Lansoprazole – Induce Black Hairy Tongue-A Case Report

Lansoprazole induced black hairy tongue has been rarely reported. The purpose of this paper is to report a case of lansoprazole induce black hairy tongue and review the literature. A 75 year man from eastern part of Kathmandu presented with black hairy fine growth from tongue along with discomfort, burning and halitosis from oral cavity after taking lansoprazole for acute peptic disease(APD) from over the counter and after discontinuation of lansoprazole, black hairy tongue was resolving. Clinically and histopathologically: lansoprazole induced black hairy tongue was confirmed. Black hairy tongue is characterized by abnormal hypertrophy and elongation of filliform papillae.. Lansoprazole is a proton-pump inhibitor (PPI) with a racemic 1:1 mixture of the enantiomers dexlansoprazole which inhibits the stomach’s production of gastric acids.


Introduction
D iscolora on of tongue and oral mucosa is a reac on pa ern of endogenous and exogenous substances.Proton pump inhibitors (PPI) are widely used as a treatment for pep c ulcer disease and prophylaxis for drug induced gastric ulcer and along with oral steroid, which alter both gastric acid and pH of oral cavity and gastrointes nal tract which lead to change color of tongue. 1 Linguavillosa Nigra (LN) also known as Black Hairy tongue (BHT) is painless, benign hairy growth on dorsum surface of tongue; due to defec ve desquama on and reac ve hypertrophy of fi liform papillae of the tongue. 2It is also known as Keratomycosis Linguae, Melanotrichia, Linguavillosa nigra and Hyperkeratosis of tongue. 3It was fi rst described by Lusitanus in 1557 as hair on tongue which can regrow even a er being removed. 2,3Its e ology and pathophysiology have not been fully elucidated, but is mostly present with chronic smoking, alcohol use, poor oral hygiene and certain medica ons like an bio cs, linezolid and an cancer drug.The purpose of this ar cle is to present a case of lansoprazole induced Black Hairy tongue (BHT), which has been rarely reported ll date.

Case Presentation
A healthy 75 year old male from eastern part of Kathmandu presented to dermatology OPD with chief complaints of burning sensa on, discomfort and bad breath from oral cavity for 8 weeks.He, smoker for last 20 years, had abdominal discomfort along with heartburn and bloa ng since last 2 years.He had been taking lansoprazole, on and off , for last the 12 months and since the last 2 months, he has been taking it regularly from local chemist as over the counter (OTC) drug without consul ng the physician.He was of normal built with vitals within normal limits.On intra oral examina on, there was poor oral hygiene with stains on teeth with superfi cial black to brown hairy like growth on dorsum of tongue that appeared as an elonga on of fi llliform papillae almost 3 mm in growth (fi g:1).There was no history of pain, itching and bleeding from oral cavity.
Culture of the dorsal surface of tongue was nega ve for bacterial and fungal outgrowth a er 48 and 72 hours.Rou ne blood inves ga on were within normal limit along with nega ve HIV test.A 4 mm punch biopsy was taken under sterile condi on, with consent from pa ent, from the dorsum of tongue.Histopathological study showed elonga on and hyperparakeratosis of the fi liform papillae (fi g:2).
Clinically and histopathologically diagnosis of BHT was made.Pa ents was advised to stop lansoprazole along with cessa on of smoking along with gentle tongue debridement with so toothbrush and was referred to dental department for assessment and management of oral cavity.On follow up a er 8 weeks (fi g:3), there was resolving BHT with almost normal texture.Hence fi nal diagnosis was Black Hairy Tongue (Clinically: Lansoprazole induced).

Discussion
BHT has been reported in pa ent with poor oral hygiene and chronic smoker.Our pa ent had been smoking since last 20 years and though we advised him to stop smoking, he con nued with decreased frequency of smoking.This might have helped in improving his condi on.A study in Turkish dental pa ents showed causal smoker poses slightly increased risk of having BHT compared to non smoker and male subjects had greater prevalence of BHT. 4 Excessive coff ee, black tea, poor oral hygiene and radia on therapy of head and neck region can trigger BHT. 4 Dry mouth due to radia on therapy can cause severe xerostomia and even many drugs like an cholonergic, an depressant and an hypertensive drugs can further aggravate xerostomia which lead to alter pH of oral cavity and lead to defec ve desquama on and prevent normal debridement leading to accumula on of kera nized layer and hypertrophy of fi liform papillae into hair like growth. 5Similarly a case of BHT has been reported in pa ent with trigeminal neuralgia with decreased tongue movement and mas ca on ul mately hindering desquama on of kera nized fi liform papillae. 5,6Use of systemic and local medica on has been implicated in development of BHT.
An bio c including penicillin, erythromycin, doxycycline and neomycin are mostly associated with this disorder. 5Linezolid induced BHT, which resolved spontaneously a er stopping it, has been reported. 7,8ocal and systemic an bio c signifi cantly alter oral fl ora, thus poten ally predisposing the pa ent to develop BHT.This altera on of oral fl ora predispose to trapping of foreign material and s mulate local microbial overgrowth that lead to color change with delayed desquama on of cells in central column of fi liform papillae and marked reten on of secondary papillary cells that express hair type kera ns. 9 Many capsule and tablet contain red, black, yellow ferric oxide as a colorant which accumulates as debris with overgrowth of bacteria and yeasts which lead to synthesis of porphyrin producing chromogenic organisms resul ng in BHT. 5 Our pa ent was on lansoprazole since last one year irregularly but regularly since last 2 months.He no ced black hairy growth on tongue 6 weeks a er star ng lansoprazole which was diagnosed clinically and microscopically as Black Hairy Tounge (BHT).He was advised to stop lansoprazole completely with maintaining proper oral hygiene with regular follow up.We no ced, improvement in tongue a er 8 weeks of discoun nua on of lansoprazole.This evidence   PPI are widely used along with oral steroid as a prophylaxis and as treatment of pep c ulcer.PPI inhibit the hydrogen-potassium adenosine triphosphatase enzyme system, which is the fi nal stage of produc on of gastric acid in stomach. 10The decrease or change of gastric acid produc on by PPI lead to increase pH in stomach and oral saliva leading altera on of oral microbial growth and overgrowth of chromogene micro-organism and hence tongue discolora on. 11ix cases of BHT in associa on of PPI (omeprazole, pantoprazole) with posi ve rechallenge in one pa ents was reported in database of Netherlands Pharmacoviglance Centre Lab and WHO on July 14, 2009.Similarly, in a case report by Sakallioglu Ohas, six years girl developed BHT a er second week of Helicobacter pylori regimen containing an boio c along with lansoprazole and it resolved a er one week cessa on of drugs 12 .In dermatological prac ce we use oral steroid along with PPI as one of the main line of treatment.So we need to be even more aware about the possible side eff ecst of not only oral steroid but also of PPI.

Conclusion
BHT is asymptoma c, but can cause serious psychological impact on pa ent and need to manage with proper educa on of oral hygiene maintenance.Any drug, even commonly used , may cause BHT and should be documented and reported, so that in coming future we can have more evidence based database.

Figure 3 :
Figure 3: BHT a er 8 weeks of discon nua on of lansaprazole

Figure 1 :
Figure 1: BHT on dorsum of tongue with 4mm punch biopsy