Abstract: Methicillin-resistant Staphylococcus aureus (MRSA) infections are a major source of morbidity in Hamlet, NC; in 2011, there were 58 emergency room visits resulting from MRSA infections, leading to 31 admissions to Sandhills Regional Medical Center (Hamlet, NC). The situation is complicated by illegal tattoo artists offering less-expensive artwork, as their bargain prices often involve stinting on sterile technique. Three patients with infected tattoos were seen at Sandhills Center for Wound Healing and Hyperbaric Medicine (Hamlet, NC) with a range of tissue damage requiring different treatment plans. Closer scrutiny of tattoo ink and use of preservatives could prevent accidental or deliberate contamination, and reduce the risk of tattoo infection.

Introduction

  According to a 2003 survey, 15 percent of the adult population in the United States have tattoos, and for individuals under the age of 25, the number rises to 28 percent.1 Why people get tattoos is often attributed to peer pressure and the need for identity and conformity, particularly in a military setting; contradictorily, tattoos also are seen as expressions of rebellion and individual artistic expression. Since the 1990s, increasing numbers of influential trendsetters have acquired visible tattoos including Mike Tyson, Angelina Jolie, and Paris Hilton, and popular books and movies that include tattooed protagonists are changing the cultural lens through which this type of art is seen.2   Nevertheless, tattooing is a surgical procedure with a current procedural terminology code (11920). It involves the permanent introduction of insoluble opaque pigments to a depth of 1/16th inch into the skin, using arrays of up to 9 needles simultaneously, with diameters of up to 0.35 mm, depending on whether lining or shading is being done. The tattoo gun can pierce the skin 3,000 times a minute; for a tattoo that takes approximately 60 minutes, this equates to 180,000 puncture wounds. Tattooing carries the same risks as any other surgical procedure, including infections and malpractice suits. Nonmedical persons who get a permit from Richmond County Health Department in North Carolina may legally perform tattooing in the county. Legal tattoo establishments are well-regulated, frequently inspected, and not a cause for concern. In fact, they have a remarkably good record compared to a similar surgical procedure carried out in a hospital, central line insertion, where infection rates of 10% are common and there is a significant mortality rate.3 Both procedures require the need for multiple needle sticks; in the case of central lines, the needles serve to anesthetize the skin and to find the vein. In addition, both result in the retention of a foreign body—in one case ink, and in the other, a plastic catheter.   The problem lies with tattooists operating illegally who do not have access to autoclaves, and who may stint on sterile techniques to save money. Given the high overhead expenses required to comply with the law, a legal tattoo is correspondingly more expensive. For example, a tattoo covering the shoulder and using 3 colors may cost more than $500. Expense is probably the major reason why young people seek out illegal operators, particularly with the prevailing depressed economic climate in the United States.4 Additionally, Richmond County, NC, borders South Carolina, where tattoo laws are more strict, both with regard to age required to obtain a tattoo (21 years) and location of tattoos (South Carolina does not allow operators to tattoo on the head, neck, or face).5 Patrons wishing to circumvent these laws need only to drive a few miles to Richmond County.   With the current epidemic of community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) it was just a matter of time before the worlds of illegal tattooing and CA-MRSA collided.6-8 This report describes 2 cases of CA-MRSA infections complicating illegal tattoos and causing significant tissue damage, and a third case involving a non-MRSA Staphylococcus infection. These cases were all treated at Sandhills Regional Medical Center and Wound Care Center (Hamlet, NC) between June 2011 and December 2011.

