What Causes a Black Colored Tongue?

Patient Presentation
A 14-year-old caucasian male came to clinic because he had noticed his tongue becoming darker over the previous week. He was very concerned about the coloring as he said it would not go away. He was studying for school examinations and had been self-medicating an upset stomach with Pepto-Bismol®. About 1 month ago he was diagnosed with bronchitis at an urgent care center and had taken antibiotics. The past medical history was negative except for being overweight. The review of systems was negative. The pertinent physical exam showed a well-appearing male whose BMI was 28.9 with normal vital signs. HEENT showed poor oral hygiene with obvious caries. He had dark brown coloring of the top of the tongue anteriorly, not involving the sides, that was uniform. Scraping appeared to decrease the discoloration but it didn’t completely go away. There was no elevation of the tongue nor oral masses visible or palpable. There were some shoddy anterior cervical nodes. His neck had a normal thyroid examination and no masses. Skin examination showed acne on his face, and a few brown macules and freckles scattered on his trunk, arms and face that he reported to be unchanged. He had no discoloration of the palms or soles. The diagnosis of poor oral hygiene along with taking bismuth was made. He was counseled about the bismuth use and school stress. He was also counseled about oral hygiene including scraping of his tongue. Followup at 1 month showed that the discoloration had resolved and his stress after examinations.

Discussion
Although dental caries, strep throat and oral candidiasis are some of the most common oral pathology. The tongue itself can be a source of potential pathology. Geographic tongue, oral candidiasis, and lingual ulcerations are common problems. Most discolorations of the tongue are because of food, drink or medications that are ingested and are self-limited. However discoloration can be a sign of more significant problems.
Hairy tongue, often colored black, is a relatively uncommon problem in the US but has a higher incidence reported in Turkey and Iran. It is more common in adults than children but has been reported in a child 2 months of age. It is also called lingua villosa nigra and is a benign condition caused by keratin accumulation usually in the setting of poor oral hygiene and/or xerostomia. The accumulation is on the filliform papillae and will be seen on the dorsal surface anterior to the circumvallate papillae and not on the lateral sides of the tongue or tip. The discoloration can be different colors depending on the oral flora. Hairy tongue usually responds to oral hygiene including scraping of the tongue, but sometimes retinoids, keratolytic agents and other treatments are used.

Learning Point
The differential diagnosis of a black tongue includes:

  • Normal variation
  • Poor oral hygiene
  • Acanthosis nigracans
  • Adrenal insufficiency
  • Congenital lingual melanotic macules
  • Congenital melanocytic naevi
  • Drugs
    • Antibiotics use
    • Linzezold
    • Minocycline
    • Graft vs. Host Disease
    • Heavy metals
    • Infection
      • Candida
      • Kocuria (Micrococcus) kristinae
    • Lingua villosa nigra “Black hairy tongue”
    • Lupus (possibly associated)
    • Neurofibromatosis
    • Oncological
      • Melanoma
      • Post-radiation
    • Peutz Jegher
    • Staining
      • Bismuth
      • Food coloring including coffee, tea
      • Smoking

    Questions for Further Discussion
    1. What is the differential diagnosis of white lesions in the mouth?
    2. What are the indications for referral for discoloration of the tongue and to whom would you refer?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Tongue Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    McGrath EE, Bardsley P, Basran G. Black hairy tongue: what is your call? CMAJ. 2008 Apr 22;178(9):1137-8.

    Akl KF. Black tongue. J Paediatr Child Health. 2009 Jan-Feb;45(1-2):73-4.

    Akay BN, Sanli H, Topcuoglu P, Zincircioglu G, Gurgan C, Heper AO. Black hairy tongue after allogeneic stem cell transplantation: an unrecognized cutaneous presentation of graft-versus-host disease. Transplant Proc. 2010 Dec;42(10):4603-7.

    Thompson DF, Kessler TL. Drug-induced black hairy tongue. Pharmacotherapy. 2010 Jun;30(6):585-93.

    Nisa L, Giger R. Black hairy tongue. Am J Med. 2011 Sep;124(9):816-7.

    Oncel EK, Boyraz MS, Kara A. Black tongue associated with Kocuria (Micrococcus) kristinae bacteremia in a 4-month-old infant. Eur J Pediatr. 2011 Sep 21.

