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Moutapam-Ngamby-Adriaansen Y, Maillot F, Labarthe F, Lioger B. Blood cytopenias as manifestations of inherited metabolic diseases: a narrative review. Orphanet J Rare Dis 2024; 19:65. [PMID: 38355710 PMCID: PMC10865644 DOI: 10.1186/s13023-024-03074-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/03/2024] [Indexed: 02/16/2024] Open
Abstract
Inherited Metabolic Diseases (IMD) encompass a diverse group of rare genetic conditions that, despite their individual rarity, collectively affect a substantial proportion, estimated at as much as 1 in 784 live births. Among their wide-ranging clinical manifestations, cytopenia stands out as a prominent feature. Consequently, IMD should be considered a potential diagnosis when evaluating patients presenting with cytopenia. However, it is essential to note that the existing scientific literature pertaining to the link between IMD and cytopenia is limited, primarily comprising case reports and case series. This paucity of data may contribute to the inadequate recognition of the association between IMD and cytopenia, potentially leading to underdiagnosis. In this review, we synthesize our findings from a literature analysis along with our clinical expertise to offer a comprehensive insight into the clinical presentation of IMD cases associated with cytopenia. Furthermore, we introduce a structured diagnostic approach underpinned by decision-making algorithms, with the aim of enhancing the early identification and management of IMD-related cytopenia.
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Affiliation(s)
- Yannick Moutapam-Ngamby-Adriaansen
- Service de Médecine Interne, CHRU de Tours, Tours Cedex 1, France.
- Service de Médecine Interne Et Polyvalente, 2, Centre Hospitalier de Blois, Mail Pierre Charlot, 41000, Blois, France.
| | - François Maillot
- Service de Médecine Interne, CHRU de Tours, Tours Cedex 1, France
- Reference Center for Inborn Errors of Metabolism ToTeM, CHRU de Tours, Hôpital Clocheville, 49 Bd Béranger, 37000, Tours, France
- INSERM U1253, iBrain, Université François Rabelais de Tours, 10 Boulevard Tonnellé, 37000, Tours, France
- INSERM U1069, Nutrition, Croissance et Cancer, Faculté de Médecine, Université François Rabelais de Tours, 10 Boulevard Tonnellé, 37000, Tours, France
| | - François Labarthe
- Reference Center for Inborn Errors of Metabolism ToTeM, CHRU de Tours, Hôpital Clocheville, 49 Bd Béranger, 37000, Tours, France
- INSERM U1069, Nutrition, Croissance et Cancer, Faculté de Médecine, Université François Rabelais de Tours, 10 Boulevard Tonnellé, 37000, Tours, France
- Service de Pédiatrie, CHRU de Tours, Tours Cedex 1, France
| | - Bertrand Lioger
- Service de Médecine Interne Et Polyvalente, 2, Centre Hospitalier de Blois, Mail Pierre Charlot, 41000, Blois, France
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2
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Głowska-Ciemny J, Szmyt K, Kuszerska A, Rzepka R, von Kaisenberg C, Kocyłowski R. Fetal and Placental Causes of Elevated Serum Alpha-Fetoprotein Levels in Pregnant Women. J Clin Med 2024; 13:466. [PMID: 38256600 PMCID: PMC10816536 DOI: 10.3390/jcm13020466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
The most common association related to alpha-fetoprotein (AFP) is fetal neural tube defect (NTD), and indeed, this is where the international career of this protein began. In times when ultrasonography was not yet technically advanced, the detection of high levels of AFP in maternal serum (MS-AFP) and amniotic fluid was the basis for suspecting neural tube defects. In cases where there was no confirmation of NTD, other causes were sought. It has been established that high titers of MS-AFP could originate in other defects or diseases, such as (1) increased proteinuria in severe fetal kidney diseases; (2) pathological overproduction in liver diseases; (3) penetration through the membranes of gastrointestinal organs exposed to amniotic fluid; (4) passage through the walls of skin vessels; and as a side effect of (5) hepatic hematopoiesis and increased transfer through the edematous placenta in fetal anemia. This article provides a review of the current literature on congenital defects and genetic diseases in the fetus where an elevated level of MS-AFP may serve as the initial diagnostic clue for their detection.
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Affiliation(s)
- Joanna Głowska-Ciemny
- PreMediCare Prenatal Research Center, 21 Czarna Rola St., 61-625 Poznan, Poland; (K.S.); (A.K.); (R.K.)
- New Med Medical Center, 100 Szamotulska St., 60-566 Poznan, Poland
| | - Konrad Szmyt
- PreMediCare Prenatal Research Center, 21 Czarna Rola St., 61-625 Poznan, Poland; (K.S.); (A.K.); (R.K.)
| | - Agata Kuszerska
- PreMediCare Prenatal Research Center, 21 Czarna Rola St., 61-625 Poznan, Poland; (K.S.); (A.K.); (R.K.)
- Department of Gynecology and Obstetrics, Institute of Medical Sciences, University of Zielona Gora, 28 Zyty St., 65-046 Zielona Gora, Poland;
| | - Rafał Rzepka
- Department of Gynecology and Obstetrics, Institute of Medical Sciences, University of Zielona Gora, 28 Zyty St., 65-046 Zielona Gora, Poland;
| | - Constantin von Kaisenberg
- Department of Obstetrics and Gynecology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany;
| | - Rafał Kocyłowski
- PreMediCare Prenatal Research Center, 21 Czarna Rola St., 61-625 Poznan, Poland; (K.S.); (A.K.); (R.K.)
- New Med Medical Center, 100 Szamotulska St., 60-566 Poznan, Poland
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3
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Toscano MM, Cintra FF, Resende LO, Casteleti P, Moraes LHA, Rivitti-Machado MCDM, Nico MMS, Del Bigio JZ, Carvalho WBD. Bullous lesions following phototherapy in a newborn. EINSTEIN-SAO PAULO 2023; 21:eRC0256. [PMID: 37255061 DOI: 10.31744/einstein_journal/2023rc0256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/24/2022] [Indexed: 06/01/2023] Open
Abstract
A male infant presented with progressive jaundice immediately after birth. Fecal acholia and choluria associated with extensive bullous skin lesions in his trunk, abdomen, and upper and lower limbs developed during phototherapy. Several diagnostic hypotheses were presented, including neonatal porphyria, hemochromatosis, Alagille syndrome, and neonatal lupus. A 24-hour urine sample for the dosage of urinary porphyrins was collected, showing high results (1823.6µg in 100mL). At 50 days of life, fluorescence spectroscopy using a Wood's lamp revealed simultaneous bright red fluorescence of urine-stained diapers and sample blood. A definitive diagnosis of congenital erythropoietic porphyria was made following identification of a mutation of the uroporphyrinogen synthetases III gene on genetic testing. The patient was subsequently maintained in a low light environment since then, resulting in improvement of the lesions. Congenital erythropoietic porphyria is a disease of the group of porphyrias that presents shortly after birth with blistering occurring in regions exposed to the sun or other ultraviolet light. Atrophic scars, mutilated fingers, and bright red fluorescence of the urine and teeth may also be observed. There is no specific treatment, and prophylaxis comprising a total avoidance of sunlight is generally recommended. A high degree of suspicion is required for diagnosis. An early diagnosis can lead to less damage. Here, we present the case of a newborn with congenital erythropoietic porphyria diagnosed after presenting with bullous lesions secondary to phototherapy.
