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Year : 2022  |  Volume : 26  |  Issue : 2  |  Page : 77-79

Linezolid-induced black hairy tongue: A case report and review of literature

Department of Dermatology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission02-Jan-2022
Date of Acceptance05-Jul-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Mohammad Adil
Department of Dermatology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdds.jdds_1_22

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Black hairy tongue is an asymptomatic and benign condition presenting with black-to-brownish discoloration of the dorsum of the tongue with elongated filiform papillae. Several medications, particularly antibiotics, are implicated in its causation. Xerostomia, abnormal desquamation of the tongue, use of oxidizing mouthwashes, excessive intake of nicotine, coffee, and tea, and immunosuppressive states predispose to the development of this condition. Herein, we describe a case of a young female who developed black hairy tongue within 5 days of linezolid intake. The discoloration disappeared after 7 days of stopping the drug. We also summarize the various reports of black hairy tongue due to linezolid in a tabular form. We aim to highlight the importance of medication history in the identification of this uncommon condition. We also emphasize identifying risk factors for this condition and educating the patients about them.

Keywords: Adverse drug reaction, black hairy tongue, linezolid

How to cite this article:
Siddiqui MA, Adil M, Amin SS, Xess K. Linezolid-induced black hairy tongue: A case report and review of literature. J Dermatol Dermatol Surg 2022;26:77-9

How to cite this URL:
Siddiqui MA, Adil M, Amin SS, Xess K. Linezolid-induced black hairy tongue: A case report and review of literature. J Dermatol Dermatol Surg [serial online] 2022 [cited 2023 Mar 29];26:77-9. Available from: https://www.jddsjournal.org/text.asp?2022/26/2/77/366402

  Introduction Top

Black hairy tongue is also known as lingua villosa nigra. It is a benign condition characterized by hypertrophied filiform lingual papillae with black discoloration of the dorsum of the tongue. It is usually asymptomatic but few patients may experience halitosis, nausea, tickling, and dysgeusia. It is caused due to defective desquamation.[1] Various factors such as male sex, old age, smoking, alcohol use, and poor oral hygiene are considered predisposing factors. Medications such as cephalosporins, penicillins, sulfonamides, methyldopa, and linezolid have been reported to cause black discoloration of the tongue.[2]

Herein, we report a rare case of black hairy tongue due to linezolid in a young female which occurred in a short duration. We also review the literature regarding black hairy tongue due to this antibiotic.

  Case Report Top

A 29-year-old female developed a solitary, unilateral swelling on the left side of the neck for 3 weeks. It was initially 2 cm × 2 cm, which gradually progressed to 4 cm × 4 cm. It was associated with mild pain and moderate-to-high-grade fever. For these complaints, she visited a quack, who performed incision and drainage and prescribed tablet paracetamol 500 mg twice daily with tablet linezolid 600 mg twice daily. The patient did not give a history of taking any other medications.

Five days later, the patient developed blackish discoloration of the dorsum of the tongue. On examination, brownish-to-black discoloration on the posterior part and dorsal aspect of the tongue was noticed with elongated and hypertrophied filiform papillae, with complete sparing of the margins of the tongue [Figure 1]. Examination of teeth, gums, buccal mucosa, lips, and palate revealed no abnormality. Nail and hair examinations were normal.
Figure 1: Black–brown discoloration of the dorsum of the tongue with elongated papillae

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Complete hemogram and serum Vitamin B12 levels were normal. Scraping for fungal elements and culture for bacteria and Candida was negative. Serology for human immunodeficiency virus (HIV) was nonreactive. Consent for biopsy was not given by the patient.

A diagnosis of linezolid-induced black hairy tongue was made. The patient was advised to stop linezolid and clean her tongue thrice a day with normal saline. She was also referred to the department of tuberculosis (T.B.) and respiratory medicine, where she was investigated and her cartridge-based nucleic acid amplification test for T.B. was positive. She was started on antitubercular treatment for tubercular lymphadenopathy.

