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Linezolid-Induced Lingua Villosa Nigra

2008; Elsevier BV; Volume: 121; Issue: 6 Linguagem: Inglês

10.1016/j.amjmed.2008.02.023

1555-7162

Marwan Refaat, Emily P. Hyle, Rajeev Malhotra, Dominika Seidman, Bimalangshu R. Dey,

Autoimmune and Inflammatory Disorders

With the increased occurrence of methicillin-resistant Staphylococcus aureus infections, linezolid treatment might be administered more often. New rare adverse events are likely to be seen. We report a rare association of linezolid and black hairy tongue in an elderly man that improved with discontinuation of linezolid. We present this case to increase clinicians' awareness of a potential adverse effect of linezolid.A 74-year-old man with a history of T-cell-rich B-cell lymphoma developed fever secondary to coagulase-negative staphylococci and was initially treated with intravenous vancomycin. With a subsequent decrease in his renal function and a concern for acute interstitial nephritis, the patient's antibiotic regimen was switched to intravenous linezolid. Two days later, the patient was found to have black discoloration and hairy appearance of the tongue (Figure). He did not smoke or use oral tobacco products, and he was not taking any bismuth-containing compounds. Physical examination revealed a black coating on the surface of the tongue, with hairy elevations arranged in the form of a “V” extending from the posterior region of the dorsal surface of the tongue toward the anterior region without involvement of the undersurface; no tonsillar exudates, adenopathy, or hepatosplenomegaly was noted. A throat culture was negative for Candida albicans. The black discoloration and hairy appearance of the tongue completely resolved in 3 days after discontinuation of the linezolid.Black hairy tongue, also known as lingua villosa nigra, is a painless, benign disorder characterized by elongation and hyperplasia of the filiform papillae into “hair-like” projections and the development of a brown or black coating on the posterior dorsum of the tongue.1Ramsakal A. Mangat L. Images in clinical medicine Lingua villosa nigra.N Engl J Med. 2007; 357: 2388Crossref PubMed Scopus (13) Google Scholar Electron microscopic imaging has revealed that the filiform lengthening evident clinically is secondary to the accumulation of keratinized layers.2Manabe M. Lim H.W. Winzer M. Loomis C.A. Architectural organization of filiform papillae in normal and black hairy tongue epithelium: dissection of differentiation pathways in a complex human epithelium according to their patterns of keratin expression.Arch Dermatol. 1999; 135: 177-181Crossref PubMed Google Scholar Symptoms may include nausea, halitosis, dysgeusia, and unattractive appearance of the tongue. Lingua villosa nigra may be associated with the presence of chromogenic organisms (eg, C. albicans) and the use of certain medications (eg, tetracycline, olanzapine, and bismuth).3Tamam L. Annagur B.B. Black hairy tongue associated with olanzapine: a case report.Mt Sinai J Med. 2006; 73: 891-894PubMed Google Scholar We add to the medical literature on lingua villosa nigra as an adverse event of linezolid. The histopathology does show bacterial overgrowth in some instances. Although the exact pathogenesis is unclear, antibiotics associated with black hairy tongue—such as linezolid—might alter the normal flora of the mouth, leading to the overgrowth observed on histopathology. With the increased occurrence of methicillin-resistant Staphylococcus aureus infections, linezolid treatment might be administered more often. New rare adverse events are likely to be seen. We report a rare association of linezolid and black hairy tongue in an elderly man that improved with discontinuation of linezolid. We present this case to increase clinicians' awareness of a potential adverse effect of linezolid. A 74-year-old man with a history of T-cell-rich B-cell lymphoma developed fever secondary to coagulase-negative staphylococci and was initially treated with intravenous vancomycin. With a subsequent decrease in his renal function and a concern for acute interstitial nephritis, the patient's antibiotic regimen was switched to intravenous linezolid. Two days later, the patient was found to have black discoloration and hairy appearance of the tongue (Figure). He did not smoke or use oral tobacco products, and he was not taking any bismuth-containing compounds. Physical examination revealed a black coating on the surface of the tongue, with hairy elevations arranged in the form of a “V” extending from the posterior region of the dorsal surface of the tongue toward the anterior region without involvement of the undersurface; no tonsillar exudates, adenopathy, or hepatosplenomegaly was noted. A throat culture was negative for Candida albicans. The black discoloration and hairy appearance of the tongue completely resolved in 3 days after discontinuation of the linezolid. Black hairy tongue, also known as lingua villosa nigra, is a painless, benign disorder characterized by elongation and hyperplasia of the filiform papillae into “hair-like” projections and the development of a brown or black coating on the posterior dorsum of the tongue.1Ramsakal A. Mangat L. Images in clinical medicine Lingua villosa nigra.N Engl J Med. 2007; 357: 2388Crossref PubMed Scopus (13) Google Scholar Electron microscopic imaging has revealed that the filiform lengthening evident clinically is secondary to the accumulation of keratinized layers.2Manabe M. Lim H.W. Winzer M. Loomis C.A. Architectural organization of filiform papillae in normal and black hairy tongue epithelium: dissection of differentiation pathways in a complex human epithelium according to their patterns of keratin expression.Arch Dermatol. 1999; 135: 177-181Crossref PubMed Google Scholar Symptoms may include nausea, halitosis, dysgeusia, and unattractive appearance of the tongue. Lingua villosa nigra may be associated with the presence of chromogenic organisms (eg, C. albicans) and the use of certain medications (eg, tetracycline, olanzapine, and bismuth).3Tamam L. Annagur B.B. Black hairy tongue associated with olanzapine: a case report.Mt Sinai J Med. 2006; 73: 891-894PubMed Google Scholar We add to the medical literature on lingua villosa nigra as an adverse event of linezolid. The histopathology does show bacterial overgrowth in some instances. Although the exact pathogenesis is unclear, antibiotics associated with black hairy tongue—such as linezolid—might alter the normal flora of the mouth, leading to the overgrowth observed on histopathology.