    Guinovart RM, Carrascosa JM, Bielsa I, Rodriguez C, Ferrandiz C. A black tongue in a young woman. Clin Exp Dermatol. 2011 Jun;36(4):429-30.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Who Was Virginia Apgar and How Good is Her Scoring System?

    Patient Presentation
    A medical student had seen a 6-month-old, former 32 week premature female in the clinic for a health supervision visit. The past medical history showed the infant had some mild respiratory distress at birth that was treated with nasal canula oxygen for 48 hours. She had done very well and was discharged at 32 days of life after she had learned to feed well orally. The pertinent physical exam revealed a smiling infant with growth parameters below the 5th percentile for chronological age but at the 5-10% when corrected for prematurity with a curve showing good catchup growth. The rest of her examination was normal including her development which found her to roll over from front to back, bring her hands to midline and starting to transfer objects, and she was cooing with various vowel sounds.
    The diagnosis of a healthy former premature infant was made, and she was given routine health maintenance information. She had an appointment with the neonatal follow-up program in about a month to monitor her weight and development.

    The medical student had several questions about premature infants, but in particular had noted the infant’s initial Apgar score was 6 and a 5-minute Apgar score of 8. He thought these were low and also asked how good the Apgar scores were for predicting how well the infant would do. The attending physician gave him a brief history of the Apgar score and emphasized that it was a measure of the status of the infant at that time only and wasn’t good for predicting outcomes. The attending said, “It really gives everyone an idea of how well the infant is transitioning from fetus to neonate at that point in time. The change in the score is even more important if the infant wasn’t doing very well to begin with and then we can see how the infant is responding to our resuscitation efforts. You always want to see the scores go up if they are initially low and you want them to remain high if they were high to begin with. Low scores aren’t good but they aren’t predictive by themselves. I suppose there are sensitivities and specificities for using the scores with certain groups of infants but I don’t think there is standard specificity and sensitivity overall as neonates are such a diverse group of patients.”

    Discussion
    Dr. Virginia Apgar was the first woman at Columbia University College of Physicians and Surgeons to hold a full professorship. She was also the Chairman of the Department of Anesthesia and was interested in obstetrical anesthesia and newborn resuscitation. Although it is unclear how she developed the “Apgar score,” a peer of hers says she began to be upset at the lack of resuscitation and treatment efforts for “…apneic, small for age or malformed newborns…[She]began to resuscitate these infants and to develop a scoring system that would ensure observation and documentation of the true condition of each newborn during the first minute of life.” The first minute was used because clinical depression is often maximal at this time. Pictures and a fuller biography of Dr. Apgar can be found on the Changing Face of Medicine website from the National Library of Medicine.

    The scoring system gives 0-2 points for 5 different signs. The scoring system using the mneumonic “APGAR” is

    Sign						0			1					2
    Appearance - Color			Blue or pale	Acrocyanosis			Completely pink
    Pulse - Heart Rate			Absent		 100/minute
    Grimace - Reflex irritability	 No response	Grimace				Cry or active withdrawal
    Activity - Muscle tone		Limp	 		Some Flexion			Active motion
    Respiration				Absent		Weak cry or hypovention	Good cry
    

    Basic interpretation of the scores is

      0-4 = Severely depressed infants
      5-7 = Mildly depressed infants
      8-10 = Vigorous infants

    Learning Point
    The Apgar scoring system is very good because it is easy to learn, to apply, can be standardized and requires no special equipment. It focuses attention on the infant’s condition immediately after birth and can be a method to do ongoing assessment of the efficacy of the resuscitation efforts. There are problems with the scoring system though. Color, reflexes and muscle tone are subjective signs. Low birth weight and prematurity often have low scores. Congenital anomalies, hypoxia, hypovolemia, trauma and maternal drugs can also affect the score, as well as resuscitation efforts.

    Initially the scoring system was used at 1 minute of life but was expanded to be used at 5 minutes, when it was shown to be correlated with neonatal mortality. A 5 minute score and particularly the change “…in the score between 1 and 5 minutes, is a useful index of the response to resuscitation.”

