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Clinical Practice Points • Immune checkpoint inhibitors (ICIs) are associated with the development of unique immune-related adverse events (irAEs), which emerged primarily during post-marketing surveillance. Oral irAEs have already been reported, with the most common manifestations being mucositis and xerostomia. It has been suggested that a T-cell activation, similar to that observed in autoimmune conditions, may play a role. • Here, we report a case of black hairy tongue (BHT) in a patient receiving first-line pembrolizumab for advanced non–small-cell lung cancer (NSCLC). Although the BHT was symptomatic for burning mouth and dysgeusia, ICI use was continued due to its clinical and radiological benefit, which persisted for a long time. • BHT is characterized by hypertrophy and lengthening of the filiform papillae. Despite being a rare benign condition, it can often result in a significant burden on quality of life. • Many predisposing factors have been described, and cancer patients represent a population particularly at risk. Based on the temporal association and excluding possible alternative causes, we proposed that, in our patient, BHT was likely ICI related through the development of xerostomia, which represents a key factor in BHT pathogenesis. • To the best of our knowledge, this is the first report of BHT after ICI use, suggesting that it may represent an atypical oral irAE. To date, the oral irAEs have not been well explored, and further studies are needed to elucidate the underlying mechanisms and possible associations with anti-tumor responses, with significant implications on prognosis and quality of life. In the present context, our case emphasizes the need to remain vigilant for atypical and new irAEs.

Hairy tongue is a benign pathology, characterized clinically by hyperkeratinized plaques on the dorsal surface of the tongue, hairlike, whose coloration ranges from unpigment, whitish, yellowish, green, brown to black. Diagnosis is clinical, and, in cases of whitish plaques, it may be difficult to differentiate between oral hairy leukoplakia, potentially malignant leukoplakia or squamous cell carcinoma. Thus, widefield optical fluorescence complementary examination may allow a better visualization of the local hairlike pattern of hyperkeratinization, typical of the hairy tongue, facilitating the diagnosis. In this work, a 57-year-old man was referred to the Dental Specialties Department of the Divinópolis Health Department (MG, Brazil) by a general dental practitioner, aiming a differential diagnosis of possible malignant lesion on the dorsal tongue surface. The complementary examination by wide-field optical fluorescence was performed. For this, it was employed a device with high-power light-emitting diode emitting light centered at a wavelength of (400±10) nm and maximum irradiance of (0.040±0.008) W/cm2 was used for fluorescence visualization. Fluorescence images showed projections of hairlike appearance in tongue dorsal surface with no aspects of malignancy. Hairlike appearance is the principal feature of hairy tongue. In this way, the final diagnosis was established. In conclusion, in this case, the use of widefield optical fluorescence in oral diagnostic routine provided a differential diagnosis, with no need of an incisional biopsy. Resumo A língua pilosa é uma patologia benigna, caracterizada clinicamente por placas hiperqueratinizadas na face dorsal da língua, semelhante a pelos, cuja coloração varia de despigmentada, esbranquiçada, amarelada, verde, acastanhada a preta. O diagnóstico é clínico, e em casos de placas esbranquiçadas, pode ser difícil diferenciar entre leucoplasia pilosa oral, leucoplasia potencialmente maligna ou carcinoma de células escamosas. Assim, o exame complementar de fluorescência óptica de campo amplo pode permitir uma melhor visualização do padrão local de hiperqueratinização semelhante à pelos, os quais são característicos de língua pilosa, facilitando o diagnóstico. Neste trabalho, um paciente do sexo masculino, 57 anos, foi encaminhado ao Departamento de Odontologia da Secretaria de Saúde de Divinópolis (Minas Gerais) por um clínico geral, visando o diagnóstico de uma possível lesão maligna na face dorsal da língua. O exame complementar por fluorescência óptica de campo amplo foi realizado. Para isso, foi empregado um dispositivo com diodo emissor de luz de alta potência, com luz centrada em um comprimento de onda de (400±10) nm e irradiância máxima de (0,04 ±0,008) W/cm2 para visualização de fluorescência. As imagens de fluorescência mostraram projeções de aparência semelhante à pelos na superfície dorsal da língua, sem aspectos de malignidade. A aparência similar à pelos é a principal característica da língua pilosa. Dessa maneira, o diagnóstico final foi estabelecido. Em conclusão, neste caso, o uso da fluorescência óptica de campo amplo permitiu um diagnóstico diferencial, sem a necessidade de uma biópsia incisional.

