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Gandhi Mehta RK, Caress JB, Rudnick SR, Bonkovsky HL. Porphyric neuropathy. Muscle Nerve 2021; 64:140-152. [PMID: 33786855 DOI: 10.1002/mus.27232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 03/10/2021] [Accepted: 03/14/2021] [Indexed: 12/15/2022]
Abstract
Acute hepatic porphyrias are inherited metabolic disorders that may present with polyneuropathy, which if not diagnosed early can lead to quadriparesis, respiratory weakness, and death. Porphyric neuropathy is an acute to subacute motor predominant axonal neuropathy with a predilection for the upper extremities and usually preceded by a predominantly parasympathetic autonomic neuropathy. The rapid progression and associated dysautonomia mimic Guillain-Barré syndrome but are distinguished by the absence of cerebrospinal fluid albuminocytologic dissociation, progression beyond 4 wk, and associated abdominal pain. Spot urine test to assess the porphyrin precursors delta-aminolevulinic acid and porphobilinogen can provide a timely diagnosis during an acute attack. Timely treatment with intravenous heme, carbohydrate loading, and avoidance of porphyrinogenic medications can prevent further neurological morbidity and mortality.
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Affiliation(s)
| | - James B Caress
- Department of Neurology, Wake Forest Baptist Health, Winston Salem, North Carolina, USA
| | - Sean R Rudnick
- Section on Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest Baptist health, Winston Salem, North Carolina, USA
| | - Herbert L Bonkovsky
- Section on Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest Baptist health, Winston Salem, North Carolina, USA
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Yasuda M, Gan L, Chen B, Yu C, Zhang J, Gama-Sosa MA, Pollak DD, Berger S, Phillips JD, Edelmann W, Desnick RJ. Homozygous hydroxymethylbilane synthase knock-in mice provide pathogenic insights into the severe neurological impairments present in human homozygous dominant acute intermittent porphyria. Hum Mol Genet 2020; 28:1755-1767. [PMID: 30615115 DOI: 10.1093/hmg/ddz003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 12/07/2018] [Accepted: 12/31/2018] [Indexed: 12/13/2022] Open
Abstract
Acute intermittent porphyria (AIP) is an inborn error of heme biosynthesis due to the deficiency of hydroxymethylbilane synthase (HMBS) activity. Human AIP heterozygotes have episodic acute neurovisceral attacks that typically start after puberty, whereas patients with homozygous dominant AIP (HD-AIP) have early-onset chronic neurological impairment, including ataxia and psychomotor retardation. To investigate the dramatically different manifestations, knock-in mice with human HD-AIP missense mutations c.500G>A (p.Arg167Glu) or c.518_519GC>AG (p.Arg173Glu), designated R167Q or R173Q mice, respectively, were generated and compared with the previously established T1/T2 mice with ~30% residual HMBS activity and the heterozygous AIP phenotype. Homozygous R173Q mice were embryonic lethal, while R167Q homozygous mice (R167Q+/+) had ~5% of normal HMBS activity, constitutively elevated plasma and urinary 5-aminolevulinic acid (ALA) and porphobilinogen (PBG), profound early-onset ataxia, delayed motor development and markedly impaired rotarod performance. Central nervous system (CNS) histology was grossly intact, but CNS myelination was delayed and overall myelin volume was decreased. Heme concentrations in liver and brain were similar to those of T1/T2 mice. Notably, ALA and PBG concentrations in the cerebral spinal fluid and CNS regions were markedly elevated in R167Q+/+ mice compared with T1/T2 mice. When the T1/T2 mice were administered phenobarbital, ALA and PBG markedly accumulated in their liver and plasma, but not in the CNS, indicating that ALA and PBG do not readily cross the blood-brain barrier. Taken together, these studies suggest that the severe HD-AIP neurological phenotype results from decreased myelination and the accumulation of locally produced neurotoxic porphyrin precursors within the CNS.
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Affiliation(s)
- Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lin Gan
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brenden Chen
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chunli Yu
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jinglan Zhang
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miguel A Gama-Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY, USA
| | - Daniela D Pollak
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Stefanie Berger
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - John D Phillips
- Division of Hematology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Sylantiev C, Schoenfeld N, Mamet R, Groozman GB, Drory VE. Acute neuropathy mimicking porphyria induced by aminolevulinic acid during photodynamic therapy. Muscle Nerve 2005; 31:390-3. [PMID: 15490483 DOI: 10.1002/mus.20167] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
An 82-year-old man developed severe, acute, predominantly motor polyneuropathy, signs of autonomic involvement, and skin changes following aminolevulinic acid (ALA) administration. The compound was used as a prodrug for photodynamic therapy of Barrett's esophagitis. Changes were observed in various parameters of the heme pathway. The case reported represents a rare response to ALA treatment, resembling an acute attack of hepatic porphyria with neurological features.