    The scoring system was unfortunately abused. While low Apgar scores at longer time frames (ie. 5, 10, 15, and 20 minutes) after delivery indicate continued problems with the infant, they cannot by themselves indicate outcomes. More recent studies have found that low 5 minute Apgar scores (0-3 range) still correlate with neonatal mortality, but they do not correlate with neonatal morbidity with poor correlation with neurological outcomes in the future.

    The American Academy of Pediatrics and the American College of Obstetrics and Gynecology in 1996 developed guidelines for determining hypoxic-ischemic encephalopathy.
    All of the following must be present for the definition of asphyxia that is severe enough to result in neurological injury.

    • “Profound metabolic or mixed acidemia (pH < 7) in an umbilical artery blood sample, if obtained
    • Persistence of an Apgar score of 0-3 for longer than 5 minutes
    • Neonatal neurologic sequelae (eg, seizures, coma, hypotonia)
    • Multiple organ involvement (eg, kidney, lungs, liver, heart, intestines)”

    The Apgar score continues to be an excellent scoring system for initial and ongoing assessment of the newborn in the very early perinatal period when properly used. The American Academy of Pediatrics recommends using an expanded scoring form which includes the 5 Apgar signs but with correlated documentation of the resuscitation efforts including amount of oxygen used, oxygen delivery method used (ie positive-pressure ventilation or nasal continuous positive airway pressure, intubation) chest compressions and epinephrine. A copy of the scoring form can be found in the To Learn More section below.

    Questions for Further Discussion
    1. What other pediatric subspecialties were started or influenced by non-pediatricians?
    2. At what gestational age and/or weight is functional viability for preterm infants at your institution?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Newborn Screening

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Apgar V. A proposal for a new method of evaluation of the newborn infant. Anesth Analg 1953;32:260-7.

    Committee on Fetus and Newborn, American Academy of Pediatrics and Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Use and Abuse of the Apgar Score. Pediatrics. 1996;98;141-142.

    Changing the Face of Medicine Exhibition. National Library of Medicine. Virginia Apgar. Available from the Internet at http://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_12.html (exhibition closed 11/19/2005, cited 10/13/11).

    Finster M, Wood M. The Apgar score has survived the test of time. Anesthesiology. 2005 Apr;102(4):855-7.

    American Academy of Pediatrics, Committee on Fetus and Newborn; American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. The Apgar Score. Pediatrics. 2006;117:1444-1447.

    Zanelli SA, Rosenkranz T. Hypoxic-Ischemic Encephalopathy. Medscape. Available from the Internet at http://emedicine.medscape.com/article/973501-clinical (rev. 8/17/2011, cited 10/13/11).

    ACGME Competencies Highlighted by Case

  • Patient Care
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Do You Start Children on Lipid Lowering Medications?

    Patient Presentation
    A 12-year-old female came to clinic for health supervision. Her mother had concerns that she was obese, hypothyroid and was more tired over the past few months. Her mother was well versed in dietary interventions and said that she kept a strict watch on the amount and type of food including specifically measuring out quantities. The patient drank water and skim milk. Her mother also said that she was compliant with her levothyroxine. She was not active in general but had been more tired that usual and got tired with regular activities. She was doing well in school and had good social interactions with her family and peers despite recently moving to the area. Previous records were unavailable. The past medical history showed her hypothyroidism was noted 3 years previously and no changes in the levothyroxine had been made since then. The family history showed parents, 2 siblings, and other family members with obesity and dyslipidemias. There was no diabetes, stroke or early cardiovascular deaths. The father was on lipid-lowering medication. The review of systems was negative.