Patient: Female, 3-month-old Final Diagnosis: Black hairy tongue Symptoms: Discolored tongue Medication:— Clinical Procedure: Gentle tongue brushing Specialty: Pediatrics and Neonatology Objective: Rare disease Background: Black hairy tongue is a self-limiting, usually asymptomatic, benign lesion that most often affects men and people aged over 30–40 years. The lesion is extremely rare among newborns and infants. Lingua villosa nigra is characterized by the presence of elongated filiform papillae of the dorsum of the tongue, which gives a hairy appearance. The overgrown papillae can accumulate fungi, bacteria, pigments originating from food, or any other debris that can contribute to the discoloration of the tongue. The prognosis for black hairy tongue is positive. Gentle tongue brushing or scraping as well as the elimination of predisposing factors usually leads to cessation of the lesion. Case Report: A generally healthy, exclusively breastfed 3-month-old female baby was admitted to the Oral Pathology Department of Wrocław Medical University due to a persistent tongue lesion. Intraorally, dark, blackish, elongated tongue papillae were observed. Three weeks earlier, the baby’s pediatrician had diagnosed thrush and prescribed systemic antifungal treatment with Nystatinum, without prior mycological examination. The lesion did not resolve and the girl was referred to the Department of Oral Pathology. A meticulous medical and dietary interview revealed that since the 28th day of life the baby had been supplemented with vitamin C. This, together with an intraoral examination, led to the diagnosis of black hairy tongue. The lesion disappeared partially after 4 weeks of tongue brushing. Conclusions: To prevent infants from undergoing persistent and unnecessary treatment (topical or systemic drugs) or additional diagnostic procedures, such as biopsy, it is essential to be familiar with the characteristics of lingua villosa nigra as well as its origin and management. The consideration of this condition is invaluable for babies’ health and safety.

Excluding human papillomavirus (HPV)-driven conditions, oral papillary lesions consist of a variety of reactive and neoplastic conditions and, on occasion, can herald internal malignancy or be part of a syndrome. The objectives of this paper are to review the clinical and histopathological features of the most commonly encountered non-HPV papillary conditions of the oral mucosa. These include normal anatomic structures (retrocuspid papillae, lingual tonsils), reactive lesions (hairy tongue, inflammatory papillary hyperplasia), neoplastic lesions (giant cell fibroma), lesions of unknown pathogenesis (verruciform xanthoma, spongiotic gingival hyperplasia) and others associated with syndromes (for instance Cowden syndrome) or representing paraneoplastic conditions (malignant acanthosis nigricans). Common questions regarding differential diagnosis, management, and diagnostic pitfalls are addressed, stressing the importance of clinico-pathologic correlation and collaboration.

Black hairy tongue (BHT) is a benign condition commonly found among people who smoke, have poor oral hygiene, are immunocompromised, or have a medical condition limiting their ability to practice good oral hygiene. Though this condition is harmless, patients need to be educated on etiology as many common medications are associated with this condition. Patients being placed on certain antibiotics or antipsychotics should be educated on the importance of good oral hygiene or cessation of habits that promote BHT. Similarly, those with medical conditions increasing the risk for the development of BHT should schedule routine visits with their dentist or dental hygienist. Prognosis is good, and treatment consists of gentle brushing of the tongue, but many anecdotal reports exist demonstrating the use of medications or other products to treat this condition. This review addresses the epidemiology, clinical presentation, pathophysiology, etiology, histology, differential diagnosis, and treatment of BHT and lists all of the medications reported to cause this condition.

Black hairy tongue (BHT) is characterized by a discolored, hairy tongue. We herein report two cases of BHT associated with antibacterial agents and review previous cases. In Case 1, a 17-year-old girl with a central neurocytoma was administered intravenous piperacillin–tazobactam for postoperative infection, and BHT developed 12 days later. Her symptoms resolved 8 days after she discontinued the piperacillin–tazobactam and brushed her tongue three times daily. In Case 2, a 65-year-old man was administered intravenous piperacillin–tazobactam and levofloxacin to treat multidrug-resistant Pseudomonas aeruginosa, and BHT developed 15 days later. The piperacillin–tazobactam was discontinued and the patient brushed his tongue, and the discoloration gradually subsided thereafter. However, the BHT reappeared after linezolid treatment. The patient had adverse drug reactions to both the piperacillin–tazobactam and linezolid treatments. The BHT might have been related to antibiotic use in both cases. We identified 19 cases of antibiotic-related BHT in a literature search, but none were related to piperacillin–tazobactam use. In all cases, symptoms resolved after discontinuation of the drug and brushing of the tongue. BHT may be a rare adverse effect of antibiotics. Treatment strategies include removal of the causative agents, mechanical debridement, and good oral hygiene.