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Affiliation(s)
- Marina Moura Toscano
- Department of Pediatrics, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Flavia Fernandes Cintra
- Department of Pediatrics, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ludmila Oliveira Resende
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Paula Casteleti
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Lucas Hirano Arruda Moraes
- Department of Pediatrics, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | - Marcello Menta Simonsen Nico
- Department of Dermatology, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Juliana Zoboli Del Bigio
- Department of Pediatrics, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Werther Brunow de Carvalho
- Department of Pediatrics, Instituto da Criança e do Adolescente, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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4
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Mickevicius T, Holtmann C, Draganov J, Prues-Hoelscher J, Geerling G, Borrelli M. Lagophthalmos-induced corneal perforation in a patient with congenital erythropoietic porphyria. Orbit 2023:1-7. [PMID: 36734461 DOI: 10.1080/01676830.2023.2169718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/12/2023] [Indexed: 06/18/2023]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder in which the activity of uroporphyrinogen III synthase (UROS) is decreased. This results in the accumulation of photoreactive porphyrinogens, primarily in the skin and bone marrow. We describe a case of a patient with CEP who initially presented with scarring and shortening of the anterior and posterior lid lamella, which led to the development of lagophthalmos. Vascularized hyperkeratotic plaques in both corneas were also present. Despite treatment with topical ocular surface lubricants, corneal perforation with iris and uvea prolapse developed and evisceration of the right eye under local anesthesia was performed. The presented case suggests that despite topical therapy, ocular complications may exacerbate requiring surgical intervention, especially in the presence of lagophthalmos.
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Affiliation(s)
- Tomas Mickevicius
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Christoph Holtmann
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Jutta Draganov
- Department of Anesthesiology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | | | - Gerd Geerling
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Maria Borrelli
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
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5
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Carotenoids in human skin. Biochim Biophys Acta Mol Cell Biol Lipids 2019; 1865:158588. [PMID: 31838152 DOI: 10.1016/j.bbalip.2019.158588] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/29/2019] [Accepted: 12/04/2019] [Indexed: 11/22/2022]
Abstract
The skin is shielding our organism from exogenous threats including solar radiation. Carotenoids which are ingested with the diet accumulate in the skin with the highest levels occurring in skin of the forehead and in the palms of the hands. Blood and skin levels of carotenoids increase during supplementation and due to their antioxidant properties and UV-absorbing effects carotenoids are used as photoprotective agents. Systemic photoprotection with carotenoids after supplementation or ingestion of a carotenoid rich diet has been demonstrated in several human intervention studies. Although protection is only moderate it may contribute to UV protection in combination with other measures. Beyond photoprotection, ingestion of carotenoids has been postulated to be of additional benefit for cutaneous tissue and influences moisture and texture or elasticity of the skin. However, only a limited number of studies is available yet to substantiate such a claim.
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6
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Erwin AL, Desnick RJ. Congenital erythropoietic porphyria: Recent advances. Mol Genet Metab 2019; 128:288-297. [PMID: 30685241 PMCID: PMC6597325 DOI: 10.1016/j.ymgme.2018.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder characterized by photosensitivity and by hematologic abnormalities in affected individuals. CEP is caused by mutations in the uroporphyrinogen synthase (UROS) gene. In three reported cases, CEP has been associated with a specific X-linked GATA1 mutation. Disease-causing mutations in either gene result in absent or markedly reduced UROS enzymatic activity. This in turn leads to the accumulation of the non-physiologic and photoreactive porphyrinogens, uroporphyrinogen I and coproporphyrinogen I, which damage erythrocytes and elicit a phototoxic reaction upon light exposure. The clinical spectrum of CEP depends on the level of residual UROS activity, which is determined by the underlying pathogenic loss-of-function UROS mutations. Disease severity ranges from non-immune hydrops fetalis in utero to late-onset disease with only mild cutaneous involvement. The clinical characteristics of CEP include exquisite photosensitivity to visible light resulting in bullous vesicular lesions which, when infected lead to progressive photomutilation of sun-exposed areas such as the face and hands. In addition, patients have erythrodontia (brownish discoloration of teeth) and can develop corneal scarring. Chronic transfusion-dependent hemolytic anemia is common and leads to bone marrow hyperplasia, which further increases porphyrin production. Management of CEP consists of strict avoidance of exposure to visible light with sun-protective clothing, sunglasses, and car and home window filters. Adequate care of ruptured vesicles and use of topical antibiotics is indicated to prevent superinfections and osteolysis. In patients with symptomatic hemolytic anemia, frequent erythrocyte cell transfusions may be necessary to suppress hematopoiesis and decrease marrow production of the phototoxic porphyrins. In severe transfection-dependent cases, bone marrow or hematopoietic stem cell transplantation has been performed, which is curative. Therapeutic approaches including gene therapy, proteasome inhibition, and pharmacologic chaperones are under investigation.
