Black Hairy Tongue vs. Mucormycosis in Dialysis: A Case Report of Statin- Associated Lesion and 7-Day Resolution

Background Black hairy tongue (BHT), while typically benign, presents significant diagnostic challenges in immunocompromised patients where it may mimic life-threatening conditions like mucormycosis. This case is noteworthy due to its exceptionally rapid onset in a high-risk patient and its association with statin therapy, a rarely reported trigger. The clinical urgency of distinguishing BHT from malignant or invasive fungal processes in vulnerable populations makes this report particularly valuable to the medical community. Case presentation A 73-year-old male with end-stage renal disease (on hemodialysis), poorly controlled diabetes mellitus, and long-term atorvastatin use developed dramatic black discoloration of the tongue over 24 hours. Physical examination revealed characteristic elongated, hyperpigmented filiform papillae without evidence of necrosis or ulceration. The patient denied pain but reported significant cosmetic concern. Diagnostic workup included an urgent tongue biopsy which showed reactive hyperkeratosis with Candida species colonization, definitively excluding mucormycosis or malignant transformation. Management consisted of three key interventions: discontinuation of atorvastatin, implementation of twice-daily mechanical debridement using a soft toothbrush, and strict avoidance of tobacco products. Remarkably, complete resolution occurred within seven days without requiring antifungal therapy. Conclusions This case highlights three crucial clinical lessons: first, the critical importance of histopathological confirmation in immunocompromised patients presenting with rapid tongue discoloration to rule out sinister pathology; second, the potential role of statins in triggering acute BHT onset, suggesting temporary discontinuation may accelerate resolution; and third, the demonstrated efficacy of conservative measures alone in managing even dramatic presentations of BHT, avoiding unnecessary antimicrobial use. These findings have immediate practical implications for clinicians managing high-risk patients with similar presentations.