En el attach el CASO REPORTADO en la referencia No. 2 

 Saludos a todos !!! 

 Dr. José Lapenta R.,,, 

 EDITORIAL ENGLISH 
 ================= 
 Hello friends of the net. DERMAGIC again with you, today's topic: THE   LUCIO'S PHENOMENON.

 Last week I saw a 14 year-old patient in my private   office, she was a adolescent with a LEPROSY. THE LUCIO'S   PHENOMENON also called ERYTHEMA NECROTIC is also one of the types of   reaction leprous (Reaction type II), not very common and described for  the   first time by Lucio and Alvarado in 1852, and reidentified by Latapi in 1936.

 It is presented mainly in the diffuse lepromatous leprosy,  call   leprosy of Lucio, characterized mainly by the absence of NODULES, this  leprosy type is quite   common in Central America and Mexico.

The   CHARACTERISTIC lesions are ULCERS that affect mainly inferior members,  but   other parts of the body can be involved. Histopathologically is a   leukocytoclastic vasculitis. The treatment, an entire CHALLENGE.

 It  seemed   a LIE, but TODAY in OUR DAYS OF modernism we EVEN FIND THIS PHENOMENON. 
  
 I wait you enjoy these 41 references. 
  
 In the attach file THE CASE REPORT of the REFERENCE No. 2 

 Greetings to ALL,  !! 

 Dr. Jose Lapenta R.,,, 
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 REFERENCIAS BIBLIOGRÁFICAS / BIBLIOGRAPHICAL REFERENCES 
 =================================================================== 
 1.) Lepra type reactions 
 2.) Diffuse Painless Ulcerations 
 3.) [Lucio-Latapi leprosy and the Lucio phenomenon] 
 4.) [Lucio's leprosy]. 
 5.) [22 years of leprosy: histopathology] 
 6.) Lucio's phenomenon. 
 7.) Lucio's phenomenon and diffuse nonnodular lepromatous leprosy. 
 8.) Lucio's phenomenon: a comparative histological study. 
 9.) [Diffuse lepromatous leprosy disclosed by cutaneous vasculitis. The   Lucio phenomenon]. 
 10.) Immunologic aspects of leprosy as related to leucocytic  isoantibodies 
 and platelet aggregating factors. 
 11.) The role of protein malnutrition in the pathogenesis of ulcerative   "Lazarine" leprosy. 
 12.) Dermal ultrastructure in leprosy. 
 13.) Lepromatous and tuberculoid leprosy: clinical presentation and  cytokine   responses. 
 14.) Leprosy (Hansen's disease) in South Dakota. 
 15.) [Virchowian Hansen's disease, Lucio's phenomenon, cryptococcosis]. 
 16.) Erythema nodosum leprosum in Singapore. 
 17.) Epidermal keratinocyte Ia expression, Langerhans cell hyperplasia  and   lymphocytic infiltration in skin lesions of leprosy. 
 18.) Specific antigen and antibody to Mycobacterium leprae in the   cryoprecipitate of a patient with Lucio phenomenon. 
 19.) In situ characterization of T lymphocyte subsets in the reactional   states of leprosy. 
 20.) Ultrastructure of the dermal microvasculature in leprosy. 
 21.) Lucio's phenomenon: a comparative histological study. 
 22.) Serum macrophage migration inhibition activity in patients with leprosy. 
 23.) [Leprosy tests: diagnostic problems]. 
 24.) Serum and tissue lysozyme in leprosy. 
 25.)[Reactional status of leprosy]. 
 26.) Auricular chondritis as a rheumatologic manifestation of Lucio's  phenomenon: clinical improvement after plasmapheresis. 
 27.) Contemplative immune mechanism of Lucio phenomenon and its global   status. 
 28.) Plasma exchange therapy in Lucio's phenomenon. 
 29.) [Lepromatous leprosy with extensive ulcerations and cachexia. The   Lucio phenomenon? Lazarine leprosy]? 
 30.) [2 cases of Lucio phenomenon in Paraguay]. 
 31.) An unusual case of leprosy with pathological features common to  Lucio's phenomenon. 
 32.) Primary diffuse lepromatous leprosy with erythema necrotisans   (lucio phenomenon). 
 33.) The "Lucio phenomenon" in diffuse leprosy. 
 34.) [Macular leprosy of Lucio--antimalarials in leprotic reaction]. 
 35.) [Dermatology in the Central American tropics. I. Lucio's spotted   leprosy. Antimalarials in the leprous reaction]. 
 36.) [Lucio's leprosy]. 
 37.) [Lucio phenomenon in leprosy reactions]. 
 38.) Lucio's phenomenon: an overview. 
 39.) Lucio's phenomenon: an immune complex deposition syndrome in   lepromatous leprosy. 
 40.) [Lucio's leprosy]. 
 41.) Antiphospholipid antibodies thrombotic syndrome misdiagnosed as   Lucio's phenomenon. 
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 ============================================================= 
 1.) Lepra type reactions 
 ============================================================= 
 Source: Mandell, Douglas and Bennett's 
 Principles and Practice of Infectious Diseases Fourth Edition: 1.995 

