Black Hairy Tongue

A 60-year-old man who smokes presents to the physician’s office smelling of alcohol. He complains of a black discoloration of his tongue and a gagging sensation on occasion. He admits to smoking
1 to 2 packs per day along with drinking at least 6 to 8 beers per day. The patient brushes his teeth infrequently and has not seen a dentist for a long time.
On physical exam, his teeth are stained and his tongue shows elongated papillae with brown discoloration . See picture below:

Diagnoses include black hairy tongue (BHT), poor oral hygiene, and tobacco and alcohol addiction.

Case Discussion:

Black Hairy Tongue: 

Black hairy tongue (BHT) is a benign disorder of the tongue characterized by abnormally hypertrophied and elongated filiform papillae on the surface of the tongue. In addition, there is defective desquamation of the papillae on the dorsal tongue resulting in a hair-like appearance
Also known as : Hyperkeratosis of the tongue and lingua villosa nigra.

Risk factors include:

Cor pulmonale

Definition: Cor pulmonale is right heart failure caused by chronic pulmonary arterial hypertension.

Pathophysiology: Patients with pulmonary hypertension develop changes in the small blood vessels of the lungs that can lead to increased blood pressure in the right side of the heart. This makes it harder for the heart to pump blood to the lungs. If the pressure continues , the strain on the right side of the heart leads to cor pulmonale.

Chest radiograph showing enlarged pulmonary arteries from pulmonary artery hypertension.

Causes: include:
1. Lung diseases:

• Asthma ( severe and chronic)
• COPD
• Bronchiectasis
• Pulmonary fibrosis
• Lung resection

2. Pulmonary vascular disease:

• Pulmonary emboli
• Pulmonary vasculitis
• Primary pulmonary hypertension. 
• Sickle cell disease
• Acute respiratory distress syndrome.
• Parasite infestation

Introduction To Lyme Disease

 Circular red rash with central clearing characteristic of Lyme disease. Rash is known as Erythema chornicum migrans.

Introduction: Caused by the spirochete Borrelia burgdorferi, Lyme disease is transmitted by the bite of the deer tick (Ixodes dammini).
Although reported in most states, it appears to be predominant in the Great Lakes area and the Western and Northeastern United States.

Clinical features: The symptoms occur in three stages:

First stage. This stage usually begins with malaise, fever, headache, stiff neck, and back pain. Generalized lymphadenopathy with splenomegaly occurs, and a large annular erythematous lesion forms at the bite site and shows central clearing (erythema chronicum migrans). Multiple lesions may occur and affect other areas of the body. The lesions are warm but not often painful. As many as 25% may not exhibit skin manifestations. These symptoms usually appear within a few days to up to 1 month after the tick bite.

Second stage. This is the disseminated stage. Complications include carditis with AV block, palpitations, dyspnea, chest pain, and syncope. Pericarditis may also occur. Neurologic manifestations, including peripheral neuropathies and meningitis, are sometimes present. Large-joint arthritis is also common.

Burner's Syndrome

Which of the following statements about Burner’s syndrome is true?
A) The mechanism of injury involves acute hyperextension of the shoulder while the neck and head are forced in the same direction.
B) Symptoms include temporary weakness, pain, paresthesias, and decreased sensation of the distal extremity.
C) The injury involves traction forces on the spinal cord’s dorsal columns.
D) Most cases cause permanent neurologic deficits.
E) The condition is associated with overuse injury of the knees.

Answer and Discussion
The answer is B. (Symptoms include temporary weakness, pain, paresthesias, and decreased sensation of the distal extremity.)

Mechanisms of “burners syndrome .” :
(A)  Traction to the brachial plexus from ipsilateral shoulder depression and contralateral lateral neck flexion. 
(B) Direct blow to the supraclavicular fossa at Erb's point. 
(C)Compression of the cervical roots or brachial plexus from ipsilateral lateral flexion and hyperextension.


Burner’s syndrome is seen mostly in football players and results from a tackling or blocking injury.

Psoriasis And Its Different Clinical Types.

 Q 1 ; What is the diagnosis? 

Answer: Nail pitting and psoriasis .

Q 2 : Describe the skin lesions and the clinical features in patients with Psoriasis? 

Answer: The clinical features in psoriasis may differ from patient to patient but the most commonly observed signs and symptoms include:

• Red patches of skin covered with silvery scales.
• The patches of psoriasis are seen over the bony prominence, particularly the elbows and knees, and also on the trunk and scalp and in the intragluteal cleft (the latter two areas are frequently overlooked).
• The plaques are circular with well-defined edges and they are red with a silvery scaly surface.
• There is pitting of the fingernails. 
• Dry , cracked skin may sometimes bleed. 
• There may be associated arthropathy with swollen ad stiff joints. 

Q 3. Describe briefly different types of Psoriasis? 

Answer : There are different types of Psoriasis . A few are described (with pictures) below :

An 18-month-old Boy Comes to Clinic With a History of Eczematous Rash

An 18-month-old boy comes to clinic with a history of eczematous rash covering his extremities and face. His parents state that it worsens after the ingestion of certain foods. He has had increased fussiness over the last several months, as well as some difficulty gaining weight. Food allergy is suspected. Which of the following foods is NOT commonly implicated in food allergy?

A) Milk.
B) Corn.
C) Wheat.
D) Soy.
E) Egg.


Answer And Discussion