Introduction Linezolid was approved for clinical use for methicillin resistant Staphylococcus aureus and vancomycin-resistant Enterococci. Additionally it is used in the management of drug resistant tuberculosis. It is well-tolerated however bone marrow suppression and neuropathies may occur in patients taking this antibiotic for more than 2 weeks. Black discoloration and black hairy tongue (BHT) due to linezolid is rarely reported. We report two cases of BHT. Case reports Two patients of drug resistant pulmonary tuberculosis developed benign hairy tongue with linezolid 600 mg per day. In both the cases black colored/hairy tongue was reported within 2–3 weeks of linezolid treatment. Both patients improved after withdrawal of linezolid. Subsequent reintroduction of linezolid with good oral hygiene was well tolerated and both patients completed the treatment of 2 years duration without any recurrence. Conclusion Black discoloration and BHT is a rare but transient adverse reaction with linezolid. Reintroduction of linezolid with good oral hygiene is well tolerated.

Proposed causes include medications, hyposalivation, poor oral hygiene, smoking, and infection.

A 27-year-old woman presented with blackish discolouration over the tongue for the last 2 weeks. She reported feeling nauseous and having a bad taste in her mouth. Three weeks prior to her present complaints, she had been prescribed minocycline for treatment of grade 3 acne. On examination, a brownish-black patch with prominent hair-like filiform lingual papillae covered the dorsum of tongue, giving a carpet-like appearance (figure 1). A diagnosis of black hairy tongue, secondary to minocycline …

Black hairy tongue (BHT) developed in five patients (2.6%) among 192 patients undergoing chemotherapy for malignant brain tumors. Three patients with a history of diabetes mellitus developed BHT within 10 days after the initiation of chemotherapy. The other two patients suffered more than 100 days after induction and lymphopenia of grade 3 or worse developed for more than 20 days, which was not observed in the three patients with diabetes. We found that BHT could develop after chemotherapy for malignant brain tumors. Patients with diabetes mellitus presented early after chemotherapy, while patients with longstanding severe lymphopenia presented in late phase.

The tongue is a complex organ involved in speech and expression as well as in gustation, mastication, and deglutition. The oral cavity, along with the tongue, are sites of neoplasms, reactive processes, and infections, and may be a harbinger of systemic diseases. This review includes both common and rare diseases that occur on the tongue, including: vascular and lymphatic lesions (infantile hemangiomas and oral varices), reactive and inflammatory processes (hairy tongue, pigmented fungiform papillae of the tongue, benign migratory glossitis, and fissured tongue), infections (oral hairy leukoplakia, herpes simplex and varicella-zoster virus infections, human papillomavirus, and candidiasis), premalignant lesions (leukoplakia and erythroplakia), malignant lesions (squamous cell carcinoma, Kaposi sarcoma, and lymphoproliferative diseases), and signs of systemic disease (nutritional deficiency and systemic amyloidosis).

Black hairy tongue (BHT) is an unusual condition in adults characterized by marked accumulation of keratin on the dorsum of the tongue, resulting in a hair-like appearance. Herein, we have described 15 patients developing BHT after allogeneic stem cell transplantation (allo-SCT). BHT was generally accompanied by other cutaneous manifestations of cutaneous graft-versus-host disease (GVHD) or a precursor of GVHD. Our experience in this series emphasized that histopathologic evaluation is required for seemingly harmless eruptions like BHT in the posttransplantation period. Given the important prognostic implications of GVHD, physicians should be careful when confronted with BHT.

Black Hairy Tongue A 55-year-old woman started treatment with meropenem and minocycline for a polymicrobial infection. Within 1 week, she had tongue discoloration that was consistent with black hairy tongue.

Black hairy tongue (BHT) is a benign, self-limiting disorder characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. The prevalence of BHT is quite variable, ranging from 0-53.8% depending on the population. Many predisposing factors to BHT exist, and several drugs and drug classes have been implicated in causing this disorder. A modified Naranjo adverse drug reaction probability nomogram specific for BHT was used to rate causality for the available published case reports of drug-induced BHT. From the available data, antibiotics and drugs capable of inducing xerostomia are the drug classes that have modest evidence of causality and a rational mechanism. The presence of underlying predisposing factors in these cases along with the variable prevalence of BHT make drawing firm conclusions difficult. Treatment for BHT involves eliminating any predisposing issues and practicing scrupulous oral hygiene. Drug therapy and physical removal of the elongated filiform papillae are available for resistant cases. Clinicians should be aware of the prevalence, the predisposing factors and drug classes that may play a role in the development, and the treatment of BHT.

