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Multiple Bumps on Lips and Tongue

Case Challenge Number: 72

Diagnostic Information

History of Present Illness The patient is a 54-year-old Hispanic female who recently immigrated to the United States from Honduras. She comes to your clinic with a chief complaint of, “Can you tell me what these bumps are on my lips?” She notes she has had them since childhood and they have never bothered her, and up until now she never felt different from everyone else. However, since moving here she perceives the people at her new job look at her funny and she wants to know what she has. She has been married for 30 years, has three healthy children and 4 grandchildren. Nobody else in her family has similar lip bumps. A biopsy of the lower labial mucosa was performed. After you have finished reviewing the available diagnostic information, make the diagnosis. Medical History - Pertinent medical history: hypertension x 15 years; 3 day hospitalization in 1990 due to a motor vehicle accident (concussion, broken forearm); 3 uncomplicated pregnancies

- Medications: Losartan, calcium, vitamin D3

- Adverse drug effects: none

- Pertinent family history: maternal: diabetes type 1; paternal: noncontributory; siblings: 4 healthy brothers, 1 sister with diabetes type 2

- Social history: denies tobacco use; drinks 1 -2 beers per night x 30 years; denies recreational drug use Clinical Findings

Case Challenge 72 - Content - Diagnostic Information - Figure 1

Figure 1. Multiple sessile, focally pigmented, papulonodular lesions on labial vermilion border and perioral skin.

Case Challenge 72 - Content - Diagnostic Information - Figure 2
Case Challenge 72 - Content - Diagnostic Information - Figure 3

Figure 2-3. Multiple sessile, confluent, “cobblestone” nodules present on the upper and lower labial mucosa.

Case Challenge 72 - Content - Diagnostic Information - Figure 4

Figure 4. Multiple nodules on dorsal tongue surface.

Histopathologic Findings Histologic sections of the biopsy show a mucosal soft tissue fragment exhibiting epithelial hyperplasia with a vaguely papillated architecture, elongated rete ridges, acanthosis, and irregular hyperparakeratosis. There are proliferative epithelial changes with increased cellularity, disordered maturation, mild reactive cytologic atypia, dyskeratosis, binucleate cells, mitosoid cells, and basal mitotic activity.

Case Challenge 72 - Content - Diagnostic Information - Figure 5

Figure 5. Low power histologic image showing epithelial hyperplasia with increased cellularity and hyperparakeratosis.

Case Challenge 72 - Content - Diagnostic Information - Figure 6

Figure 6. High power histologic image showing viral cytopathic changes with mild cytologic atypia, binucleate cells, dyskeratosis and a mitosoid cell.