 Lepra Type-1 Reactions (Downgrading and Reversal Reactions) 
 ========================================= 
 Borderline leprosy patients (BT to BL) may develop before therapy   (downgrading reaction) or after the initiation of therapy (reversal   reaction) inflammation within previous skin lesions; neuritis; at times,   new, multiple, small "satellite" maculopapular skin lesions; and  low-grade   fever. If neuritis is not treated within the first 24 hours or so,   irreversible nerve damage and consequent deformity and muscular  dysfunction   may result.   Reversal reactions are associated with histologic shifts toward the   tuberculoid end of the spectrum. Lesions demonstrate increased numbers of   CD4+ helper cells, increased levels of interferon-g and IL-2, and an   abundance of T cells bearing g- and d-receptors. This pattern is shared   with Mitsuda-positive skin tests and does not occur spontaneously  otherwise   in leprosy. 

 ======================================== 
 Lepra Type-2 Reaction (Erythema Nodosum Leprosum) 
 ======================================== 
  Erythema nodosum leprosum (ENL) is a syndrome affecting nearly half of   lepromatous leprosy patients, 90 percent of the time occurring after the   initiation of antimicrobial therapy and generally within the first 2  years   of treatment. Clinical manifestations include, in order of frequency,   painful papules, generally on the extensor surfaces of extremities, which 
 may pustulate and ulcerate and may appear as recurrent crops; neuritis 
 (most frequently the ulnar nerve); fever; uveitis; lymphadenitis;  orchitis;   and glomerulonephritis. Lepromatous leprosy patients should be forewarned   of signs and symptoms of ENL, lest their appearance result in loss of   confidence with antimicrobial therapy and noncompliance. ENL is   histologically an acute vasculitis or paniculitis primarily thought to be   secondary to immune complex deposition. It is also thought to be  associated   with a local increase in cell-mediated immunity: increased numbers of T   helper cells and levels of IL-2 and interferon-g, and loss of suppresor   T-cell activity. 61 
  
 Lucio's Reaction and Nerve Abscesses 
 ============================ 
 Patients with diffuse lepromatosis may develop shallow, often large   polygonal sloughing ulcerations on the lower extremities that heal  poorly,   are frequently recurrent, and may be generalized. Histopathologically,   these lesions appear to be either a variant of ENL or a result of   arteriolar infarction. When generalized, Lucio's reaction is frequently   fatal, generally a result of secondary bacterial infection and sepsis.   Also, leprosy patients, particularly BT or neural leprosy patients, may   develop nerve abscesses requiring urgent surgical decompression  and drainage. 

 Therapy of Reactions > ================   Lepra type-1   ================   reactions can be effectively treated only with corticosteroids. We   generally initiate therapy with prednisone, 40-60 mg daily. Because   relapses commonly occur if steroids are rapidly discontinued, steroids at   reduced doses as signs and symptoms allow must be maintained for 2-3   months. Because of the requirement that steroids be maintained for long   durations, strict indications are neuritis, lesions that threaten to   ulcerate, and lesions that appear on cosmetically important places such  as   the face. 