Burning mouth syndrome (BMS) is characterized by burning pain in the tongue or other oral mucous membrane often associated with symptoms such as subjective dryness of the mouth, paraesthesia and altered taste for which no medical or dental cause can be found. The difficulty in diagnosing BMS lies in excluding known causes of oral burning. A pragmatic approach in clarifying this issue is to divide patients into either primary (essential/idiopathic) BMS, whereby other disease is not evident or secondary BMS, where oral burning is explained by a clinical abnormality. The purpose of this article was to provide the practitioner with an understanding of the local, systemic and psychosocial factors which may be responsible for oral burning associated with secondary BMS, therefore providing a foundation for diagnosing primary BMS.

A 64-year-old institutionalised woman presented to our clinic for the management of black hairy tongue. Despite the predictable outcome in treating this disease, this case presents multiple challenges such as the patients’ cognitive impairment, her family dynamics, social factors and the health system as a whole, that makes it difficult to treat.

Black hairy tongue (BHT) is a benign medical condition characterized by elongated filiform lingual papillae with typical carpet-like appearance of the dorsum of the tongue. Its prevalence varies geographically, typically ranging from 0.6% to 11.3%. Known predisposing factors include smoking, excessive coffee/black tea consumption, poor oral hygiene, trigeminal neuralgia, general debilitation, xerostomia, and medication use. Clinical presentation varies but is typically asymptomatic, although aesthetic concerns are common. Differential diagnosis includes pseudo-BHT, acanthosis nigricans, oral hairy leukoplakia, pigmented fungiform papillae of the tongue, and congenital melanocytic/melanotic nevi/macules. Clinical diagnosis relies on visual observation, detailed history taking, and occasionally microscopic evaluation. Treatment involves identification and discontinuation of the offending agent, modifications of chronic predisposing factors, patient’s re-assurance to the benign nature of the condition, and maintenance of adequate oral hygiene with gentle debridement to promote desquamation. Complications of BHT (burning mouth syndrome, halitosis, nausea, gagging, dysgeusia) typically respond to therapy. Prognosis is excellent with treatment of underlying medical conditions. BHT remains an important medical condition which may result in additional burden on the patient and health care system and requires appropriate prevention, recognition and treatment.

Unilateral hairlike discoloration of the tongue is described in a patient with ipsilateral mandibular division trigeminal neuralgia. This unusual physical sign coincided with the patient's painful trigger zone and was attributed to hypertrophy of keratinized filiform papillae, where guarded avoidance of mechanical stimulation over time prevented normal desquamation.

An eight-week-old infant was referred to our clinic because of a four-week history of black discoloration of the tongue ([Figure 1][1]). The infant’s birth history was unremarkable, and he had no history of infections or antibiotic use. There was no family history of Peutz–Jegher syndrome, von

Oral hairy leukoplakia occurs mainly on the tongue of human immunodeficiency virus (HIV)-infected persons. An HIV-infected patient with hairy leukoplakia involving the tongue and buccal mucosa was studied by light and electron microscopic methods, in situ hybridization, and polymerase chain reaction. Our findings indicate that hairy leukoplakia may involve the buccal mucosa and should be considered in the differential diagnosis of white oral lesions in HIV-positive patients. Epstein-Barr virus particles were found in the epithelial cells of both buccal and tongue mucosa.

A 71-year-old man presents for evaluation of an asymptomatic black discoloration of the tongue. What is the most likely diagnosis?

Black hairy tongue (BHT) is a benign disease characterized by elongated filiform lingual papillae, with a carpet-like appearance of the dorsum of the tongue. It is has been reported to occur with a prevalence ranging from 0.6% to 11.3%. Although its etiology is not fully understood, BHT may be triggered by smoking, excessive coffee or black tea drinking, poor oral hygiene, trigeminal neuralgia, general debilitation, dry mouth as well as certain drugs. We present here a case of a patient with psychosis, depression, and benign prostatic hyperplasia, who developed BHT following treatment with a fixed dose combination (FDC) of olanzapine and fluoxetine and recovered within 3 months after withdrawal of treatment with FDC.

