A Tale of Two Tongues
Brothers present with residual findings from a bad bout of lower GI distress. Their tongues will speak for themselves. What's your Dx?
Brothers aged 10- and 18-years-old present to primary care after weekend ED visit for symptoms of lower GI virus. Treated with symptomatic home therapy.
Tests ordered by ED: electrolytes, BUN, CBC, sed rate; stool specimens for cultures; abdominal x-rays; d/c to home as both appeared well.
At office visit both 10- and 18-year-old appear well; only physical finding is their tongues.
Tongue of 10-year-old appears to be black in several areas and this does not come off with gauze.
The tongue of the 18-year-old also has patches of black that do not resolve with rubbing.
The 10-year-old's abdominal x-rays are available to view.
Seen on the x-ray of the 10-year-old are radiopaque flecks.
Differential diagnosis of black tongue: Pepto-Bismol; hairy tongue â poor desquamation of keratin with elongation of filiform papillae; staining - coffee, tea, tobacco, licorice; antibiotics; radiation.
What might cause both black tongue and radiopaque flecks? A. Licorice ingestion B. A home remedy prescribed by the mother C. Pepto-Bismol D. Some sort of anomaly E. Fragments of aluminum foil
Answer C. Pepto-Bismol. The bismuth oxidizes on the surface of the tongue.
What else can cause radiopaque flecks on abdominal x-ray?
Try this mnemonic for radiopaque flecks: C.H.I.P.P.P.E.D Chloral hydrate--Heavy metals-Iron-Pepto-Bismol-Play dough-Phenothiazine tablets-Enteric coated tablets-Dental amalgam
The appointment ends well with lessons for all: Pepto-Bismol has side effects; a complete history is essential; don't order unneeded tests; use the ED appropriately.
In Monday morning clinic you are presented with 10- and 18-year-old brothers who recently missed nearly a week of school for similar lower GI symptoms. Their mother was concerned and took them to the ED where they were examined, discharged, and referred to primary care for follow-up.They look well now but there is one odd finding seen in both boys and a second one noted in the 10-year-old. Walk through the case inthe slides above. Can you figure this one out?
