Diffuse Leprosy of Lucio and Latapi. By J.H. Frenken. Oranjestad, Aruba, Netherlands Antilles, De Wit, Inc., 1963. 240 pp., 100 photos, 29 figs. US $7.50

 

The original of this treatise was a thesis in the Dutch language, presented at Utrecht University in June 1962. Part I gives a detailed reproduction of the masterful dissertation by Rafael Lucio and Ignacio Alvarado on clinical types of leprosy as observed in the mid-nineteenth century, with emphasis on the so-called spotted (or lazarine) form of leprosy, which, in the 1930's, Fernando Latapí called teh Lucio phenomenon (erythema necroticans).
Frenken credits Latapí with rediscovering this forgotten form of leprosy, describing its fundamental character, and adding other salient aspects of what is now known as the diffuse leprosy of Lucio and Latapí. A carefully systematized record of present knowledge and opinions on the Lucio phenomenon is presented by the author, with the addition of observations by other leprosy workers on cases of diffuse leprosy, with or without the Lucio phenomenon, occuring outside Mexico.

 

The second part of the treatise deals with the author's own investigation and evaluation of 16 lepromatous cases, with either pure and primitive or secondary diffuse leprosy, some of which exhibited the typical necrotic spots of the Lucio phenomenon. He compares the Lucio phenomenon with the phenomenon of Schwarzman and the allergic vasculitis of Ruiter. Frenken favors fitting the Lucio phenomenon into the latter category because it follows the same pathogenetic sequence and has the same fundamental anatomic lesion (vascular inflammation and necrosis), although its allergic nature can only be assumed, rather than considered established. Whereas the allergic vasculitis of Ruiter affects the narrow superficial vessels of the dermis, the vascular alterations in the Lucio phenomenon occur in the deeper vessels lying in the subcutaneous fatty tissue. Thus the spots of Lucio appear much larger and few in number as compared to lesions of allergic vasculitis, which are often small and numerous.

 

Alopecia in diffuse leprosy and treatment of this condition are touched upon in the final chapters of the book. The author concludes that diffuse leprosy occurs much more often than is presently accepted and that a large percentage of cases are missed until after a long infectious state. Of the two types of diffuse leprosy, the secondary form occurs more frequently than the pure and primitive form; the former starts as indeterminate leprosy, while the latter has an insidious, imperceptible, nonlocalizing, initial phase in the spread of infiltration over the body's surface.

 

For the benefit of the many leprologists who know of but never see a case of diffuse leprosy of Lucio and Latapí exhibiting the relatively rare characteristic spots, the reviewer presents excerpts of the definitions of some terms commonly associated with this form of lepromatous leprosy:

 

1. Pure and primitive diffuse leprosy. --This is a diffuse or generalized cutaneous infiltration involving the entire body, associated with a pseudo-myxedematous involvement of the face (Latapí calls this 'full-moon' face), hands and feet, in the early stages, and epidermal atrophy and ichthyosis in the later phases of the disease. here is also alopecia, and telangiectasis of the face and trunk. Nodular lesions are absent, a fact differentiating it from the nodular form of lepromatous leprosy.

 

2. Secondary diffuse leprosy. --This condition presents the same features as the pure diffuse type, but in addition, macules with sensory disturbances characteristic of the indeterminate group, and neurologic disorders and deformities, are present.

 

3. Medina reaction. --This is an intracutaneous response to integral lepromin characterized by an early (Fernández) type of reaction, appearing as soon as 4 hours after injection and ending with the formation of an intradermal abscess. It differs from the 48-hour reaction of Fernández in that in the first few hours the Medina reaction lesion shows histologically many polymorphonuclear leucocytes and eosinophils in the cellular infiltrate, with edema and necrosis of the collagen, resulting in abscess formation a few days later. This reaction is almost always positive in the pure and primitive form of diffuse leprosy.

 

4. Colima type of diffuse leprosy. --The reactional lesion in this type of diffuse leprosy is manifested not by red, painful, necrotic spots, but by nodules of teh erythema nodosum variety. Where these nodular reactional lesions predominate, the Lucio phenomenon is absent.

 

5. Lucio phenomenon. --This peculiar reactional state is found only in patients with diffuse leprosy of Lucio and Latapí. It is characterized by red and painful spots on the arms and legs and more rarely on the face and trunk. The centers have a tendency to necrotize and ulcerate, leaving crusts over the ulceration, and ultimately distinct scars. Patients with untreated diffuse leprosy often experience recurrent attacks of these spots. Fulminant cases are complicated with gastrointestinal disturbances, the latter condition being the cause of death. The Lucio phenomenon is regarded as a secondary episode condition of lepra reaction produced by multiple necrotizing vasculitis.

 

Individually, each chapter is authoritative and worthwhile reading. The volume contains much factual information on this least known type of leprosy, as well as much material that is speculative. The case illustrations and microphotographs are distinct and illuminating. The book will prove valuable for physicians in leprosy or dermatologic practice.

 

M.C. Mabalay, M.D., in the International Journal of Leprosy, 1964.

 

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