The purpose of this study was to determine whether there are any differences in the appearance of tongue-surface structure in different kinds of collagen diseases, because red tongue is well known to be a very important feature of suspected Sjogren's syndrome (Sjs). To clarify some features of the filiform papillae on the dorsal surfaces of the tongues of patients with speculated Sjs, we observed a total of 565 individuals with primary Sjs (n = 24, M/F = 0/24), secondary Sjs (n = 16, M/F = 1/15), possible Sjs (n = 96, M/F = 21/75), collagen diseases (CD) (n = 55, M/F = 15/40; 15 SSc, 10 SLE 10, two MCTD, six dermatomyositis, and 22 others), various cutaneous disorders (n = 324, M/F = 118/206), and healthy controls (HC) (n = 50, M/F = 32/18) by using a dermopscope. The average ages of the patients with Sjs, CD (non-Sjs), cutaneous disorders (non-Sjs/CD), and HC were 56.4 ± 14.8, 55.1 ± 116.4, 51.1 ± 121.2, and 37.1 ± 110.6 years of age, respectively. The filiform papillae were classified into four patterns by their structural characteristics: normal papillae (no abnormality with clear comified tips) (pattern I, n = 162), slightly rounded papillae with unclear cornified tips (pattern II, n = 239), rounded papillae without cornified tips (pattern III, n = 86), and completely flattened papillae (pattern IV, n = 28). Their patterns were reversely related to the volume of salivary fluid (gum test) (P = 0.046) and the degree of furor coating of the tongue (P = 0.051). Pattern IV is predominant in definitive Sjs (primary and secondary Sjs) (n = 15; 53.6%) with positive anti-SS-A or -B antibody (n = 8) with a specificity of 53.6% and a sensitivity of 36.6%. The present dermoscopic finding that the completely flattened pattern (IV) is predominant in definite Sjs patients may indicate a useful marker for suspicion of Sjs.

Black hairy tongue (BHT) also called as lingua villosa nigra, is a self limiting benign condition characterized by hypertrophy and elongation of filiform papillae of tongue with brown or black discoloration. Smoking, poor oral hygiene, xerostomia, using peroxide containing mouth washes, substance abuse and drugs (steroids, methyldopa, olanzapine, etc) are the predisposing factors. However its occurrence in relation to linezolid ingestion among south Indians has not been reported in PubMed database. Here we report a case, where significant association of linezolid intake with BHT was found in a 10-year-old boy, who was treated with tablet linezolid for post surgical infection of left side radial neck fracture. This case is reported for the rarity of occurrence with linezolid therapy. According to Naranjo adverse drug reaction (ADR) causality scale, the association of BHT due to linezolid in our case was probable.

A 73-year-old male smoker attended a follow-up outpatient clinic 18 months after starting antibiotic therapy (rifampicin, isoniazid and clarithromycin) for a nontuberculous mycobacterial lung infection. His infection was clinically improving, but the patient had noticed that his tongue had become

Background An inadequate understanding of the complex morphologic characteristics of human filiform papillae has hampered the histopathological characterization of disorders affecting tongue keratinization. To better define the 3-dimensional cytoarchitecture of tongue epithelium, we performed detailed immunohistochemical analyses of normal and black hairy tongue tissues using a panel of antikeratin antibodies. Observations The dome-shaped base of the human filiform papilla (primary papilla) is surmounted by 3 to 8 elongated structures (secondary papillae). These secondary papillae are composed of a central column of epithelial cells expressing hair-type keratins and an outer rim of cells expressing skin-type keratins. The epithelium overlying the primary papillae and between the individual primary papillae express esophageal-type keratins. In black hairy tongue disease, there is a marked retention of secondary papillary cells expressing hair-type keratins. Conclusions Using a panel of antikeratin probes, we define the precise topographical localization of cell populations undergoing 3 distinct differentiation programs in dorsal tongue epithelium. Comparative analyses of black hairy tongue specimens indicate that defective desquamation of the cells in the central column of filiform papillae results in the formation of highly elongated, cornified spines or "hairs"—the hallmark of this disease.