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Affiliation(s)
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Address all Correspondence to: R. J. Desnick, PhD, MD, Dean for Genetic and Genomic Medicine Professor and Chairman Emeritus, Department of Genetic and Genomic Sciences Icahn School of Medicine at Mount Sinai New York, NY 10029, Phone: (212) 659-6700 Fax: (212) 360-1809
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7
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Chen KL, Kuemmet TJ, Chiu YE. Progressive blistering and hypertrichosis in a young child. Pediatr Dermatol 2019; 36:951-952. [PMID: 31778569 DOI: 10.1111/pde.13977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kristen L Chen
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Travis J Kuemmet
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yvonne E Chiu
- Departments of Dermatology (Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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8
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Urquiza P, Laín A, Sanz-Parra A, Moreno J, Bernardo-Seisdedos G, Dubus P, González E, Gutiérrez-de-Juan V, García S, Eraña H, San Juan I, Macías I, Ben Bdira F, Pluta P, Ortega G, Oyarzábal J, González-Muñiz R, Rodríguez-Cuesta J, Anguita J, Díez E, Blouin JM, de Verneuil H, Mato JM, Richard E, Falcón-Pérez JM, Castilla J, Millet O. Repurposing ciclopirox as a pharmacological chaperone in a model of congenital erythropoietic porphyria. Sci Transl Med 2019; 10:10/459/eaat7467. [PMID: 30232228 DOI: 10.1126/scitranslmed.aat7467] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 06/04/2018] [Accepted: 08/23/2018] [Indexed: 12/30/2022]
Abstract
Congenital erythropoietic porphyria is a rare autosomal recessive disease produced by deficient activity of uroporphyrinogen III synthase, the fourth enzyme in the heme biosynthetic pathway. The disease affects many organs, can be life-threatening, and currently lacks curative treatments. Inherited mutations most commonly reduce the enzyme's stability, altering its homeostasis and ultimately blunting intracellular heme production. This results in uroporphyrin by-product accumulation in the body, aggravating associated pathological symptoms such as skin photosensitivity and disfiguring phototoxic cutaneous lesions. We demonstrated that the synthetic marketed antifungal ciclopirox binds to the enzyme, stabilizing it. Ciclopirox targeted the enzyme at an allosteric site distant from the active center and did not affect the enzyme's catalytic role. The drug restored enzymatic activity in vitro and ex vivo and was able to alleviate most clinical symptoms of congenital erythropoietic porphyria in a genetic mouse model of the disease at subtoxic concentrations. Our findings establish a possible line of therapeutic intervention against congenital erythropoietic porphyria, which is potentially applicable to most of deleterious missense mutations causing this devastating disease.
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Affiliation(s)
- Pedro Urquiza
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Ana Laín
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Arantza Sanz-Parra
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Jorge Moreno
- Prion Research Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | | | - Pierre Dubus
- Univerité de Bordeaux, Bordeaux Research in Translational Oncology, INSERM U1053, F-33000 Bordeaux, France.,INSERM, Biothérapie des Maladies Génétiques, Inflammatoires et Cancers, U1035, Bordeaux, France
| | | | | | | | - Hasier Eraña
- Atlas Molecular Pharma S. L., 48160 Derio, Spain
| | - Itxaso San Juan
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Iratxe Macías
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Fredj Ben Bdira
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain.,Department of Macromolecular Biochemistry, Leiden Institute of Chemistry, 2300 RA Leiden, Netherlands
| | - Paula Pluta
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Gabriel Ortega
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain.,Department of Chemistry and Biochemistry, University of California, Santa Barbara, Santa Barbara, CA 93106-9510, USA
| | - Julen Oyarzábal
- Small Molecule Discovery Platform, Center for Applied Medical Research, University of Navarra, 31008 Pamplona, Spain
| | | | | | - Juan Anguita
- Animal Facility, CIC bioGUNE, 48160 Derio, Spain.,Ikerbasque, Basque Foundation for Science, 48013 Bilbao, Spain.,Macrophage and Tick Vaccine Laboratory, CIC bioGUNE, 48160 Derio, Spain
| | - Emilio Díez
- Atlas Molecular Pharma S. L., 48160 Derio, Spain
| | - Jean-Marc Blouin
- Université de Bordeaux, Biothérapie des Maladies Génétiques, Inflammatoires et Cancers, U1035, F-33000 Bordeaux, France
| | - Hubert de Verneuil
- Université de Bordeaux, Biothérapie des Maladies Génétiques, Inflammatoires et Cancers, U1035, F-33000 Bordeaux, France
| | - José M Mato
- Liver Metabolism Laboratory, CIC bioGUNE, 48160 Derio, Spain.,CIBERehd-ISCiii, 28029 Madrid, Spain
| | - Emmanuel Richard
- Université de Bordeaux, Biothérapie des Maladies Génétiques, Inflammatoires et Cancers, U1035, F-33000 Bordeaux, France
| | - Juan M Falcón-Pérez
- Exosomes Laboratory, CIC bioGUNE, 48160 Derio, Spain.,Ikerbasque, Basque Foundation for Science, 48013 Bilbao, Spain.,CIBERehd-ISCiii, 28029 Madrid, Spain
| | - Joaquín Castilla
- Prion Research Laboratory, CIC bioGUNE, 48160 Derio, Spain.,Ikerbasque, Basque Foundation for Science, 48013 Bilbao, Spain
| | - Oscar Millet
- Protein Stability and Inherited Disease Laboratory, CIC bioGUNE, 48160 Derio, Spain.
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9
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Isanta-Otal C, López-Valverde G, Orobia AJM, Pablo LE. Ocular manifestations in patient with congenital erythropoietic porphyria. Indian J Ophthalmol 2019; 67:1765-1768. [PMID: 31546559 PMCID: PMC6786212 DOI: 10.4103/ijo.ijo_1776_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We present the case of a 52-year-old woman referred to our service because of extreme ocular surface dryness. The patient showed corneal, conjunctival, and eyelid manifestations of ocular congenital erythropoietic porphyria (CEP). We started treatment with autologous serum, topical steroids, and cyclosporine twice a day, topical retinoids, and intense corneal lubrication. The patient referred significant improvement of ocular bothering and less discomfort since treatment was initiated. We describe the management of the herewith presented case of ocular CEP.
