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 Table of Contents  
MEDICAL QUIZ
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 105-107

Medical quiz: Lingua villosa nigra (black hairy tongue)


1 Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
2 Department of Medicine, Hamad General Hospital, Hamad Medical Corporation; College of Medicine, Qatar University; Weill Cornell College of Medicine-New York/Qatar, Doha, Qatar

Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Almurtada Ali Razok
Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O Box 3050, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_51_19

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  Abstract 


Black hairy tongue is a temporary, harmless oral condition that gives the tongue a dark, furry appearance. The distinct look usually results from a build-up of dead skin cells on the papillae of the surface of the tongue that contains taste buds. The differential diagnosis includes a variety of medical conditions and medication side effect. We present a medical quiz about an occasionally missed cause of black hairy tongue.

Keywords: Antibiotics, immunosuppression, inflammatory bowel disease, lingua villosa nigra


How to cite this article:
Razok AA, Yousaf Z, Elzouki AN. Medical quiz: Lingua villosa nigra (black hairy tongue). Libyan J Med Sci 2019;3:105-7

How to cite this URL:
Razok AA, Yousaf Z, Elzouki AN. Medical quiz: Lingua villosa nigra (black hairy tongue). Libyan J Med Sci [serial online] 2019 [cited 2019 Nov 18];3:105-7. Available from: http://www.ljmsonline.com/text.asp?2019/3/3/105/269226




  Medical Quiz Top


A 39-year old man with medical background of Type II Diabetes Melitis, hypertension, Bronchial asthma and ulcerative colitis, presented with fever, abdominal pain and bloody diarrhea. Before his admission, he was on sulfasalazine and mesalazine as maintenance therapy for his ulcerative colitis. A working diagnosis of an acute flare of ulcerative colitis was made, and he was initiated on prednisone enema and 6-mercaptopurine along with ciprofloxacin and metronidazole empirically. The patient showed good response clinically with inflammatory markers trending down. However, approximately 10 days after initial presentation, the patient developed dysphagia, sensation of dryness in his mouth, and dysgeusia. Oropharyngeal examination revealed central blackish discoloration of the tongue with sparing of tip and sides [Figure 1]. There was some green hue on exposure to flash light. The tongue also displayed hypertrophy of the filiform papillae. The discoloration was nonscrapable. A diagnosis of lingua villosa nigra was made, and the samples using swab were sent for microscopic examination and cultures.
Figure 1: Central blackish discoloration of the tongue with sparing of tip and sides

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  Which of the Following is the Most Likely Underlying Cause of Lingua Villosa Nigra in This Patient? Top


  1. 6-mercaptopruine
  2. Sulfasalazine
  3. Extraintestinal manifestation of ulcerative colitis
  4. Sicca syndrome
  5. Candida infection
  6. Hairy leukoplakia.


Quiz answer

The fungal culture grew non-albicans candida species, namely Candida parapsilosis and Candida lusitaniae. The patient was started on nystatin oral suspension (100,000 units/ml) 6 ml, four times daily. He started showing improvement after 2 days of nystatin therapy [Figure 2] and complete resolution after 21 days.
Figure 2: Improvement after 2 days of nystatin therapy

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Explanation

The patient's long history of exposure to immunosuppressive medications and recent use of antibiotics predisposed him to oral thrush which manifested as black hairy tongue. Candida, especially non-albicans species, has been reported to be associated with lingua villosa nigra.[1],[2] Historically, the cause or effect between Candida and lingua villosa nigra has been a topic of debate, with suggestions that Candida infection is an effect rather than a cause of lingua villosa nigra.[3] However, the positive culture and rapid response after the initiation of nystatin suggest Candida infection as the underlying cause of lingua villosa nigra in our patient.

  • Choice A: There are some case reports showing association between 6-mercaptopruine and lingua villosa nigra; however, the timing of the infection, positive fungal culture, and response to nystatin do not support this possibility
  • Choice B: Sulfasalazine does not have a strong association with lingua villosa nigra
  • Choice C: Lingua villosa nigra is not known to be an extraintestinal manifestation of ulcerative colitis
  • Choice D: While Sicca syndrome can predispose to Candida infection, it usually presents more gradually with other manifestations. The patient also tested negative for SS-A and SS-B antibodies
  • Choice F: The location, timing, and improvement of the lesion after nystatin therapy do not suggest leukoplakia. The patient tested negative for HIV antigen/antibodies.



  Discussion Top


Black hairy tongue has been referred to by various names, including hyperkeratosis of the tongue, lingua villosa nigra, and nigrities linguae.[4] Black hairy tongue is a temporary, harmless oral condition that gives the tongue a dark, furry appearance. The distinct look usually results from a build-up of dead skin cells on the papillae on the surface of the tongue that contains taste buds. These papillae, which are longer than normal, can easily trap and be stained by bacteria, yeast, tobacco, food, drugs, or other substances. Black hairy tongue typically does not cause significant health problems, and it is usually painless. The exact mechanism leading to this entity is not well studied. The differential diagnosis includes a normal tongue that has been stained black by food colorings or bismuth ingestion, oral hairy leukoplakia, pigmented fungiform papillae of the tongue, and acanthosis nigricans. [Table 1] summarizes the main differentiating points between the above-mentioned causes. Black hairy tongue usually resolves by eliminating possible causes or contributing factors and practicing good oral hygiene.
Table 1: Selected differential diagnosis of lingua villosa nigra

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts for interest

There are no conflicts for interest.



 
  References Top

1.
Khermach A, Er-rami M. The black hairy tongue. Saudi J Pathol Microbiol 2018;3:394-7.  Back to cited text no. 1
    
2.
Yi-Chun L. Black tongue. Eur J Intern Med 2018;48:e1-2.  Back to cited text no. 2
    
3.
Ramsakal A, Mangat L. Images in clinical medicine. Lingua villosa nigra. N Engl J Med 2007;357:2388.  Back to cited text no. 3
    
4.
Prinz H. Black tongue. Br Dent J 1925;46:1265-74.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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