    The pertinent physical exam showed an obese female with BMI of 29.9 (>>95%), blood pressure of 103/68 and the rest of her vital signs were normal. HEENT showed normal thyroid without masses and a Tanner stage 3 female. Skin examination showed multiple striae but no acanthosis nigracans. The laboratory evaluation showed a TSH of 11.03 microunits/dL and T4 of 1.34 micrograms/dL. On a non-fasting sample cholesterol was 193 mg/dl (75-90%), triglycerides 208 mg/dl (>>>95%), HDL of 55 mg/dl (>50%) and LDL of 94 mg/dl (50%). Her glucose, hemoglobin A1c, renal and liver function tests were normal. The diagnosis of obesity, undertreated hypothyroidism and hypertriglyceridemia was made. The patient’s levothyroxine was increased with followup in a few weeks. It was hoped that as her hypothyroidism was better treated that she would have more energy and would be able to start a more regular exercise program. Fasting cholesterol and triglycerides were to be repeated soon. The patient was also going to try to eat more fruits and vegetables and start some soluble fiber. A multidisciplinary clinic with endocrinology, cardiology and dietary services was available for additional help with managing obesity and dyslipidemias. The family was referred as cholesterol subtypes testing was not available, the patient may need pharmacological treatment, and education for the entire family was felt to be beneficial. The mother was also going to obtain previous records for the entire family.

    Discussion
    Research has supported the idea of childhood precursors to adult disease including obesity and for cardiovascular disease. Cardiovascular disease is the leading cause of morbidity and death in the United States and dyslipidemias are one risk cardiovascular disease. Dyslipidemias do occur in childhood. Despite much research, there is still more that remains to determine the exact laboratory cut off numbers for various treatments and the best pharmacological treatments for patients that might benefit from them.

    The American Academy of Pediatrics (AAP) recommends that all children eat a healthy diet, and for those with risk factors (i.e. family history of hyperlipidemia, premature cardiovascular disease, obesity, hypertension, diabetes mellitus, cigarette smoking or an unknown family history) a fasting lipid screening panel is recommended after the age of 2 and not later than 10 years of age. For those that have normal testing, rescreening every 3-5 years is then recommended.

    Learning Point
    The AAP recommends dietary and lifestyle interventions for children with dyslipidemias. They also offer recommendations for treatment with pharmacological interventions for children with elevated LDL.

    • For children less than 8 years old, diet and exercise are the usual treatment. Pharmacological interventions are recommended for this age group only if there is “…dramatic elevation of the LDL concentration (>500 mg/dL) as seen with the homozygous form of familial hypercholesterolemia.”
    • For children more than 8 years old, pharmacological interventions are recommended using a graduated LDL the cut off. Implementation depends on risk factors. Children with no risk factors but LDL > 190 mg/dL despite diet therapy should be considered.
    • Child with risk factors including “obesity, hypertension, cigarette smoking or positive family history of premature cardiovascular disease should be consider with the LDL is persistently > 160 mg/dL despite diet therapy.
      For children with diabetes, pharmacological treatment should be considered when LDL concentration is > 130 mg/dL.

    The goal is to lower the LDL to less than 130 mg/dL or even 110 mg/dL in patients with risk factors.

    Recommendations from a lipid disorders clinic in Canada notes, “Because of the scarcity of data on the safety and efficacy of lipid-lowering medications for children and adolescents, pediatric lipid disorder specialists might be consulted before medication administration is initiated.” Because there is little to no pediatric data, their recommendations are extrapolated from adult data. These authors, like the AAP, recommend first and foremost, dietary and exercise changes along with smoking and alcohol cessation, along with treatment of underlying disorders such as diabetes and hypothyroidism.

    • For triglycerides > 130-445 mg/dL, they recommend lifestyle modifications and ω-3 fatty acids. Depending on the response, then statins are considered.
    • For triglycerides > 445-900 mg/dL, they again recommend lifestyle modifications and ω-3 fatty acids to start. Depending on the response statins and fibrates are considered.
    • For triglycerides > 900 mg/dL, referral to a lipid disorder clinic is recommended with treatment by ω-3 fatty acids, statins and fibrates as appropriate.

    Questions for Further Discussion
    1. What are the different categories of dyslipidemias?
    2. What referral resources are available in your local area for dyslipidemia?
    3. What screening laboratory tests are recommended for obese patients?
    4. What is the definition of metabolic syndrome for adults and children?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Obesity, Thyroid Diseases, and Triglycerides

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Daniels SR, Greer FR; Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008 Jul;122(1):198-208.

    Manlhiot C, Larsson P, Gurofsky RC, Smith RW, Fillingham C, Clarizia NA, Chahal N, Clarke JT, McCrindle BW. Spectrum and management of hypertriglyceridemia among children in clinical practice. Pediatrics. 2009 Feb;123(2):458-65.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital