Introduction 

Sepsis is defined as a systemic illness that occurs when microbes invade parts of the body that are sterile. As it is systemic, all parts of the body are affected. This leads to inflammation as the immune system tries to defend the body against these microbes, leading to organ failure or failures of whole organ systems. The cytokine storm, which has been largely implicated in virus, such as COVID-19, contributes to the presentation of sepsis, leading to many different symptoms which can eventually lead to death.¹ The risk of sepsis is increased when getting tattoos, which are a form of body art in which pigment is inoculated into the dermal layer (middle layer of the skin), potentially leading to cutaneous infections. This means that while the tattoo pigment is inoculated, many infections can occur on the skin, and when these infections are viral, they can lead to the infections being systemic in nature. Some patients contract human immunodeficiency virus and human papillomavirus, amongst other infections.² Bacteria, such as Staphylococcus, alongside viruses, lead to sepsis; thus, septic shock is a risk for those receiving tattoos.³ Tattoo infections that are severe in nature have the potential to lead to sepsis, which has devastating consequences. This article will investigate the relationship between sepsis and severe tattoo infections by establishing the causes, symptoms, and progression of this condition. Treatment and prevention strategies will also be explored.

Causes of severe tattoo infections

Tattoo infections are caused by various factors. A major risk factor is tattoo equipment not being adequately clean and sterile, which results in infections spreading due to microbes present on the tattoo equipment.⁴ Tattoo ink may also be contaminated in some instances, and this has led to infections being possible in countries where parlours use the same ink. The contamination typically occurs during manufacturing, causing some to have pathogens present.⁵ Moreover, it is crucial to maintain a proper aftercare regime following a tattoo procedure, as it is possible for people to receive infections via the environment, such as grass, if the tattooed area is exposed soon after the procedure. These infections can lead to sepsis; hence, this is a severe risk factor.⁶ It is also important to note that some people are more susceptible to sepsis if they have previous conditions that render their immune system weaker than normal. For example, patients who receive glucocorticoid therapy or who are on biologics typically are immunosuppressed, thus rendering them more likely to suffer from severe tattoo infections.⁷

Symptoms of tattoo infections

Tattoo infections lead to many characteristic symptoms that make them relatively easy to identify. Initially, when people contract tattoo infections, the area around the tattoo swells and is typically red and very painful. This is indicative of inflammation that results from tattoo infections.⁸ As the infection becomes more severe, the symptoms change, and lesions containing pus develop in the tattoo area. This is often accompanied by a fever, often accompanied by chills as the infection spreads throughout the body.⁹ The aforementioned symptoms may be an indication that an individual is suffering from a tattoo infection; however, this is not clearly systemic. There are more severe symptoms that indicate a systemic infection. Other areas of the body may become red, implicating that the infection is spreading around the whole body.¹⁰ Moreover, shortness of breath is another common symptom in severe tattoo infections. Heart issues, such as raised heartbeat and heart failure, can occur later down the line once the infection has adequately spread.¹¹

Progression to sepsis

Localised tattoo infections can progress to sepsis over time. When an infection spreads to your epidermal tissue (skin), which is a type of epithelial tissue, the infection

can spread to your bloodstream. This occurs via the lymph nodes, in which the lymphatic system carries the microbes from the skin to the lymph nodes. Once the microbes are in your bloodstream, they can spread to other tissues in the body.¹² As a response, the body’s immune response tries to combat these, in which macrophages and monocytes release cytokines during the cytokine storm, such as interleukin-6 (IL-6). These cytokines lead to fibrosis in the renal system and are also associated with hypertension and oxidative stress, therefore leading to organ damage, particularly the heart and the kidneys.¹³ Inflammatory cascades are activated due to damaged epithelial tissues, further triggering this immune response. There are various inflammatory pathways, which have distinctive effects. For example, IL-6, which was mentioned previously, leads to lung damage, as well as the activation of the mechanisms of other cytokines.¹⁴ Although the immune system protects the body from infections, an overactive immune system and inflammation can be devastating. As mentioned previously, those receiving tattoos are at an increased risk of developing sepsis due to pigment being contaminated as well as equipment.¹⁵ It is crucial not to leave tattoo areas exposed after receiving a tattoo, as this has been demonstrated to increase the chance of a severe infection.⁶

Diagnosis and medical treatment

Fortunately, tattoo infections can be diagnosed, and treatment options are available for those affected. A biopsy of the affected areas of skin can be taken, allowing the areas to be examined to determine whether infection has occurred. However, there are challenges associated with this, such as pigment making it more difficult for tissues to be visualised effectively.⁷ Symptoms can also be assessed to aid diagnosis; this is done by determining whether the lymph nodes are swollen (adenopathy) alongside other criteria such as photosensitivity.¹⁶ It is advised that medical advice be sought out quickly, as it is possible to misinterpret severe symptoms as a result of infection when this may not be the case.¹⁷ In order to manage infections, antibiotics are commonly prescribed to rid the body of the pathogen. Furthermore, drainage technique is often done to get rid of the pus in affected areas. When this technique is used, it is essential to clean the affected areas, and this is often used in conjunction with antibiotics.¹⁸ In severe instances, patients may need to be hospitalised in order to treat and manage the infection intensively.¹⁰ In treating sepsis, intravenous (IV) fluid therapy is utilised as this resolves hypotension and restores major organ function.¹⁹ Medications are also used to treat sepsis and the effects of this condition, such as atrial fibrillation, which is common for those who develop sepsis.²⁰ Finally, patients are situated in intensive care units to receive these treatments, amongst others, and are constantly monitored. However it is important to note that this can lead to unintended consequences, such as secondary infections, which is counterintuitive.²¹

Prevention of tattoo infections and sepsis

It is possible to reduce the risk of sepsis and severe infections after receiving a tattoo. Workers within tattoo parlours can follow certain methods to reduce the risk of their customers being affected by these conditions. Ensuring that tattoo artists and studios/ parlours are reputable and well-established will lower the chance of infection, as greater safety and hygiene measures are likely to be in place.²² It is important that all equipment is sterilised prior to use, as this will prevent the spread of any pathogenic microbes and make it safer for tattoos to be administered. This is a key reason why reputable tattoo studios are likely to be better than less established ones.²³ Proper aftercare instructions, such as washing tattoos with antibiotic soaps and ensuring that tattoos are not exposed to the environment immediately after administration, must be given to customers to help prevent infection. It is also useful to have universally set guidelines across major tattoo parlours.²⁴ As aforementioned, infection signs and symptoms should be monitored after someone has received a tattoo, and it is important to quickly seek medical care if infection symptoms occur following a tattoo.¹⁷

Summary

In summary, it is important that tattoos are administered safely and with good hygiene to reduce the risk of developing infections. Although these infections are normally localised, there is a chance that the infection spreads through the bloodstream following entry into the lymph nodes, leading to a systemic illness known as sepsis, which is associated with severe consequences. It is of utmost importance to recognise symptoms and treat them early, as once an infection enters the bloodstream, it can spread very quickly, leading to inflammation and organ failure, amongst other issues. In order to prevent the chance of sepsis, medical attention should be sought out as soon as possible if symptoms exist, so that infections can be treated promptly. In many instances, this is the difference between an infection being localised and then eradicated rather than sepsis. Increased awareness, aftercare guidelines, and better safety and hygiene measures in tattoo parlours can help reduce the risk of sepsis as a consequence of tattoo infections.