Focal Epithelial Hyperplasia (Heck’s Disease) in a 57-Year-Old Brazilian Patient: A Case Report and Literature Review

Abstract

Focal epithelial hyperplasia (FEH), or Heck’s disease, is a rare disease of the oral mucosa associated with infection by some subtypes of human papilloma virus, especially subtypes 13 or 32. The disease is predominantly found in children and adolescents with indigenous heritage, but other ethnic groups can be affected worldwide. To the best of the authors’ knowledge, it has not been reported in Brazil’s elderly population. This article describes a case of FEH in a 57-year-old Brazilian patient presenting since childhood, with multiple lesions in the lips, buccal mucosa and tongue. The solitary tongue lesion underwent excisional biopsy and the histopathological analysis showed parakeratosis, acanthosis, rete pegs with a club-shaped appearance, koilocytosis and the presence of mitosoid cells. These microscopic findings in conjunction with clinical presentation were sufficient to establish the accurate diagnosis of FEH. Polymerase chain reaction (PCR) was performed, but no one human papillomavirus (HPV) subtype could be identified. Clinicians must be aware of this rare oral disease, which can even affect elderly patients, as we described here. Treatment may be indicated in selected cases due to esthetic and/or functional problems.

Multiple oral soft tissue nodules in a Caucasian septuagenarian

“…Medications, such as topical/systemic interferon and imiquimod cream, have demonstrated benefit in treating lesions of MEH 1 . Prognosis of MEH is indeterminate with risk of recurrence; however, malignant transformation has not been associated with the condition 1‐3 . This case highlights a rare presentation of MEH in a patient with an atypical racial background and age demographic for this condition.…”

“…It has been suggested that HPV‐13 is more commonly associated with lesions found on keratinized epithelial mucosa, while HPV‐32 is more closely associated with lesions on non‐keratinized surfaces 1 . Genetic and environmental factors have also been implicated as risk factors for the condition 1‐3 …”

“…Treatment of MEH may consist of observation, as lesions are often asymptomatic with tendency to spontaneously regress 1‐3 . Surgical removal is typically recommended for those lesions of esthetic and or functional concern, which is the current management plan for this patient 1‐3 . Medications, such as topical/systemic interferon and imiquimod cream, have demonstrated benefit in treating lesions of MEH 1 .…”

Virus del papiloma humano, sus implicaciones en cavidad bucal; una revisión de la literatura

“…Clínicamente se asemeja a una coliflor con una superficie digitiforme de base sésil y crecimiento lento, su coloración va del rosado al blanco dependiendo del grado de queratinización [33,34]. La hiperplasia epitelial multifocal o enfermedad de Heck es una enfermedad poco común que afecta principalmente a niños [35,36], se localiza en la mucosa bucal, labios o lengua y, clínicamente, se caracteriza por la presencia de pápulas múltiples que dan apariencia de "empedrado" de consistencia blanda y coloración similar a la mucosa adyacente, y es el vph serotipo 13 el asociado (véase la figura 1a) [37,38].…”

Heck’s disease occurring after Epstein‐Barr virus‐associated smooth muscle tumors in an immunosuppressed child

“…Heck's disease, or focal epithelial hyperplasia, is a rare benign disease of the oral mucosa associated with infection by human papillomavirus (HPV), subtypes 13 or 32. 1 It has been typically described in children and adolescents of indigenous heritage, specifically North, South, and Central American but has also been reported in immunosuppressed individuals, primarily in the setting of human immunodeficiency virus (HIV) infection. No gender predilection is found.…”