IT'S BLACK, IT'S HAIRY . . . BUT IS IT A PROBLEM? C.C. Fu 1 , G. Applebaum 1 ; 1 University of California, Los Angeles, Los Angeles, CA (Tracking ID #74949) LEARNING OBJECTIVES: 1. Recognize the presentation of black hairy tongue. 2. Review possible predisposing conditions. 3. Emphasize benign nature of this phenomenon. CASE INFORMATION: A 53-year-old Mexican man with no significant medical history presented with one month of easy bruising and gum bleeding. The patient's only medicines were occasional aspirin for pain and bayberry extract. Lab results were significant for 2.2 WBCs, Hb 8.2, and 4 platelets. Bone marrow biopsy revealed a hypocellular and fatty marrow consistent with aplastic anemia. The patient's three-week hospital stay was complicated. He had extraction of an infected tooth and was started on a peroxide-based swish and spit regimen. Treatment for aplastic anemia was begun with anti-thymocyte globulin and cyclosporine. The patient experienced prolonged neutropenic fevers for which he was treated with ceftriaxone, tobramycin, metronidazole, and vancomycin. During this period, the patient's tongue was noted to develop a dark gray,``hairy'' appearance, the surface of which could actually be brushed with the end of a cotton swab. IMPLICATIONS/DISCUSSION: Black hairy tongue is a rare condition caused by the elongation of the filiform papillae associated with oral bacterial overgrowth. Black hairy tongue is idiopathic and has been associated with various predisposing factors including alcoholism, systemic illness, immunosuppression, cancer therapy, coffee, antibiotic use, and use of peroxide-based mouthwash. Our patient was a likely candidate to develop black hairy tongue as he had been given broad-spectrum antibiotics and used peroxide based mouthwash during immunosuppressive therapy. Treatments for black hairy tongue have included topical retinoin gel, podophyllum, and attempts at repeated tongue brushing. However, in consideration of our patient's underlying immunosuppression and profound thrombocytopenia, we chose not to treat the patient's tongue. It is important not to complicate the treatment of an ill patient with the unnecessary treatment of a benign, albeit strange, condition. A 45 year old Mexican female with a history of diabetes mellitus was brought to the emergency room by her family for increasing abdominal pain and a four day history of nausea, vomiting and diarrhea. There was no recent history of fevers, chills, or dysuria. Initial examination revealed an ill-appearing woman, moaning in response to painful stimuli, but not following commands. Although she was afebrile and normotensive, her resting heart rate of 119 beats per minute established systemic illness. Her other examination was remarkable for right lower quadrant tenderness in a soft abdomen, but no peritoneal signs. There was evidence of costovertebral angle tenderness bilaterally. Initial laboratory results were consistent with diabetic ketoacidsosis (DKA). Leukocytosis and pyuria led to the additional admitting diagnosis of pyelonephritis. Declining mentation led to rapid transfer to the intensive care unit on the day of admission. Computed tomography (CT) of the abdomen showed bilateral emphysematous pyelonephritis, emphysematous cystitis, bilateral perinephric abscesses, and air surrounding the inferior vena cava (IVC). Broad spectrum antibiotics were initiated. Emergent urology consultation recommended medical management due to high perioperative mortality risk. Bilateral percutaneous drains were placed under CT guidance. Nevertheless, the patient's condition rapidly deteriorated with development of thrombocytopenia and septic shock, requiring intubation and pressor support. She died the following hospital day. Blood, urine and perinephric fluid cultures grew Klebsiella pneumoniae. IMPLICATIONS/DISCUSSION: Emphysematous pyelonephritis (EPN) is a rare condition that causes an acute necrotizing parenchymal and perirenal infection due to gas-forming uropathogens. Bilateral disease is exceedingly rare. EPN occurs predominantly in diabetic patients and in patients with urinary tract obstruction. E.coli, Klebsiella and Proteus are the most frequently identified organisms. Computed tomography is used for diagnosis and evaluation of the extent of disease. Antibiotics and percutaneous drains can lead to successful outcomes in patients with limited disease. However, nephrectomy is often considered the treatment of choice, especially in patients with extensive disease or multiple poor prognostic factors. Bilateral disease makes the surgical decision even more difficult. Understanding the indications for surgical versus medical management may mean the difference between life and death in patients with EPN.