 Lepra type-2   =============   reactions (ENL) can also be effectively treated with corticosteroids, and   short durations are often sufficient. If ENL is recurrent, thalidomide in  a   nightly dose of 100-300 mg is the treatment of choice. In the United   States, thalidomide cannot be prescribed to fertile women on an  outpatient   basis and remains classified as an investigational new drug (IND) with   investigators at the G.W. Long Hansen's Disease Center and a number of  U.S.   Public Health Service-sponsored Regional Ambulatory Hansen's Disease  Programs.   The mechanism of action of thalidomide for ENL is not fully understood  but   may be a result of its action to reduce IgM synthesis, 62 retard   polymorphonuclear leucocyte migration, 63 and reduce tumor necrosis  factor   (TNF) levels. 64 Other than resultant birth defects when administered to   pregnant women in the first trimester, thalidomide is nontoxic, its only   side effects being tranquilization, to which tolerance develops quickly,  as   well as mild leukopenia, and constipation. 

 Lucio's Reaction   

================   

Neither thalidomide nor corticosteroid therapy has proved effective   therapy for Lucio's reaction. In severe cases, exchange transfusion may  be   effective. In general, however, the principals of good wound care and   appropriate antibiotics for sepsis are recommended. 

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2.) Diffuse Painless Ulcerations   ============================================================= 
 Fernando Gallardo Hernández, MD; Jaime Notario Rosa, MD; Anna  Jucglà Serra,   MD; Jordi Peyri Rey, MD      Ciutat Sanitària i Universitària de Bellvitge, Barcelona, Spain   Arch Dermatol, Vol. 135 No. 8, August 1999    

 REPORT OF A CASE 

 A 62-year-old man presented with a 3-month history of severe, ulcerating   skin lesions over the extremities. Painless violaceous macules, livedo,  and   occasional bullae gave rise to ulcerations after a few weeks. The lower   extremities were predominantly involved, with spontaneous amputation of   some necrotic digits. The lesions extended proximally over the buttocks.   The patient had a 4- to 5-year history of frequent painless traumatic   wounds that healed after 2 to 3 weeks, leaving atrophic scars.

The  patient   also noted progressive thickening of the skin, with loss of body hair,   especially the eyebrows. Physical examination revealed a chronically ill   man with waxy diffuse skin infiltration and a total loss of body hair.   Numerous angular ulcerations were located over the extremities (Figure 1)   and surrounded by a livedoid pattern. The findings of the rest of his   examination were unremarkable except for a sensitive polyneuropathy.   Laboratory evaluation showed the following abnormal values: hemoglobin,  90   g/L; mean corpuscular volume, 67 pg; erythrocyte sedimentation rate, 120   mm/h; and serum albumin, 16 g/L. The serum concentration of -globulin was   increased in a polyclonal pattern. A skin biopsy specimen was obtained   (Figure 2), and Ziehl-Neelsen staining was performed (Figure 3). (see the   attach file) 

 Diagnosis: Lucio phenomenon.    

 HISTOPATHOLOGIC FINDINGS AND CLINICAL COURSE 

  A punch biopsy specimen from the border of an ulcer revealed a patchy   infiltrate of foamy histiocytes and scattered lymphocytes in the dermis  and   subcutaneous fat, tending to be clustered around blood vessels. Large   number of acid-fast bacilli were present in the Ziehl-Neelsen stain of  the   specimen. Foamy histiocytes and acid-fast bacilli were also noted in the   wall of the medium-sized arteries, with narrowing of the vessel lumen. No   nuclear dust was observed. Slit-skin smears showed single and clustered   acid-fast bacilli. 

 Multidrug therapy was initiated with 100 mg/d of oral dapsone, 50 mg/d of   clofazimine, 600 mg/d of rifampin, and a single 300-mg dose of  clofazimine   per month, with good response to date. Prednisone (40 mg) was also   prescribed at decreasing doses for Lucio phenomenon and has been required   for months at low doses. Our patient's ulcers healed with irregular   atrophic scars in 10 to 12 weeks. 