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Affiliation(s)
- Constantin Sylantiev
- Department of Neurology, Tel Aviv Sourasky Medical Center, 6, Weizman Street, Tel Aviv 642 39, Israel
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Wikberg A, Andersson C, Lithner F. Signs of neuropathy in the lower legs and feet of patients with acute intermittent porphyria. J Intern Med 2000; 248:27-32. [PMID: 10947878 DOI: 10.1046/j.1365-2796.2000.00697.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess signs of distal neuropathy in patients with acute intermittent porphyria (AIP). DESIGN A population-based study. SUBJECTS All patients with DNA-verified AIP >/= 18 years of age in the four most northerly counties of Sweden. INTERVENTION Validated neuropathic signs and tests such as monofilament test, neuropathic pain, dry feet, extensor digitorum brevis (EDB) test, loss of forefoot arch, hammer toes and ulceration. RESULTS A total of 356 patients were registered and 339 of them (95%) participated in the neuropathy study. The chronic neurological signs were symmetrical and similar to those in type 1 diabetic patients. Significant impairment was found concerning perception, EDB test, lower leg pain, ankle and knee tendon reflexes, but not concerning dry feet, loss of forefoot arch and hammer toes, on comparing patients with manifest versus latent AIP. The neurological signs were more severe in the diabetic patients (n = 298). Five AIP patients had permanent quadriplegia after severe attacks. CONCLUSIONS Patients with manifest AIP had significantly more signs of distal chronic, symmetrical neuropathy of axonal type than did patients with latent AIP. More grave neurological lesions appear to develop after severe attacks.
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Affiliation(s)
- A Wikberg
- Department of Advanced Nursing, University of Umeå, Sweden
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Defanti CA, Sghirlanzoni A, Bottacchi E, Peluchetti D. Porphyric neuropathy: a clinical, neurophysiological and morphological study. ITALIAN JOURNAL OF NEUROLOGICAL SCIENCES 1985; 6:521-6. [PMID: 3003009 DOI: 10.1007/bf02331049] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A case of neuropathy in the course of an attack of acute intermittent porphyria was studied from the neurophysiological and morphological points of view. The neurophysiological findings (acute neuropathy with almost complete denervation despite normal or slightly reduced conduction velocity) and the morphological findings (no segmental demyelination after teasing, conservation of the linear fiber diameter/internodal distance ratio, mainly axonal damage on ultrastructural study) seem to indicate that the disease process is chiefly an axonal neuropathy.
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Thorner PS, Bilbao JM, Sima AA, Briggs S. Porphyric neuropathy: an ultrastructural and quantitative case study. Can J Neurol Sci 1981; 8:281-7. [PMID: 7326607 DOI: 10.1017/s0317167100043390] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We report a case of acute neuropathy in a 46 year old female with porphyria variegata. Histologic, electron microscopic, and quantitative examinations of peripheral nerves were performed at onset of the neuropathy and at autopsy. The results revealed severe qualitative and quantitative changes in myelinated and unmyelinated fibers showing features indicative of an axonopathy with a distribution in keeping with a dying-back phenomenon.
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Sima AA, Kennedy JC, Blakeslee D, Robertson DM. Experimental porphyric neuropathy: a preliminary report. Can J Neurol Sci 1981; 8:105-13. [PMID: 6271380 DOI: 10.1017/s0317167100042992] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
An experimental model for the study of porphyric neuropathy is presented. Injection of either tetraphenyl-porphinesulfonate (TPPS), hematoporphyrin derivative (HpD), or delta-amino-levulinic acid (ALA) into mice resulted in markedly decreased motor nerve conduction velocity (MNCV). THe MNCV returned to normal within one week following the injection of large doses of ALA, and within three weeks following the injection of close to lethal doses of HpD, but there was no recovery of nerve function within 50 days following injection of substantially smaller doses of TPPS. Ultrastructural examination of motor nerves at various times following TPPS injection revealed the gradual development of structural abnormalities. Ultrastructural examination of the same nerves after a single dose of either ALA or HpD failed to demonstrate any abnormalities. The present observations call for precaution as to the use of TPPS as photosensitizer in human cancer treatment.
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