The purpose of this investigation, which has been performed as two studies, was to evaluate the association between the daily exposure to nicotine (measured as cigarette smoking machine yields) and the actual uptake of nicotine by cigarette smokers, as well as the association between oral mucosal changes and the exposure to cigarette smoke. In Study 1, consumption data, soft tissue changes and nicotine intake were measured in 47 habitual smokers using cigarettes with tar and nicotine yields within the ranges 9.3-12.2 and 0.72-1.16 mg per cigarette, respectively. The subjects were divided into three groups based on daily cigarette consumption; group averages (standard deviation) were 10.8 (2.2), 17.9 (1.9) and 28.4 (6.1) cigarettes per day. The group averages of tar deliveries from their usual brands of cigarettes were 11.1, 11.0 and 10.5 mg per cigarette, and group averages of nicotine deliveries were 1.05, 1.05 and 1.06 mg per cigarette, respectively. In Study 2, the same data were measured in a group of 77 habitual smokers with an average individual consumption of 11-21 cigarettes per day. The participants in Study 2 were divided into three groups according to tar delivery from their usual brands to cigarettes, with group averages of tar being 6.4 (1.2), 11.0 (1.2) and 16.0 (1.1) mg per cigarette, and of nicotine being 0.70 (0.12), 1.05 (0.12) and 1.34 (0.08) mg per cigarette, respectively. The average consumption of all three groups was within the range 17.1 to 17.9 cigarettes per day. The daily exposures to nicotine and tar were measured as the smoking machine yields multiplied by the number of cigarettes smoked per day. Nicotine uptake was determined by monitoring nicotine and its seven main metabolites in 24-h urine samples. In Study 1 there were significant differences between the three groups in the total amount of nicotine and metabolites excreted in the 24-h urine. The average nicotine uptake was 14.9, 24.4 and 35.4 mg per day, respectively. In Study 2, the 24-h excretion of nicotine and metabolites was about the same in all three groups and averaged 24.5 mg per day. The nicotine uptake was significantly correlated to the number of cigarettes smoked per day but not to the smoking machine yields of tar and nicotine per cigarette. The average prevalences for each of the different oral mucosal lesions (leukoedema, smoker's palate and hairy tongue) were found to increase with increasing consumption and nicotine uptake (Study 1); they were also independent of tar and nicotine yields from the cigarettes smoked (Study 2). These results indicate that the actual uptake of nicotine by smokers could not be estimated from the smoking machine yields. Reduction in exposure to smoke components may best be accomplished if smokers are encouraged to smoke fewer lower-yield cigarettes and to avoid smoking more of each cigarette.

A 15-year-old boy presented with an eight-year history of painless black patches of the tongue that had persisted despite repeated consultations with …

A 4-month-old female infant was admitted to the hospital with a history of prolonged diarrhea and severe failure to thrive. The patient's diarrhea started when she was 2 months old which prompted hospitalization a month later for further investigation. Discontinuation of enteral feeding resulted in resolution of her diarrhea, and total parenteral nutrition was continued via a central venous catheter (CVC). After 10 days, she developed fever. Physical examination was unremarkable except for a black discoloration of the tongue (Fig. 1). Empirical antibiotic treatment was provided with ceftriaxone. However, early report of a grampositive growth in blood cultures at 48 h prompted addition of vancomycin to the treatment regimen. This growth was later identified as Kocuria (Micrococcus) kristinae, which was detected in two separate aerobic blood cultures. The patient showed a dramatic response to vancomycin treatment, and blood cultures obtained 48 h later from the indwelling CVC and from a peripheral vein were negative. The black discoloration of the tongue completely resolved a week after initiation of vancomycin treatment (Fig. 2), and combination antibiotic therapy was discontinued after a total of 14 days. To the best of our knowledge, this is the first reported case in the English literature of K. kristinae bacteremia as a cause of black hairy tongue. Fig. 1 Black discoloration of the dorsal tongue

In March, 2010, a 53-year-old woman developed a black discolouration of her tongue. 4 weeks before developing the discolouration, she had had elective gynaecological surgery, from which she was recovering as an inpatient under our care. She did not smoke, but had a high intake of caff einated drinks, including six cups of tea and two cups of coff ee each day. During the course of her hospital stay she completed a 3-week course of amoxicillin clavulanate and metronidazole for a suspected postoperative pelvic infection. Tongue scrapings confi rmed Candida infection, and we diagnosed our patient with lingua villosa nigra (black hairy tongue) caused by a Candida infection

– Over a period of 10 months, 1013 consecutive dental outpatients attending the Screening Clinic in Faculty of Dentistry, Jordan University of Science and Technology, in the city of Irbid were investigated for the presence of tongue lesions. All subjects were seeking treatment for caries and periodontal diseases and none was complaining of oral mucosal disorder. The results showed that 240 subjects (23.7%) had one or more tongue lesions. Geographic tongue and fissured tongue were detected in 6.8% and 11.4% of the examined population respectively, and an association of the two conditions was observed in 2.9% of the subjects. Hairy tongue was diagnosed in 3.4% of the subjects with significantly higher prevalence in males (P < 0.0005). A strong correlation was found between hairy tongue and smoking.