 DISCUSSION;

 Our patient manifested the clinical and histopathologic features of a   diffuse, lepromatous leprosy with skin ulcerations characteristic of  Lucio   phenomenon, a severe, necrotizing reaction described by Lucio and  Alvarado1   in 1852. The reactional states in leprosy are characterized by acute   inflammatory changes, and they occur more commonly toward the borderline   and lepromatous end of the clinical spectrum. Lucio phenomenon is an   infrequent reaction in leprosy. It has usually been described in diffuse   lepromatous leprosy, so-called Lucio leprosy, which is unique because of   the absence of cutaneous nodules. This type of leprosy is almost   exclusively seen in Mexico and Central America. Lucio phenomenon is a   cutaneous necrotizing reaction that most commonly involves the  extremities   but may also affect the buttocks and trunk. The acute constitutional   symptoms of Lucio phenomenon are variable and, occasionally, may be   fatal.2, 3 It is believed to be an immune complex–mediated disease  like the   Arthus phenomenon and is included as a type 2 reaction in leprosy.4, 5   Lucio phenomenon shows histopathologic findings of leukocytoclastic   vasculitis along with a superficial and deep mixed infiltrate of foamy   histiocytes in a perineural and perivascular distribution. In some  reported   cases, the vascular damage may have been the result of direct invasion of   Mycobacterium leprae, with endothelial cell proliferation, thrombosis,  and   tissue necrosis.6 

 The treatment of Lucio phenomenon is the same as that for other type 2   reactions in leprosy. Local care and supportive therapy are important to   prevent secondary infections and loss of proteins. Prednisone therapy,   which is initially administered at dosages of 20 to 60 mg/d and then   tapered, may be required for weeks to months. Thalidomide (400 mg/d with   reduction to maintenance doses of 100 mg/d) may be prescribed as an   alternative to prednisone. Clofazimine administered at a dosage of 300  mg/d   has a useful anti-inflammatory effect. It is not necessary to discontinue   multidrug therapy for leprosy. 

 REFERENCES 

 1. Lucio R, Alvarado Y, Latapi F, Cited by, Zamora AC, Cited by. The   spotted leprosy of Lucio. Int J Lepr. 1948;16:421-430. 

 2. Pursley TV, Jacobson RR. Lucio's phenomenon. Arch Dermatol. 1980;116:   201-204. MEDLINE 

 3. Bernadat JP, Faucher JF, Huerre M. Lèpre lépromateuse diffuse  révélée   par une vasculite cutanée: le phenomene de Lucio. Ann Dermatol  Venereol.   1996;123:21-23. MEDLINE 

 4. Touma DJ, Phillips TJ, Kurban AK, Goldberg L. Recurrent rapidly   progressive infiltrated plaques and bullae. Arch Dermatol.   1996;132:1432-1434. MEDLINE 

 5. Murphy GF, Sánchez NP, Flynn TC, Sánchez JL, Mihm MC, Soter  NA. Erythema   nodosum leprosum. J Am Acad Dermatol. 1986;14:59-69. MEDLINE 

 6. Rea TH, Levan NE. Lucio's phenomenon and diffuse nonnodular  lepromatous 
 leprosy. Arch Dermatol. 1978;114:1023-1028. MEDLINE 
  
  
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 3.) [Lucio-Latapi leprosy and the Lucio phenomenon] 
 ============================================================ 
 ARTICLE SOURCE:  Acta Leprol  (Switzerland), Jul-Sep 1983, 1(3) p115-32 

 AUTHOR(S):  Saul A; Novales J   

PUBLICATION TYPE:  JOURNAL ARTICLE; REVIEW (18 references) 

 ABSTRACT: 

 The Lucio-Latapi's leprosy or diffuse lepromatous leprosy is a   clinical variety of lepromatous leprosy first described by Lucio and   Alvarado in 1852 and reidentified by Latapi in 1936. It is frequent in   Mexico (23%) and in Costa Rica and very rare in other countries. It is   characterized by a diffuse infiltration of all the skin which never is   transformed into nodule, by a complete alopecia of eyebrows and eyelashes   and body hair, by anhydrotic and dysesthesic zones of the skin and by a   peculiar type of lepra reaction named Lucio's phenomenon or necrotic   erythema which is a vascularitis of vessels especially of the   dermohypodermic union and of the hypodermis. Clinically this vascularitis   is represented by well-shaped erythematous spots, later becoming necrotic   with scabs, ulcerations and scars. Three points of confusion are  stressed:   the differences between nodules and nudosities, Lucio's leprosy and  Lucio's   phenomenon and necrotic erythema and necrotic erythema nodosum leprosum.   The differences between the pure and primitive form of Lucio's leprosy  and   the secondary one is also discussed such as the laboratory findings,   histopathological data, pronostic and treatment. Lucio's leprosy is   considered the most anergic one of the all immunological spectrum  of leprosy. 