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Affiliation(s)
- C Isanta-Otal
- Department of Ophthalmology, Miguel Servet University Hospital; GIMSO Research and Innovative Group, Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain
| | - G López-Valverde
- Department of Ophthalmology, Miguel Servet University Hospital; GIMSO Research and Innovative Group, Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain
| | - A J Mateo Orobia
- Department of Ophthalmology, Miguel Servet University Hospital; GIMSO Research and Innovative Group, Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain
| | - L E Pablo
- Department of Ophthalmology, Miguel Servet University Hospital; GIMSO Research and Innovative Group, Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain
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10
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Edel Y, Mamet R, Snast I, Kaftory R, Mazor S, Hodak E, Lapidoth M, Elis A, Molad Y, Levi A. Epidemiology of cutaneous porphyria in Israel: a nationwide cohort study. J Eur Acad Dermatol Venereol 2019; 34:184-187. [PMID: 31264284 DOI: 10.1111/jdv.15769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/13/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND From a dermatologist's perspective, there are four major types of cutaneous porphyrias (CPs): porphyria cutanea tarda (PCT), erythropoietic protoporphyria (EPP), variegate porphyria (VP) and hereditary coproporphyria (HCP). Scarce data are available regarding the epidemiology of CPs. OBJECTIVES To describe the epidemiology of CPs in Israel, including distribution, incidence and prevalence rates of major types. METHODS This retrospective study includes all patients who were diagnosed with CPs between the years 1988-2018. It is based on data from Israel's National Service for the Biochemical Diagnoses of Porphyrias, and Israeli patients' nationwide electronic medical charts. Incidence and prevalence rates were calculated. RESULTS Of 173 patients with CPs diagnosed during a 30-year period, 65 (38%) had VP, 62 (36%) had PCT, 31 (18%) had HCP and 15 (9%) had EPP; with incidence rates of 0.29, 0.30, 0.17, 0.07, and prevalence rates of 6.3, 4.8, 2.9, 1.6, respectively, per million population. Characteristics of patients with PCT differed from those with other CPs with regard to lack of family history, older mean age at diagnosis [51 vs. 36 (VP), 35 (HCP) and 25 (EPP) years] and male predominance (81% vs. similar distribution). All patients with PCT were diagnosed at adulthood, while 20%, 19% and 15% of patients with VP, HCP and EPP, respectively, were diagnosed during childhood or adolescence. CONCLUSIONS Variegate porphyria and PCT were found to be the most prevalent in Israel; however, CPs might be underdiagnosed, thus dermatologists' awareness of these rare disorders is highly important.
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Affiliation(s)
- Y Edel
- National Service for the Biochemical Diagnoses of Porphyrias, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Mamet
- National Service for the Biochemical Diagnoses of Porphyrias, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - I Snast
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
| | - R Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mazor
- Department of Community Dentistry, School of Dental Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - E Hodak
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
| | - M Lapidoth
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
| | - A Elis
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department "C" of internal, Belinson Hospital, Petah Tikva, Israel
| | - Y Molad
- Rheumatology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - A Levi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Photodermatosis Clinic, Department of Dermatology, Beilinson Hospital, Petach Tikva, Israel
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11
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Luo E, Shi B, Chen QM, Zhou XD. [Dental-craniofacial manifestation and treatment of rare diseases in China]. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2019; 37:130-142. [PMID: 31168978 DOI: 10.7518/hxkq.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Rare diseases are genetic, chronic, and incurable disorders with relatively low prevalence. Thus, diagnosis and management strategies for such diseases are currently limited. This situation is exacerbated by insufficient medical sources for these diseases. The National Health and Health Committee of China recently first provided a clear definition of 121 rare diseases in the Chinese population. In this study, we summarize several dental-craniofacial manifestations associated with some rare diseases to provide a reference for dentists and oral maxillofacial surgeons aiming at fast-tracking diagnosis for the management of these rare diseases.
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Affiliation(s)
- En Luo
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Qian-Ming Chen
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Xue-Dong Zhou
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
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Murugan SB. Commentary: Discerning the porhyrias! Indian J Ophthalmol 2018; 66:1469-1470. [PMID: 30249838 PMCID: PMC6173041 DOI: 10.4103/ijo.ijo_1041_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- S Bala Murugan
- Consultant, Uveitis Services, Aravind Eye Hospital, Puducherry, India
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Sahay P, Dhanda S, Singhal D, Maharana PK, Titiyal JS, Sharma N. Scleritis in congenital erythropoietic porphyria - infective or inflammatory? Indian J Ophthalmol 2018; 66:1467-1468. [PMID: 30249837 PMCID: PMC6173006 DOI: 10.4103/ijo.ijo_513_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Pranita Sahay
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Suman Dhanda
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Deepali Singhal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prafulla K Maharana
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jeewan S Titiyal
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Al-Harazi AA, Al-Eryani BM, Al-Sharafi BA. Neonatal hemolytic anemia does not always indicate thalassemia: a case report. BMC Res Notes 2017; 10:476. [PMID: 28899405 PMCID: PMC5596485 DOI: 10.1186/s13104-017-2803-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 09/07/2017] [Indexed: 11/10/2022] Open
Abstract
Background Congenital erythropoietic porphyria is a rare autosomal recessive disorder that affects heme-porphyrin synthesis. This disorder is due to the genetic defect of uroporphyrinogen III cosynthase. This defect results in the accumulation of high amounts of uroporphyrin I in all tissues, leading to clinical manifestations ranging from mild to severe chronic damage of the skin, cartilage and bone. Hypertrichosis, erythrodontia and reddish-colored urine are often present, as well as hemolytic anemia accompanied by hepatosplenomegaly. Case presentation Here, we present a case of a 5-year-old male child of Middle Eastern origin who had been diagnosed as having alpha thalassemia and was undergoing chronic blood transfusions. He later presented with hypopigmented skin lesions and atrophy post-photosensitivity, persistent red-colored urine and hepatosplenomegaly. Laboratory investigations showed a high level of porphyrin metabolites in his plasma and erythrocytes. As a result, he was diagnosed as having Congenital erythropoietic porphyria. Conclusion Here, we diagnose a case of congenital erythropoietic porphyria which was initially missed, although the clinical features were clear (red-colored urine, hepatosplenomegaly and hemolytic anemia were present since birth, and skin manifestations appeared at the age of 22 months after being exposed to sunlight). After a DNA test was performed, the patient was initially diagnosed as having alpha thalassemia. We identified two causes of hemolytic anemia (congenital erythropoietic porphyria and alpha thalassemia) in this patient. The diagnosis of congenital erythropoietic porphyria was missed up until the child turned 5 years old. To our knowledge, this is the first case of hemolytic anemia to be reported with a diagnosis of both congenital erythropoietic porphyria and alpha thalassemia.