Case Reports

  Case 1. An 18-year-old white female presented at Sandhills Regional Medical Center for Wound Healing and Hyperbaric Medicine on June 2011 with a CA-MRSA infection of a tattoo on her right upper thigh. The previous week, the patient underwent an incision and drainage at another hospital. The patient reported that her antibiotics had been stolen, and that and the infection had become more painful (Figure 1). After a drainage procedure, the wound was 1.5 cm by 0.5 cm by 0.5 cm in depth (Figure 2). The wound was treated with Algidex strip packing (DeRoyal Medical Products, Powell, TN) and the patient was given a supply to take home. In addition, the patient’s Bactrim oral antibiotic (AR Scientific, Philadelphia, PA) was refilled. A friend of the patient who was a nurse assumed care, and the patient did not return to the clinic for follow-up. When contacted by phone, the patient told the author she completed regular packing of the wound for 2 months before it completely healed.   Case 2. A 22-year-old white female was referred to the center by her primary care physician on November 8, 2011, with a CA-MRSA abscess on her right scapular area, the site of a tattoo completed a few days earlier (Figure 3). The patient’s medical history included cystitis, anxiety, drug detoxification, irritable bowel syndrome, and kidney stones.   After debridement in the operating room on November 9, the wound was 3.5 cm x 2.2 cm x 2.5 cm deep (Figure 4). Initially, the patient was treated with Algidex packing and oral Bactrim. Despite treatment, the wound increased in size and continued to culture out MRSA. The treatment plan was changed on November 28 to daily outpatient IV vancomycin and negative pressure therapy (200 mm Hg and black foam, changed 3 times per week [Kinetic Concepts, Inc, San Antonio, TX]). As the wound healed, Prisma (Johnson and Johnson, New Brunswick, NJ) was used in place of the negative pressure starting December 12, and by December 19 the wound was completely healed (Figure 5).   Case 3. A 37-year-old white male was admitted to the author’s center on December 21, 2011 with a Staph infection of the left lower leg, where he had received a tattoo 1 week earlier. The patient had 11 abscesses, each approximately 1 cm in diameter, associated with cellulitis, and cultured to show non-MRSA Staphylococcus and Streptococcus pyogenes. The patient’s medical history included a ruptured diaphragm from an automobile accident and resection of a thoracic aortic aneurysm, malignant hypertension, pancreatitis, seizures, and chronic obstructive pulmonary disease complicated by heavy smoking.   The wound was treated with topical Silvadene (King Pharmaceuticals, Inc, Bristol, TN) and IV vancomycin with a good result. The patient was discharged December 27 on oral Bactrim, with instructions to be followed at the center. The wound completely healed after 3 weeks.

Discussion

  Staphylococcus aureus has made quantum leaps of virulence in the past few decades, first with the emergence of methicilin resistance, then, in the late 1990s, with the more aggressive community-acquired form.9 Community-acquired-MRSA infections continue to be a major source of morbidity in Richmond County, NC; there were 31 hospital admissions for a variety of CA-MRSA and MRSA wound and ulcer infections through the Sandhills Regional Medical Center emergency room in 2011. Two patients with tattoo infections were admitted, 1 with CA-MRSA the other with a combination of Streptococcus and nonmethicillin-resistant Staphylococcus aureus. The third tattoo infection also contained CA-MRSA, but the individual’s wound was managed as an outpatient. The author thinks it speaks to the prevailing high standards and regulation of hygiene in Richmond County that no legal tattoo parlor was determined to be the source of any of these infections.   The author posits that, probably for economic reasons, and possibly because they are under the age to legally acquire a tattoo, a number of would-be tattoo recipients have sought out illegal artists, thereby increasing the chances of acquiring an infection. Neophyte artists can even purchase tattoo “Starter Kits” for as little as $59.99 online. The author contacted one such vendor who explained the kit did not come with any warnings about the possibility of infection, but that a separate DVD on the subject was available for purchase.   The 2 cases of CA-MRSA infection described in this paper clearly demonstrate the pathogenicity of this bacterium, both in the sheer volume of tissue necrosis resulting from a relatively shallow skin penetration, and in the morbidity in terms of time to heal. The author speculates Case 3 may represent ink contamination because there was regular distribution of the lesions and they were associated with one color.   Tattoo inks contain many substances, including automobile paint, iron oxide, cadmium, chromium, and copper phthalocyanine,10 and they originate from various sources including foreign countries that may not adhere to the same regulatory standards as the United States.11 Approximately 10% of these products arrive already contaminated with Staphylococcus, Streptococcus, and Enterococcus.12 Unfortunately, it was not possible to culture the tattoo inks used on the patients described in this paper. Traditionally, the United States Food and Drug Administration has not scrutinized tattoo inks too closely,13 but it is the author’s opinion that the time has come for a closer look.   Possibly mandating the incorporation of preservatives that would kill MRSA and hepatitis organisms would also be a good idea.   The Centers for Disease Control and Prevention has documented interventions by local health departments in an attempt to reduce the risk of infection by illegal tattoo. These interventions included talks at high schools and public service announcements on the radio and in local newspapers.8   Tattooing has come a long way from the first studio in New York in 1870, especially with the introduction of automatic equipment and exotic designs, and is now increasingly accepted the United States.14 Unfortunately, the emergence of CA-MRSA, in conjunction with illegal artists and dubious inks, has the potential to hamper further progress.

