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Tattoo pigment in axillary lymph nodes mimics occult breast malignancy: a case report

Isolated calcified axillary lymphadenopathy is an uncommon radiological finding. Its presence raises the suspicion of worrisome aetiologies such as occult breast malignancy or metastasis from mucin producing non-breast primary. A rare benign differential which poses diagnostic challenge to clinicians is tattoo pigment. Though tattooing is a common social adornment practice across Asia, tattoo pigment mimicking calcification has yet to be reported in this region. We report the first case in Asia in a lady who had presented with severe weight loss. A 45-year-old Indian lady had presented with significant weight loss. She exhibited an extensive tattoo over her right upper back, right shoulder and upper arm. Her medical history was unremarkable. Mammography and ultrasound showed isolated calcified enlarged right axillary lymph nodes. Computed tomography did not show any other abnormality. Needle biopsy of the lymph nodes showed few focal areas of fibrosis. Excision of three enlarged lymph nodes was performed. Tattoo pigment was seen within the macrophages of the excised lymph nodes which were non-birefringent. Special stain for acid fast bacilli and fungal stains were all negative. No evidence of malignancy was seen in the nodes. Tattoo pigment resulting in calcified reactive lymphadenopathy is extremely uncommon. Mammography may not be able to distinguish from occult breast malignancy due to similar radiological findings. Though needle biopsy has been widely accepted as a minimally invasive tool for evaluation of indeterminate lesions, excision may still be offered as a last resort option to achieve accurate histological diagnosis.