Tattoo pigment can precipitate numerous inflammatory states, and granulomatous tattoo reactions are a diagnostically challenging form. The skin is the most common site of inflammation, but systemic inflammation can occur. Reactions to black tattoo ink have a broad differential of cutaneous and systemic conditions. Sarcoidosis is an important consideration because it is unclear whether it is a separate entity. Here we present a 31-year-old male who developed an inflammatory eruption where he had black tattoos. He also developed circular patches of scalp alopecia, monocular uveitis, and an enlarged axillary lymph node, initially thought to represent lymphoma. Tissue biopsy of the skin and lymph node revealed findings consistent with granulomatous tattoo reaction. Investigations for other diagnoses, including sarcoidosis, were negative. He was treated with systemic corticosteroids and then with topical corticosteroids and oral hydroxychloroquine. This case report demonstrates the diagnostic challenge associated with granulomatous tattoo ink reactions. Further studies are needed to improve characterization and management of this condition.