References

1. Kang M, Jones K. Why do people get tattoos? Contexts. 2007;6(1):42-47. 2. Atkinson M. Tattooed: The Sociogenesis of a Body Art. Toronto: Toronto University Press;2003. 3. Saint S. Prevention of Intravascular Catheter-Associated Infections. US Department of Health and Human Services. http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html. Accessed October 12, 2012. 4. Brown, Abram. More Proof the US Economy is Falling Apart: GDP Revision a Grim Surprise. Forbes.com. September 27, 2012. http://www.forbes.com/sites/abrambrown/2012/09/27/u-s-economy-appears-weaker-than-feared-q2-gdp-durable-goods-much-lower-than-forecast/. Accessed October 12, 2012 5. Bill to Amend Title 44 of the Code of Laws of South Carolina, 1976. 115th Session. (SC 2004.) www.scdhec.gov/health/licen/hltattooact.pdf. Accessed October 12, 2012. 6. Shapiro A, Raman S, Johnson M, Piehl M. Community-acquired MRSA infections in North Carolina children: prevalence, antibiotic sensitivities, and risk factors. NC Med J. 2009; 70:102-107. 7. Mims B. Staph Infection Popping Up Across North Carolina. WRAL.com. October 19, 2007. http://www.wral.com/news/local/story/1947300/. Accessed: March 9, 2012. 8. Long T, Coleman D, Dietsch P, et al. Methicillin-Resistant Staphylococcus aureus Skin Infections Among Tattoo Recipients—Ohio, Kentucky, and Vermont, 2004—2005. Morbidity and Mortality Weekly Report. 2006;55(24):677-679. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5524a3.htm. Accessed December 28, 2011. 9. Otto M. Community-associated MRSA: a dangerous epidemic. Future Microbiol. 2007; 2(5):457-459. 10. Chemistry: Tattoo Ink Chemistry. About.com Web site. http://chemistry.about.com/library/weekly/aa121602a.htm. Accessed April 7,2012. 11. Hamsch C, Hartschuh W, Enk A, Flux K. A Chinese tattoo paint as a vector of atypical mycobacteria-outbreak in 7 patients in Germany. Acta Dermato-Venereologica. 2011;91(1):63-64. http://www.medicaljournals.se/acta/content/?doi=10.2340/00015555-1015&html=1. Published January 2011. Accessed October 12, 2012. 12. Høgsberg T, Saunte DM, Frimodt-Møller N. and Serup J. Microbial status and product labelling of 58 original tattoo inks. J Eur Acad Dermatol Venereology. 2011. doi: 10.1111/j.1468-3083.2011.04359.x 13. Gorss J. Chemicals in tattoo inks need closer scrutiny. Medical News Today Web site. March 14, 2005. http://www.medicalnewstoday.com/releases/21202.php. Accessed April 3, 2012. 14. Tattoos in the USA. The Tattoo Museum Web site. http://www.vanishingtattoo.com/tattoo_museum/united_states_tattoos.html. Accessed March 21, 2012. Alan S. Coulson, MD is from the Hamlet PPM, LLC –Sandhills Surgical, Hamlet, NC. Address correspondence to: Alan S. Coulson, MD Hamlet PPM, LLC – Sandhills Surgical 108 Endo Lane Hamlet, NC 28345 alan.coulson@hma.com