The discoloration totally disappeared after 7 days of stopping linezolid [Figure 2].
Figure 2: Complete resolution of discoloration of the tongue after 7 days of stopping linezolid

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  Discussion Top

Black hairy tongue was first described by Dr. Amatus Lusitanus as early as 1557. Black hairy tongue is caused by several drugs such as antibiotics (penicillins, tetracyclines, macrolides, linezolid, and metronidazole); antipsychotics; antidepressants; antineoplastic agents; and other drugs such as methyldopa.[3] Immunosuppressive states such as HIV, late stages of cancer, and radiotherapy in the head-and-neck area are also associated. The use of oxidizing mouthwashes, excessive intake of black tea, coffee, tobacco chewing, smoking, and alcohol intake are said to increase the risk of this condition. Conditions causing xerostomia and those preventing normal desquamation (trigeminal neuralgia causing pain in mastication, soft diets, and edentulous patients) may also lead to black hairy tongue.[4]

The patient presents with tongue discoloration with elongated filiform papillae which may reach a centimeter or more in length. The discoloration is usually black or brown but green, yellow, and blue discoloration of the dorsal tongue has also been described. Antibiotics may alter normal bacterial flora and lead to the growth of chromogenic bacteria such as Porphyromonas gingivalis (a Gram-negative anaerobic bacillus that produces porphyrins).[4],[5] In addition, antibiotics may themselves stain the tongue or may lead to the growth of fungi, as evidenced by the growth of Candida from the throat and tongue swabs in case reports. Restricted movements of the tongue or xerostomia may cause excessive accumulation of keratin. Penicillin also decreases nicotinamide production by inhibiting intestinal bacteria, which may lead to hyperpigmentation of the tongue.[4]

Linezolid is a synthetic oxazolidinone antibiotic. It binds to bacterial rRNA, thereby inhibiting protein synthesis. It has a broad-spectrum antibacterial activity against infections caused by vancomycin-resistant Enterococcus faecium, Staphylococcus aureus-induced hospital-acquired pneumonia, etc., Usual adverse effects associated with linezolid include peripheral and ocular neuropathy, anemia, and thrombocytopenia due to bone marrow suppression, hyperlactatemia, diarrhea, nausea, and headache. Black hairy tongue is a rare side effect seen in patients receiving linezolid therapy.[6],[7],[8] Linezolid-induced black hairy tongue has been reported previously. The details of the previously reported cases are summarized in [Table 1].
Table 1: Reported cases of linezolid-induced black hairy tongue

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Black hairy tongue is a spontaneously resolving benign condition. The condition is managed by maintaining good oral and dental hygiene. If the condition persists, gentle cleansing with a soft toothbrush and baking soda or hydrogen peroxide is advised.[20],[21] Trichloroacetic acid, urea solution, thymol, gentian violet, and Vitamin B have also been used. Antifungals were tried by some authors based on positive fungal cultures in a few cases but are usually not indicated. The offending drug may be stopped. However, the culprit drug may be reintroduced if the physician deems it necessary.

Black hairy tongue is an uncommon and transient adverse effect of linezolid. Diagnosis of this condition and identification of the cause requires a thorough history of all medications. The patients who may be at risk must be identified and educated regarding prevention. All patients on linezolid therapy should be instructed to maintain good oral hygiene.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