Black hairy tongue is the name given to the appearance of an abnormal coating of the tongue and occurs only in adults. It is the result of hyperkeratosis of the filiform lingual papillae which, on gross examination appear hair-like with a variable tinctorial aspect from yellow-brown to black. The pathogenesis is unknown and often no definite cause can be identified. A number of aetiologic factors have been implicated including the administration of topical or systemic antibiotics, poor oral hygiene, smoking, alcohol and the use of mouthwashes. Often there are no symptoms other than the aesthetic or anxiety over its aetiology. Some patients complain of gagging, nausea, alteration of taste or halitosis. The condition may be very persistent and recognized treatments include brushing with a soft tooth brush which is enhanced by the prior application of a 40% solution of urea, scraping, topical triamcinolone acetonide, gentian violet, thymol, salicylic acid, vitamin B complex, and surgical excision of the papillae.

A patient with tongue malignancy associated with a black hairy tongue is presented. Specimens from e area fo the black hairy tongue and from a normally appearing part were studied with the scanning electron microscope. The "hairs" consisted of elongated filiform papillae due to accumulated keratinized layers. In-between these layers, fungi and bacteria were found. The aetiology of the blck hairy tongue in this patient is discussed.

Morphologic variations on the surface of the human tongue were examined in 381 patients divided by age into three groups (Group I--3 to 8 years old; Group II--9 to 16 years old; and Group III--17 to 35 years old). In Group I there were 84 pre-school children; in Group II there were 146 schoolchildren; in Group III there were 151 dental students and dental nurse students. The prevalence of variations in the morphology of the tongue surface in the three groups combined was as follows: fissured tongue, 5.0 percent; filiform atrophy, 5.5 percent; geographic tongue, 2.1 percent, and hairy tongue, 8.3 percent. Prevalence of both fissured tongue (p less than 0.05) and filiform atrophy (p less than 0.01) increased with the age of the population. Geographic tongue and hairy tongue did not increase significantly with age. Fissured tongue was more common in males than in females (p less than 0.05). The amount of filiform atrophy and hairy tongue was not significantly different in males and females.

Salivary condition and its correlation to tongue morphology was studied in 149 dental students. The students were divided according to the morphologic form of the tongue. The salivary pH and the buffer capacity of resting and stimulated saliva were determined. The pH values in the resting saliva of the fissured tongue group were more alkaline than those in the control group. The difference in pH values of stimulated saliva in the fissured tongue and control groups was only indicative. The stimulated saliva values of the normal tongue and the geographic tongue groups were similar. The pH valves of resting saliva in the geographic tongue group were more acidic than those in the normal tongue group. The salivary pH values of the filiform atrophy group were more acidic than those of the control group: resting salivar highly significantly and stimulated saliva significantly. The pH values of the hairy tongue group were also more acidic than those of the control group: both resting saliva and stimulated saliva highly significantly. No differences were observed in salivary buffer capacity, although buffer capacity in the hairy tongue group seemed to be lower than in the other groups.

The prevalence of oral carriers of Candida in patients with tongue abnormalities was investigated among 51 patients and 23 controls. The salivary sample technique was used; salivary pH was measured. In the control group and in the fissured tongue group negative fungus growth was prominent. A positive culture was found in 16·6 per cent of the patients with filiform atrophy. Patients with geographic tongue had the highest carrier rate (90 per cent) compared with all the other tongue groups. A positive culture was found in 66·7 per cent of the patients with hairy tongue. A relationship between oral yeasts and salivary acidity was found; candidal carriers had a lower salivary pH than non-carriers.

Optical microscopical studies were carried out on biopsies from 22 patients affected by saburral tongue (ST). The histopathological pattern consisted of a papillomatous acanthosis covered with a very thick horny layer. Abundant colonies of banal germs were seen in the keratin. There was an alternation of suprapapillary orthokeratosis and interpapillary parakeratosis. Under the keratin layer all the keratinocytes were large and clear with a glycogen-filled cytoplasm. Two specimens, studied with a transmission electron microscope, only showed that the keratinocytes were filled with glycogen. The clear glycogen-filled epithelial cells are common either in normal lingual epithelium or in some pathological conditions. The microscopic field of ST is quite similar to that of the hairy black tongue; but these peculiar clinical aspects of the tongue do not evolve one through the other.