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Aguilera P, Badenas C, Whatley SD, To-Figueras J. Late-onset cutaneous porphyria in a patient heterozygous for a uroporphyrinogen III synthase gene mutation. Br J Dermatol 2016; 175:1346-1350. [PMID: 27086902 DOI: 10.1111/bjd.14675] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/28/2022]
Abstract
Deficiency of uroporphyrinogen III synthase (UROS) causes congenital erythropoietic porphyria (CEP). The disease, originating from the inheritance of mutations within the UROS gene, presents a recessive form of transmission. In a few patients, a late-onset CEP-like phenotype without UROS mutations appears to be associated with a myelodysplastic syndrome. We report a 60-year-old man with late-onset signs of cutaneous porphyria and accumulation in urine, plasma and faeces of type I porphyrin isomers characteristic of CEP. Analysis of DNA from peripheral leucocytes, skin and bone marrow aspirate showed that he was a heterozygous carrier of a Cys73Arg (c.217 T>C) mutation within UROS. Sequencing of cDNA from peripheral blood confirmed heterozygosity and expression of the normal allele. Measurement of UROS enzymatic activity in erythrocytes showed values ~70% of normal, indirectly indicating expression of the normal allele. Differently from other cases of late-onset uroporphyria, the patient did not present thrombocytopenia or any evidence of a myelodysplastic syndrome. Five years of clinical follow-up showed persistence of skin signs and increased excretion of porphyrins, independently of lifestyle factors or changes in medication regimes. We hypothesize acquired mosaicism (in the bone marrow) affecting the UROS gene. Thus, unstable cellular clones initiated overproduction of isomer I porphyrins leading to a CEP phenotype. This could be explained either by a clonal expansion of the porphyric (Cys73Arg) allele or by loss of function of the normal allele. Cellular turnover would facilitate release of uroporphyrins into circulation and subsequent skin lesions. This is the first case of a CEP heterozygous carrier presenting clinical manifestations.
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Affiliation(s)
- P Aguilera
- Departments of Dermatology, Biochemistry and Molecular Genetics, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - C Badenas
- Departments of Dermatology, Biochemistry and Molecular Genetics, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - S D Whatley
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, U.K
| | - J To-Figueras
- Departments of Dermatology, Biochemistry and Molecular Genetics, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Di Pierro E, Brancaleoni V, Granata F. Advances in understanding the pathogenesis of congenital erythropoietic porphyria. Br J Haematol 2016; 173:365-79. [PMID: 26969896 DOI: 10.1111/bjh.13978] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare genetic disease resulting from the remarkable deficient activity of uroporphyrinogen III synthase, the fourth enzyme of the haem biosynthetic pathway. This enzyme defect results in overproduction of the non-physiological and pathogenic porphyrin isomers, uroporphyrin I and coproporphyrin I. The predominant clinical characteristics of CEP include bullous cutaneous photosensitivity to visible light from early infancy, progressive photomutilation and chronic haemolytic anaemia. The severity of clinical manifestations is markedly heterogeneous among patients; and interdependence between disease severity and porphyrin amount in the tissues has been pointed out. A more pronounced endogenous production of porphyrins concomitant to activation of ALAS2, the first and rate-limiting of the haem synthesis enzymes in erythroid cells, has also been reported. CEP is inherited as autosomal recessive or X-linked trait due to mutations in UROS or GATA1 genes; however an involvement of other causative or modifier genes cannot be ruled out.
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Affiliation(s)
- Elena Di Pierro
- U.O. di Medicina Interna, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milano, Italy
| | - Valentina Brancaleoni
- U.O. di Medicina Interna, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milano, Italy
| | - Francesca Granata
- U.O. di Medicina Interna, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milano, Italy
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Debjani M, Somnath M. A Rare Case of Puberty Onset Congenital Erythropoietic Porphyria with Ophthalmological Manifestations. Middle East Afr J Ophthalmol 2016; 23:160-2. [PMID: 26957860 PMCID: PMC4759899 DOI: 10.4103/0974-9233.171771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old male patient was presented with foreign body sensation in both the eyes for 2 years duration and blisters followed by scarring and pigmentation in the photo-exposed areas of the body over the previous 12 years. His urine was reddish colored for the previous year. On examination, there was scarring, hyper-pigmentation of photo-exposed parts of the body along with resorption of the distal phalanges of fingers in both hands except the smallest digit which had onycholysis. Ocular examination indicated scleral necrosis in the interpalpebral areas in both eyes and bilateral dry eye. Hematological examination indicated a picture suggestive of hemolytic anemia. Abdominal ultrasonography indicated an enlarged spleen. These clinical features are suggestive of puberty onset congenital erythropoietic porphyria with ophthalmological manifestations.
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Affiliation(s)
- Mishra Debjani
- Department of Ophthalmology, Nil Ratan Sircar (NRS) Medical College and Hospital, Kolkata, West Bengal, India
| | - Mukhopadhyay Somnath
- Department of Ophthalmology, Nil Ratan Sircar (NRS) Medical College and Hospital, Kolkata, West Bengal, India
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Barupala DP, Dzul SP, Riggs-Gelasco PJ, Stemmler TL. Synthesis, delivery and regulation of eukaryotic heme and Fe-S cluster cofactors. Arch Biochem Biophys 2016; 592:60-75. [PMID: 26785297 PMCID: PMC4784227 DOI: 10.1016/j.abb.2016.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 11/25/2022]
Abstract
In humans, the bulk of iron in the body (over 75%) is directed towards heme- or Fe-S cluster cofactor synthesis, and the complex, highly regulated pathways in place to accomplish biosynthesis have evolved to safely assemble and load these cofactors into apoprotein partners. In eukaryotes, heme biosynthesis is both initiated and finalized within the mitochondria, while cellular Fe-S cluster assembly is controlled by correlated pathways both within the mitochondria and within the cytosol. Iron plays a vital role in a wide array of metabolic processes and defects in iron cofactor assembly leads to human diseases. This review describes progress towards our molecular-level understanding of cellular heme and Fe-S cluster biosynthesis, focusing on the regulation and mechanistic details that are essential for understanding human disorders related to the breakdown in these essential pathways.
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Affiliation(s)
- Dulmini P Barupala
- Departments of Biochemistry and Molecular Biology, and Pharmaceutical Sciences, Wayne State University, Detroit, MI 48201, USA
| | - Stephen P Dzul
- Departments of Biochemistry and Molecular Biology, and Pharmaceutical Sciences, Wayne State University, Detroit, MI 48201, USA
| | | | - Timothy L Stemmler
- Departments of Biochemistry and Molecular Biology, and Pharmaceutical Sciences, Wayne State University, Detroit, MI 48201, USA.