  References Top

Khasawneh FA, Moti DF, Zorek JA. Linezolid-induced black hairy tongue: A case report. J Med Case Rep 2013;7:46.  Back to cited text no. 1
Raj RT, Raj R, Nagpal J, Kumar R. Linezolid induced black hairy tongue an uncommon phenomenon: A case report with update of review of literature. Am J Med Sci Med 2016;4:71-6.  Back to cited text no. 2
Jover-Diaz F, Cuadrado-Pastor JM, Talents-Bolos A, Martin-Gonzalez C. Black tongue associated with linezolid. Am J Ther 2010;17:e115-7.  Back to cited text no. 3
Ren J, Zheng Y, Du H, Wang S, Liu L, Duan W, et al. Antibiotic-induced black hairy tongue: Two case reports and a review of the literature. J Int Med Res 2020;48:1-11.  Back to cited text no. 4
Luo S, Luo Q, Gao X, Li J. Adverse reaction report and retrospective analysis of black hairy tongue caused by linezolid. Respir Med Case Rep 2020;31:101159.  Back to cited text no. 5
Braggio C, Bocchialini G, Ventura L, Carbognani P, Rusca M, Ampollini L. Linezolid-induced black hairy tongue. Acta Biomed 2018;89:408-10.  Back to cited text no. 6
Jain AK, Puri MM, Sarin R. Black brown discoloration and hairy tongue – A rare linezolid side effect. Indian J Tuberc 2017;64:44-6.  Back to cited text no. 7
Braga-Simões J, Santos LA. Linezolide-induced hairy tongue. Oxf Med Case Reports 2016;2016:omw088.  Back to cited text no. 8
Matson KL, Miller SE. Tooth discoloration after treatment with linezolid. Pharmacotherapy 2003;23:682-5.  Back to cited text no. 9
Amir KA, Bobba RK, Clarke B, Nagy-Agren S, Arsura EL, Balogun SA, et al. Tongue discoloration in an elderly kidney transplant recipient: Treatment-related adverse event? Am J Geriatr Pharmacother 2006;4:260-3.  Back to cited text no. 10
Refaat M, Hyle E, Malhotra R, Seidman D, Dey B. Linezolid-induced lingua villosa nigra. Am J Med 2008;121:e1.  Back to cited text no. 11
Ma JS. Teeth and tongue discoloration during linezolid therapy. Pediatr Infect Dis J 2009;28:345-6.  Back to cited text no. 12
Bozkurt I, Yontar E, Doganay M. Black hairy tongue: A rare side effect of linezolid. Our Dermatol Online 2012;3:136-7.  Back to cited text no. 13
Marina VP, Kasmani R. An uncommon side-effect of linezolid. Int Urol Nephrol 2012;44:995-6.  Back to cited text no. 14
Petropoulou T, Lagona E, Syriopoulou V, Michos A. Teeth and tongue discoloration after linezolid treatment in children. Pediatr Infect Dis J 2013;32:1284-5.  Back to cited text no. 15
Aijazi I, Abdulla FM. Linezolid induced black hairy tongue: A rare side effect. J Ayub Med Coll Abbottabad 2014;26:401-3.  Back to cited text no. 16
Balaji G, Maharani B, Ravichandran V, Parthasarathi T. Linezolid induced black hairy tongue. Indian J Pharmacol 2014;46:653-4.  Back to cited text no. 17
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Santos JA, Varandas L, Gouveia C. Reversible teeth discoloration in children: A linezolid therapy side effect. Clin Pediatr (Phila) 2015;54:809.  Back to cited text no. 18
Mancano MA. High-dose loperamide abuse inducing life-threatening cardiac arrhythmias; topiramate-induced diarrhea in a breastfed infant; danazol-induced Stevens-Johnson syndrome; asenapine-induced Myasthenic syndrome; black hairy tongue due to linezolid; adalimumab-induced priapism. Hosp Pharm 2015;50:351-5.  Back to cited text no. 19
Rao AG, Aparna K, Reddy VS, Farheen SS, Hakkani R, Parimala D, et al. Linezolid-induced black pigmentation of tongue and perioral region. Indian J Paediatr Dermatol 2019;20:189.  Back to cited text no. 20
Lee J, Chung HS, Roh J, Oh Y, Mok J. Linezolid-induced black hairy tongue in a patient with multidrug-resistant tuberculosis: A case report. Sci Prog 2021;104:1-6.  Back to cited text no. 21


  [Figure 1], [Figure 2]

  [Table 1]


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