The increased use of antibiotics during the past few years, especially in the form of troches and lozenges has once again focused attention on the phenomenon of hairy tongue. Ronchese and Kern recently reviewed the literature very completely. They reported a case of hairy tongue following the use of chlortetracycline (Aureomycin) ointment on the lips. Unilateral hairy tongue. The textbooks of dematology and articles agree on the general characteristics of this condition. At present two types of hairy tongue are recognized. The true is characterized by longer filaments and is believed to be a hereditary anomaly. The false is of much shorter duration and looked upon as secondary to some form of irritation. The conditions are described as black, brown, sepia, yellow, or even blue patches on the dorsum of the tongue and consist of filiform projections of the papillae. They are usually situated in front of the "V"

Local reactions from the use of oral penicillin (glossitis, stomatitis and vesicular cheilitis) have frequently been described. However, another type of reaction has been reported in the foreign literaure1but not in the American journals. The condition itself, black hairy tongue, has been known for many years, but its association with penicillin therapy is of recent note. I have observed this reaction to penicillin and believe that it is of sufficient interest to be documented. REPORT OF CASES Case 1.— In January 1948 a white woman aged 37 had been using penicillin lozenges for a sore throat. Discoloration of the tongue was observed a few days later. She was examined on the eighth day, at which time the tongue presented a velvety appearance and was brownish black on its medial and posterior portions. The filiform papillae were hypertrophied and bent like the nap of wet, heavy velvet when stroked

Black, hairy tongue is a disorder of curious morphology, which, although first described more than a century ago, continues to arouse interest because of its oddity and disputed origin. It is probably more common than has been generally supposed. Mild degrees of the condition doubtless pass unrecognized. This malady may occur anywhere on the dorsum of the tongue, but in a typical example it arises in the triangular area in front of the circumvallate papillae and slopes forward as a dark fusiform mass, composed of elongated epithelial filaments, with a tendency to branching, giving the superficial impression of a tuft of hairs. The appearance has been appropriately likened to "the hair of a dog dampened by water" and "a field of corn laid low by the wind." The individual elements of the lesion, which may reach 3/4 in. (1.91 cm.) in length, represent hypertrophic filiform papillae, and the color may

Summary Two experiments were performed in which a total of 17 dogs were fed a blacktongue-producing diet and 17 controls were fed the same diet but given adequate supplements of nicotinic acid twice weekly. The dogs, after being on their respective diets for an average of 10.4 weeks, were infected orally with trophozoites of Entamoeba histolytica, given in salol-coated gelatin capsules. A much greater percentage of the experimental dogs than of the controls was positive for amebae in rectal samples taken ante-mortem (88.2 and 41.1 respectively), and the average prepatent period was considerably shorter in the experimental animals (2.1 and 4.9 days, respectively). At necropsy, performed 3–10 weeks after infection, E. histolytica was demonstrated in 82.4 per cent of the experimental dogs and in 58.8 per cent of the controls. All of the experimental dogs had amebic lesions, with an average number of 31.5 lesions, whereas only 70.6 per cent of the controls had lesions, the average being only 3.8. Since the experimental dogs and controls were handled similarly, except for supplements of nicotinic acid given to the controls, it would appear that in this host nicotinic acid is involved in the mechanism of the resistance to E. histolytica. Other experimental studies in dogs are cited which seem to have a bearing on this conclusion. In addition, observations of one authority on pellagra suggest that these results might have a similar relationship in man.

1. In an Indiscriminate survey of 896 patients at Pilgrim State Hospital, 20 patients possessed a hairy tongue. 2. Three of these patients were on no drugs whatsoever. 3. Seventeen patients were on chlorpromazine or chlorpromazine and mepazine. 4. Five of these 17 patients lost their hairy tongue afteŕ discontinuance of medication. It obviously cannot be stated definitely that the phenothiazines cause hairy tongue. But, as noted above, the 5 patients whose medication was discontinued lost their hairy tongue within 2 weeks. The rest of the patients still retain their hairy tongue while receiving their medication. This seems to point the finger of suspicion toward the phenothiazines, especially in view of the well-established concept that other drugs, notably the antibiotics, have been found to cause this condition. The occurrence of the 3 cases of hairy tongue in patients receiving no medication also points out the possibility of this being purely co-incidental. In addition, there lurks in the background o...