 ============================================================= 
 4.) [Lucio's leprosy]. 
 ============================================================= 
 Med Cutan Ibero Lat Am 1982;10(1):41-6 Related Articles, Books, LinkOut 

 Gibert E, Cubria JL, Gratacos R, Castro J, Monfort J, Castel T, Lecha M 

 A case of diffuse lepromatous leprosy with lepra reaction type II-Lucio's   phenomenon-in a 24 years old male patient is reported. The histological   examination of the necrotic lesions and of the apparently normal skin   showed the presence of dense perivascular and perianexial  lymphohystiocitic   infiltrates with great quantities of bacilli. The first biopsy did not  show   a picture a leuccocytoclastic vasculitis but only areas of necrosis. The   immunofluorescence studies revealed on direct examination complement   deposits on vessel walls. The complement levels in blood were lowered and   circulating inmunecomplexes were also detected. These data confirm the   opinion that Lucio's phenomenon is caused by circulating inmunecomplexes   fixed on dermal vessel walls causing skin necrotic lesions. 

 ============================================================= 
 5.) [22 years of leprosy: histopathology] 
 ============================================================= 
 AU: Dionisio-de-Cabalier-ME; Perez-HJ 
 AD: Ia. Catedra de Patologia, Facultad de Ciencias Medicas, Hospital Nac, 
 de Clinicas, U.N.C. 
 SO: Rev-Fac-Cien-Med-Univ-Nac-Cordoba. 1995; 53(1): 17-21   AB: In the present study, the frequency of histopathological reports of   leprosy carried out in the last 22 years at the Fst Chair of Pathology   (Medical School, U. N.C) was determined. Our findings on the frequency of   pure forms of leprosy agree with those reported by the O.M.S. On the   contrary, that was not the case with respect to reactive forms, since the   phenomenon of Lucio and Alvarado was more frequent in endemic zones. 

 ============================================================= 
 6.) Lucio's phenomenon. 
 =============================================================   ARTICLE SOURCE:  Arch Dermatol  (United States), Feb 1980, 116(2) p201-4 

 AUTHOR(S):  Pursley TV; Jacobson RR   

PUBLICATION TYPE:  JOURNAL ARTICLE 

 ABSTRACT:

  A 38-year-old woman had diffuse, nonnodular, lepromatous
 leprosy   and Lucio's phenomenon. Most cases of Lucio's phenomenon have been  reported   to have a leukocytoclastic vasculitis as the underlying pathologic   abnormality. In this patient, however, the histologic picture of an early   lesion of Lucio's phenomenon showed a milk, mononuclear cell  infiltration,   endothelial swelling, vascular thrombosis, and ischemic necrosis. Lepra   bacilli were abundant around nerves and blood vessels, and many were  noted   in vascular walls and endothelium. Our findings raise the possibility  that   some cases of Lucio's phenomenon may be caused by vascular damage due to   direct invasion of Mycobacterium leprae and not necessarily by   leukocytoclastic vasculitis. 

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 7.) Lucio's phenomenon and diffuse nonnodular lepromatous leprosy. 
 ============================================================= 

 ARTICLE SOURCE:  Arch Dermatol  (United States), Jul 1978, 114(7) p1023-8   

AUTHOR(S):  Rea TH; Levan NE   

PUBLICATION TYPE:  JOURNAL ARTICLE 

 ABSTRACT: 

The records of ten patients with Lucio's phenomenon showed   clinical and histopathological changes similar to those described by   others. Lucio's phenomenon is a syndrome distinct from erythema nodosum   leprosum as indicated by an absence of fever, leukocytosis and  tenderness,   a failure to respond to thalidomide, and a restriction to patients with   diffuse nonnodular lepromatous leprosy. Lymphopenia associated with   splenomegaly in three patients and glomerulonephritis in one patient were   unexpected findings of unknown relevance. 

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8.) Lucio's phenomenon: a comparative histological study.   =============================================================