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Ramanujam VMS, Anderson KE. Porphyria Diagnostics-Part 1: A Brief Overview of the Porphyrias. CURRENT PROTOCOLS IN HUMAN GENETICS 2015; 86:17.20.1-17.20.26. [PMID: 26132003 PMCID: PMC4640448 DOI: 10.1002/0471142905.hg1720s86] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Porphyria diseases are a group of metabolic disorders caused by abnormal functioning of heme biosynthesis enzymes and characterized by excessive accumulation and excretion of porphyrins and their precursors. Precisely which of these chemicals builds up depends on the type of porphyria. Porphyria is not a single disease but a group of nine disorders: acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), variegate porphyria (VP), δ-aminolevulinic acid dehydratase deficiency porphyria (ADP), porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP), congenital erythropoietic porphyria (CEP), erythropoietic protoporphyria (EPP), and X-linked protoporphyria (XLP). Each porphyria results from overproduction of heme precursors secondary to partial deficiency or, in XLP, increased activity of one of the enzymes of heme biosynthesis. Taken together, all forms of porphyria afflict fewer than 200,000 people in the United States. Based on European studies, the most common porphyria, PCT, has a prevalence of 1 in 10,000, the most common acute porphyria, AlP, has a prevalence of ∼1 in 20,000, and the most common erythropoietic porphyria, EPP, is estimated at 1 in 50,000 to 75,000. CEP is extremely rare, with prevalence estimates of 1 in 1,000,000 or less. Only six cases of ADP are documented. The current porphyria literature is very exhaustive and a brief overview of porphyria diseases is essential in order for the reader to better appreciate the relevance of this area of research prior to undertaking biochemical diagnostics procedures. This unit summarizes the current knowledge on the classification, clinical features, etiology, pathogenesis, and genetics of porphyria diseases.
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Affiliation(s)
| | - Karl Elmo Anderson
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas 77555-1109
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20
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Horner ME, Alikhan A, Tintle S, Tortorelli S, Davis DMR, Hand JL. Cutaneous porphyrias part I: epidemiology, pathogenesis, presentation, diagnosis, and histopathology. Int J Dermatol 2014; 52:1464-80. [PMID: 24261722 DOI: 10.1111/ijd.12305] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The porphyrias are a group of disorders characterized by defects in the heme biosynthesis pathway. Many present with skin findings including photosensitivity, bullae, hypertrichosis, and scarring. Systemic symptoms may include abdominal pain, neuropsychiatric changes, anemia, and liver disease. With advances in DNA analysis, researchers are discovering the underlying genetic causes of the porphyrias, enabling family members to be tested for genetic mutations. Here we present a comprehensive review of porphyria focusing on those with cutaneous manifestations. In Part I, we have included the epidemiology, pathogenesis, presentation, diagnosis, and histopathology. Treatment and management options will be discussed in Part II.
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Affiliation(s)
- Mary E Horner
- Department of Dermatology, Baylor University Medical Center, Dallas, TX, USA
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21
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Practice guidelines for the diagnosis and management of microcytic anemias due to genetic disorders of iron metabolism or heme synthesis. Blood 2014; 123:3873-86; quiz 4005. [PMID: 24665134 DOI: 10.1182/blood-2014-01-548776] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
During recent years, our understanding of the pathogenesis of inherited microcytic anemias has gained from the identification of several genes and proteins involved in systemic and cellular iron metabolism and heme syntheses. Numerous case reports illustrate that the implementation of these novel molecular discoveries in clinical practice has increased our understanding of the presentation, diagnosis, and management of these diseases. Integration of these insights into daily clinical practice will reduce delays in establishing a proper diagnosis, invasive and/or costly diagnostic tests, and unnecessary or even detrimental treatments. To assist the clinician, we developed evidence-based multidisciplinary guidelines on the management of rare microcytic anemias due to genetic disorders of iron metabolism and heme synthesis. These genetic disorders may present at all ages, and therefore these guidelines are relevant for pediatricians as well as clinicians who treat adults. This article summarizes these clinical practice guidelines and includes background on pathogenesis, conclusions, and recommendations and a diagnostic flowchart to facilitate using these guidelines in the clinical setting.
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22
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Guo S, Wang L, Li X, Nie G, Li M, Han B. Identification of a novel UROS mutation in a Chinese patient affected by congenital erythropoietic porphyria. Blood Cells Mol Dis 2014; 52:57-8. [DOI: 10.1016/j.bcmd.2013.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 11/25/2022]
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23
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Sidorsky TI, Christine CW, Epstein JH, Berger TG. Development of corticobasal syndrome in a patient with congenital erythropoietic porphyria. Parkinsonism Relat Disord 2013; 20:349-50. [PMID: 24388147 DOI: 10.1016/j.parkreldis.2013.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 11/01/2013] [Accepted: 12/09/2013] [Indexed: 01/12/2023]
Affiliation(s)
- Tivon I Sidorsky
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States
| | - Chadwick W Christine
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States.
| | - John H Epstein
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States
| | - Timothy G Berger
- Department of Dermatology, University of California, San Francisco, San Francisco, CA, United States
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25
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Whatley SD, Badminton MN. Role of genetic testing in the management of patients with inherited porphyria and their families. Ann Clin Biochem 2013; 50:204-16. [PMID: 23605133 DOI: 10.1177/0004563212473278] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The porphyrias are a group of mainly inherited metabolic conditions that result from partial deficiency of individual enzymes in the haem biosynthesis pathway. Clinical presentation is either with acute neurovisceral attacks, skin photosensitivity or both, and is due to overproduction of pathway intermediates. The primary diagnosis in the proband is based on biochemical testing of appropriate samples, preferably during or soon after onset of symptoms. The role of genetic testing in the autosomal dominant acute porphyrias (acute intermittent porphyria, hereditary coproporphyria and variegate porphyria) is to identify presymptomatic carriers of the family specific pathogenic mutation so that they can be counselled on how to minimize their risk of suffering an acute attack. At present the additional genetic factors that influence penetrance are not known, and all patients are treated as equally at risk. Genetic testing in the erythropoietic porphyrias (erythropoietic protoporphyria, congenital erythropoietic porphyria and X-linked dominant protoporphyria) is focused on predictive and preconceptual counselling, prenatal testing and genotype-phenotype correlation. Recent advances in analytical technology have resulted in increased sensitivity of mutation detection with success rates of greater than 90% for most of the genes. The ethical and consent issues are discussed. Current research into genetic factors that affect penetrance is likely to lead to a more refined approach to counselling for presymptomatic gene carriers.
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Affiliation(s)
- S D Whatley
- Department of Medical Biochemistry and Immunology, University Hospital of Wales and Institute of Molecular and Experimental Medicine, School of Medicine, Cardiff University, Cardiff CF14 4XN, UK.
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Tintle S, Alikhan A, Horner ME, Hand JL, Davis DMR. Cutaneous porphyrias part II: treatment strategies. Int J Dermatol 2013; 53:3-24. [PMID: 24134210 DOI: 10.1111/ijd.12016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The porphyrias are diverse in pathophysiology, clinical presentation, severity, and prognosis, presenting a diagnostic and therapeutic challenge. Although not easily curable, the dermatological manifestations of these diseases, photosensitivity and associated cutaneous pathology, can be effectively prevented and managed. Sun avoidance is essential, and patient education regarding the irreversibility of photocutaneous damage is a necessary corollary. Beyond preventative measures, the care of fragile, vulnerable skin, and pain management, each of the porphyrias has a limited number of unique additional therapeutic options. Many of the treatments have been published only in small case series or anecdotal reports and do not have well-understood nor proven mechanisms of action. This article presents a comprehensive review of available therapeutic options and long-term management recommendations for the cutaneous porphyrias.
