What is the treatment for a patient with strep throat and a black tongue?

Treatment of Strep Throat with Black Tongue

Treat the strep throat with standard antibiotic therapy as recommended for Group A Streptococcal pharyngitis; the black tongue is almost certainly unrelated to the strep infection itself and is most commonly caused by bismuth-containing medications, poor oral hygiene, or antibiotic use—it does not change your treatment approach.

Understanding Black Tongue in This Context

Black tongue (lingua villosa nigra or "black hairy tongue") is a benign condition characterized by elongation and discoloration of the filiform papillae on the tongue. This is not a manifestation of strep throat and should be considered a separate issue 1, 2.

Common Causes of Black Tongue:

• Bismuth subsalicylate (Pepto-Bismol) - most common medication cause
• Poor oral hygiene - allowing bacteria and debris to accumulate
• Antibiotic use - which can alter oral flora (ironically, the treatment itself may worsen or cause black tongue)
• Tobacco use, excessive coffee/tea consumption
• Dry mouth or dehydration

The black tongue does not indicate a more severe streptococcal infection, does not require different antibiotic selection, and does not suggest treatment failure 3.

Standard Treatment for Strep Throat

First-Line Antibiotic Therapy

Penicillin remains the treatment of choice due to proven efficacy, safety, narrow spectrum, and low cost 3, 1:

• Penicillin V: 250 mg orally twice daily for 10 days (children) or 500 mg twice daily for 10 days (adolescents/adults) 3
• Amoxicillin: 50 mg/kg/day once daily (maximum 1000 mg) for 10 days—equally effective with better adherence due to once-daily dosing 1, 2
• Intramuscular benzathine penicillin G: 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg (single dose)—preferred when adherence to oral therapy is questionable 3, 1, 2

For Penicillin-Allergic Patients

Non-anaphylactic allergy (use first-generation cephalosporins) 3, 1:

• Cephalexin or cefadroxil for 10 days

Anaphylactic/immediate-type allergy 3, 1:

• Clindamycin: 20-30 mg/kg/day in 3 divided doses (maximum 300 mg/dose) for 10 days
• Azithromycin: 12 mg/kg/day (maximum 500 mg) for 5 days—though macrolide resistance is approximately 5-8% in the United States 3, 1

Agents to Avoid

Do not use the following antibiotics for strep throat 3:

• Tetracyclines (high resistance rates)
• Sulfonamides or trimethoprim-sulfamethoxazole (do not eradicate GAS)
• Older fluoroquinolones like ciprofloxacin (limited activity against GAS)

Managing the Black Tongue

Immediate Management:

• Discontinue bismuth-containing products if the patient is taking them
• Improve oral hygiene: brush tongue gently with toothbrush, use tongue scraper
• Increase hydration
• Avoid tobacco, excessive coffee/tea

Important Caveat:

The antibiotic prescribed for strep throat may temporarily worsen the black tongue by altering oral flora 4. This is not a reason to withhold appropriate antibiotic therapy for the strep infection. Reassure the patient that black tongue is benign and typically resolves within days to weeks after the causative factor is removed 4.

Symptomatic Treatment for Strep Throat

Analgesics/antipyretics should be used as adjunctive therapy 3, 1:

• Acetaminophen or NSAIDs (ibuprofen) for moderate to severe symptoms or high fever
• Avoid aspirin in children due to risk of Reye syndrome 3, 1
• Corticosteroids are not recommended as adjunctive therapy 3, 1

Follow-Up Considerations

• No routine follow-up testing is needed after completing antibiotic therapy if the patient is asymptomatic 3, 1, 2
• Patients are non-contagious after 24 hours of appropriate antibiotic therapy 1, 2
• Reevaluate if symptoms worsen after starting antibiotics or persist beyond 5 days of treatment 5

Key Clinical Pitfalls

1. Do not assume black tongue indicates treatment failure or antibiotic resistance—it is unrelated to the strep infection 1, 2
2. Do not switch antibiotics based solely on black tongue appearance—continue standard strep throat treatment 3
3. Do not perform throat culture after treatment completion unless the patient remains symptomatic or has special risk factors (history of rheumatic fever, outbreak situations) 3, 2
4. Ensure full 10-day course of oral antibiotics (except azithromycin which is 5 days) to maximize bacterial eradication and prevent rheumatic fever 3, 1