Clinical manifestation

Indeterminate leprosy: one to a few hypop-igmented or erythematous macules, with intact sensation

Tuberculoid leprosy: skin lesions few in number; well-defined, erythematous large plaques, with elevated borders with atrophic center; arciform or annular plaques; found on the face, limbs, or elsewhere, but sparing intertriginous areas and the scalp; alternate presentation: large, asymmetric, hypopigmented macule; both types of lesions anesthetic, have localized alopecia, and sometimes spontaneously resolve in a few years, leaving pigmentary disturbances or scars; neural involvement causes tender, thickened nerves with subsequent loss of function; great auricular nerve and superficial peroneal nerves often prominent

Borderline tuberculoid leprosy: similar to tuberculoid form, but lesions smaller and more numerous, nerves less enlarged, and less alopecia

Borderline leprosy: numerous, asymmetric, moderately anesthetic, red, irregularly shaped plaques less well defined than those in the tuberculoid type; regional adenopa-thy sometimes present Lepromatous leprosy: only infectious stage; early cutaneous lesions consisting mainly of pale, small, diffuse, symmetric macules, which become infiltrated later, with little loss of sensation; nerves not thickened and sweating normal; alopecia of lateral eyebrows, eyelashes, and trunk, but scalp hair intact; lepromatous infiltrations either diffuse nodules (lepromas) or plaques, which result in appearance of leonine facies; brawny lower extremity edema; neuritic lesions symmetric and slow to develop; eye involvement causes pain; photophobia, decreased visual acuity, glaucoma, and blindness; testicular atrophy produces sterility and gynecomastia; lymphadenopathy and hepatomegaly result from organ infiltration; stridor and hoarseness from laryn-geal involvement; nasal infiltration sometimes produces a saddle-nose deformity; aseptic necrosis and osteomyelitis

Reactional state: lepra type I reaction: usually affects patients with borderline disease; downgrading reaction represents shift toward the lepromatous pole before the initiation of therapy; reversal reaction disease shift toward tuberculoid pole after the initiation of therapy; lepra type II reactions (erythema nodosum leprosum): immune complex-mediated reaction occurring in patients with borderline lepromatous or polar lepromatous disease; crops of painful red papules, usually manifesting after a few years of therapy and resolving spontaneously after about 5 years; associated fever, malaise, joint pain, nerve pain, iridocycli-tis, dactylitis, and orchitis; Lucio phenomenon: common in Mexico and Central America; cutaneous hemorrhagic infarcts in patients with diffuse lepromatous leprosy

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