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Affiliation(s)
- Suzanne Tintle
- Department of Dermatology, Tufts Medical Center, Boston, MA, USA
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27
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Martinez Peinado C, Díaz de Heredia C, To-Figueras J, Arias-Santiago S, Nogueras P, Elorza I, Olivé T, Bádenas C, Moreno MJ, Tercedor J, Herrero C. Successful treatment of congenital erythropoietic porphyria using matched unrelated hematopoietic stem cell transplantation. Pediatr Dermatol 2013; 30:484-9. [PMID: 23557135 DOI: 10.1111/pde.12117] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Congenital erythropoietic porphyria (CEP), or Günther's disease, is an inborn error of metabolism produced by a deficiency of uroporphyrinogen III synthase (UROS), the fourth enzyme of the heme biosynthesis pathway. This enzymatic defect induces the accumulation of isomer I porphyrins in erythrocytes, skin, and tissues, producing various clinical manifestations. Severe cases are characterized by extreme photosensitivity, causing scarring and mutilations, and by hemolytic anemia, reducing life expectancy. CEP is caused by mutations in the UROS gene, and one of the most severe forms of the disease is associated with a cysteine to arginine substitution at residue 73 of the protein (C73R). CEP has been successfully treated only by the transplantation of hematopoietic precursors. We report the case of a male infant with severe postdelivery symptoms diagnosed with CEP and found to be homozygous for the C73R mutation. He underwent successful allogeneic bone marrow transplantation from a matched unrelated donor at 7 months of age. The hemolytic anemia was corrected and the porphyrin overproduction was significantly reduced. The patient remained asymptomatic after 1 year. This new case confirms that patients with severe CEP can benefit from early postnatal hematopoietic stem cell transplantation.
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Report of a novel Indian case of congenital erythropoietic porphyria and overview of therapeutic options. J Pediatr Hematol Oncol 2013; 35:e167-70. [PMID: 23612387 DOI: 10.1097/mph.0b013e3182707218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital erythropoietic porphyria is a rare disorder of heme biosynthesis, resulting from decreased enzymatic activity of uroporphyrinogen III synthase. Clinical manifestations are heterogenous, of variable severity, and with occasional phenotypic-genotypic correlation. A 14-month-old boy developed fever, extensive dermatitis, and reddish colored urine. Anemia, erythrodontia, hepatosplenomegaly, and massive urinary elimination of predominantly type I porphyrins was suggestive of congenital erythropoietic porphyria. Although hemolysis remained mild and compensated, facial and digital mutilation developed indicative of moderate clinical phenotype. Mutational analysis revealed compound heterozygosity of mutant alleles, including a novel mutation (p.Pro190Leu). The child received supportive management and underwent facial reconstruction successfully.
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Bonkovsky HL, Guo J, Hou W, Li T, Narang T, Thapar M. Porphyrin and Heme Metabolism and the Porphyrias. Compr Physiol 2013; 3:365-401. [DOI: 10.1002/cphy.c120006] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Abstract
The inborn errors of heme biosynthesis, the porphyrias, are 8 genetically distinct metabolic disorders that can be classified as “acute hepatic,” “hepatic cutaneous,” and “erythropoietic cutaneous” diseases. Recent advances in understanding their pathogenesis and molecular genetic heterogeneity have led to improved diagnosis and treatment. These advances include DNA-based diagnoses for all the porphyrias, new understanding of the pathogenesis of the acute hepatic porphyrias, identification of the iron overload-induced inhibitor of hepatic uroporphyrin decarboxylase activity that causes the most common porphyria, porphyria cutanea tarda, the identification of an X-linked form of erythropoietic protoporphyria due to gain-of-function mutations in erythroid-specific 5-aminolevulinate synthase (ALAS2), and new and experimental treatments for the erythropoietic prophyrias. Knowledge of these advances is relevant for hematologists because they administer the hematin infusions to treat the acute attacks in patients with the acute hepatic porphyrias, perform the chronic phlebotomies to reduce the iron overload and clear the dermatologic lesions in porphyria cutanea tarda, and diagnose and treat the erythropoietic porphyrias, including chronic erythrocyte transfusions, bone marrow or hematopoietic stem cell transplants, and experimental pharmacologic chaperone and stem cell gene therapies for congenital erythropoietic protoporphyria. These developments are reviewed to update hematologists on the latest advances in these diverse disorders.
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Balwani M, Desnick RJ. The porphyrias: advances in diagnosis and treatment. Blood 2012; 120:4496-504. [PMID: 22791288 PMCID: PMC3512229 DOI: 10.1182/blood-2012-05-423186] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 06/07/2012] [Indexed: 02/06/2023] Open
Abstract
The inborn errors of heme biosynthesis, the porphyrias, are 8 genetically distinct metabolic disorders that can be classified as "acute hepatic," "hepatic cutaneous," and "erythropoietic cutaneous" diseases. Recent advances in understanding their pathogenesis and molecular genetic heterogeneity have led to improved diagnosis and treatment. These advances include DNA-based diagnoses for all the porphyrias, new understanding of the pathogenesis of the acute hepatic porphyrias, identification of the iron overload-induced inhibitor of hepatic uroporphyrin decarboxylase activity that causes the most common porphyria, porphyria cutanea tarda, the identification of an X-linked form of erythropoietic protoporphyria due to gain-of-function mutations in erythroid-specific 5-aminolevulinate synthase (ALAS2), and new and experimental treatments for the erythropoietic porphyrias. Knowledge of these advances is relevant for hematologists because they administer the hematin infusions to treat the acute attacks in patients with the acute hepatic porphyrias, perform the chronic phlebotomies to reduce the iron overload and clear the dermatologic lesions in porphyria cutanea tarda, and diagnose and treat the erythropoietic porphyrias, including chronic erythrocyte transfusions, bone marrow or hematopoietic stem cell transplants, and experimental pharmacologic chaperone and stem cell gene therapies for congenital erythropoietic protoporphyria. These developments are reviewed to update hematologists on the latest advances in these diverse disorders.
