A 6-year-old child presents with multiple soft pink papules on the oral mucosa that coalesce into cobblestone-like plaques on the lips and buccal mucosa. Histology shows marked acanthosis with mitoses confined to the spinous layer. Which virus is responsible?

• A Coxsackievirus A16
• B Human papillomavirus type 13 ✓
• C Herpes simplex virus type 1
• D Epstein-Barr virus

Explanation

Focal epithelial hyperplasia (Heck disease) is a benign mucosal condition caused by HPV types 13 and 32, seen mainly in children and certain indigenous populations. It presents as multiple soft coalescing mucosal papules and resolves spontaneously. Coxsackievirus B16 causes hand-foot-mouth disease with erosive ulcers, EBV causes hairy leukoplakia, and HSV causes grouped vesicles that ulcerate, none of which produce persistent cobblestone plaques.

Reference: Fitzpatrick's Dermatology, 9th ed.

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