cases of people having a bad reaction to a tattoo, pigment has been known to migrate into lesions or lymph nodes. But in this case, there was no sign of the red ink, even with deeper digging.
When people's bodies reject tattoos, the abnormal immune reactions usually stay in the upper layers of tissue, and they almost never cause tissue death. But the man's lesion went deep and was clearly an invasive, crusty, bleeding necrotic ulcer. Moreover, doctors could also see that his neck was swollen on either side of the lesion. Magnetic resonance imaging (MRI) showed that large masses had formed on both sides of the ulcer and below it. The masses were all in the ballpark of 4 cm by 3 cm, and they were eclipsing his jugular veins. Subsequent scans with enhanced computed tomography showed the internal jugular veins on both sides of his neck had formed clots.
(You can see the image of the man's ulcer and imaging here, but be warned that it is graphic.)
The doctors used a fine needle to draw out what was in the masses to try to understand what was going on. But all they got out was dead tissue debris and immune cells, which wasn't very helpful. Given the masses, blood clots, and spreading necrotic ulcer, the man was sent to surgery. The doctors surgically removed the ulcer and masses and closed off the clotted veins. They then had to use tissue from the man's thigh to reconstruct his neck.
Jinxed ink
The final diagnosis was necrotizing granulomatous lymphadenitis, which means that clumps of immune cells formed amid inflammation, his lymph nodes became inflamed and swollen, and there was also dead tissue. It's unclear exactly how it all happened, but the doctors had several hypotheses.
A central theory is that he had an abnormal immune response to the tattoo—red organic dyes and heavy metals that can be found in some tattoo ink have been linked to this before. In one possible scenario, the abnormal immune response led to immune cell clumping, causing his lymph nodes to swell and press against his vasculature. This in turn slowed blood flow in his neck, causing cells to die.
Another possibility is that chronic inflammation from the tattoo caused the walls of his veins to start eroding, also leading to cell death. A biopsy showed necrosis in his jugular veins that supports this hypothesis. It's also possible that the inflammation response involved a variety of aberrant immune responses that spurred a hyper-coagulant state, meaning his blood formed clots more easily. Blood clots in his neck could have also led to a necrotic lesion.
While doctors can't say for sure what happened—or if it involved some sort of divine retribution—they say the case expands the possibilities of bad outcomes from tattoos and clinicians should be aware of it.
Meanwhile, the man recovered from the ordeal after comprehensive support. He was likely advised to avoid tattoos—and possibly holy water.
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