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY 10029, USA
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Rivera DF, Leung LKP. A rare autosomal recessive condition, congenital erythropoietic porphyria, found in the canefield rat Rattus sordidus Gould 1858. Integr Zool 2012; 3:216-8. [PMID: 21396071 DOI: 10.1111/j.1749-4877.2008.00088.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive condition that has been reported in humans and in some animals, in which uroporphyrin 1 is deposited in the bones, teeth and urine, resulting in pink coloration and fluorescence of the tissues and urine under long-wave ultraviolet (UV) light. We observed red teeth in nine of 450 canefield rats (Rattus sordidus) captured in a small, isolated patch of sugarcane in Tully, north Queensland, Australia. The skeletons of these animals were excised and were found to be bright red under normal day light. Under UV light, the skeleton had a bright red fluorescence. It is plausible that the canefield rat population in this isolated patch of sugarcane is small and inbreeding might have occurred, resulting in incidences of the autosomal recessive genes that cause CEP. The canefield rat can be used as an animal model for research into porphyria.
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Affiliation(s)
- Dario F Rivera
- School of Animal Studies, University of Queensland, Gatton, Queensland, Australia
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Katugampola RP, Anstey AV, Finlay AY, Whatley S, Woolf J, Mason N, Deybach JC, Puy H, Ged C, de Verneuil H, Hanneken S, Minder E, Schneider-Yin X, Badminton MN. A management algorithm for congenital erythropoietic porphyria derived from a study of 29 cases. Br J Dermatol 2012; 167:888-900. [PMID: 22804244 DOI: 10.1111/j.1365-2133.2012.11154.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Congenital erythropoietic porphyria (CEP) is an autosomal recessive photomutilating porphyria with onset usually in childhood, where haematological complications determine prognosis. Due to its extreme rarity and clinical heterogeneity, management decisions in CEP are often difficult. OBJECTIVES To develop a management algorithm for patients with CEP based on data from carefully characterized historical cases. METHODS A single investigator collated data related to treatments and their outcomes in 29 patients with CEP from the U.K., France, Germany and Switzerland. RESULTS Six children were treated with bone marrow transplantation (BMT); five have remained symptomatically cured up to 11.5 years post-transplantation. Treatments such as oral charcoal, splenectomy and chronic hypertransfusion were either of no benefit or were associated with complications and negative impact on health-related quality of life. Lack of consistent genotype-phenotype correlation meant that this could not be used to predict disease prognosis. The main poor prognostic factors were early age of disease onset and severity of haematological manifestations. CONCLUSIONS A management algorithm is proposed where every patient, irrespective of disease severity at presentation, should receive a comprehensive, multidisciplinary clinical assessment and should then be reviewed at intervals based on their predicted prognosis, and the rate of onset of complications. A BMT should be considered in those with progressive, symptomatic haemolytic anaemia and/or thrombocytopenia. Uroporphyrinogen III synthase genotypes associated with poor prognosis would additionally justify consideration for a BMT. Rigorous photoprotection of the skin and eyes from visible light is essential in all patients.
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Affiliation(s)
- R P Katugampola
- Department of Dermatology and Wound Healing, Cardiff University, UK.
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Katugampola R, Badminton M, Finlay A, Whatley S, Woolf J, Mason N, Deybach J, Puy H, Ged C, de Verneuil H, Hanneken S, Minder E, Schneider-Yin X, Anstey A. Congenital erythropoietic porphyria: a single-observer clinical study of 29 cases. Br J Dermatol 2012; 167:901-13. [DOI: 10.1111/j.1365-2133.2012.11160.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Moghbeli M, Maleknejad M, Arabi A, Abbaszadegan MR. Mutational analysis of uroporphyrinogen III cosynthase gene in Iranian families with congenital erythropoietic porphyria. Mol Biol Rep 2012; 39:6731-5. [PMID: 22350154 DOI: 10.1007/s11033-012-1497-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 01/24/2012] [Indexed: 10/28/2022]
Abstract
Porphyrias are rare metabolic hereditary diseases originating from defects in specific enzymes involved in the heme biosynthesis pathway. Congenital erythropoietic porphyria (CEP) is the rarest autosomal recessive porphyria resulting from a deficiency of uroporphyrinogen III cosynthase (UROS), the fourth enzyme in heme biosynthesis. CEP leads to an excessive production and accumulation of type Ι porphyrins in bone marrow, skin and several other tissues. Clinical manifestations are presented in childhood with severe cutaneous photosensitivity, blistering, scarring and deformation of the hands and the loss of eyebrows and eyelashes. Less than 200 cases of CEP have been reported to date. Four CEP patients and their family members were studied for the first time in Iran. A missense mutation in the UROS gene was identified in this family. A, T to C change at nucleotide 34313, leading to a substitution of Leucine by Proline at codon 237, was observed in the homozygous state in these 4 patients and heterozygous state in their parents. Our data from the Iranian population emphasizes the importance of codon 237 alone, given the rarity of this disease. This fact can be taken into consideration in the mutational analysis of UROS. This work emphasizes the advantages of molecular genetic techniques as diagnostic tools for the detection of clinically asymptomatic heterozygous mutation carriers as well as CEP within families.
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Affiliation(s)
- Meysam Moghbeli
- Division of Human Genetics, Avicenna Research Institute, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran
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Sarkany RP, Ibbotson SH, Whatley SD, Lawrence CM, Gover P, Mufti GJ, Murphy GM, Masters GS, Badminton MN, Elder GH. Erythropoietic Uroporphyria Associated with Myeloid Malignancy Is Likely Distinct from Autosomal Recessive Congenital Erythropoietic Porphyria. J Invest Dermatol 2011; 131:1172-5. [DOI: 10.1038/jid.2011.5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
Oral manifestations of hematologic and nutritional deficiencies can affect the mucous membranes, teeth, periodontal tissues, salivary glands, and perioral skin. This article reviews common oral manifestations of hematologic conditions starting with disorders of the white blood cells including cyclic hematopoiesis (cyclic neutropenia), leukemias, lymphomas, plasma cell dyscrasias, and mast cell disorders; this is followed by a discussion of the impact of red blood cell disorders including anemias and less common red blood cell dyscrasias (sickle cell disease, hemochromatosis, and congenital erythropoietic porphyria) as well as thrombocytopenia. Several nutritional deficiencies exhibit oral manifestations. The authors specifically discuss the impact of water-soluble vitamins (B2, B3, B6, B9, B12, and C), fat-soluble vitamins (A, D, and K) and the eating disorders anorexia nervosa and bulimia nervosa on the oral mucosa.
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Bishop DF, Clavero S, Mohandas N, Desnick RJ. Congenital erythropoietic porphyria: characterization of murine models of the severe common (C73R/C73R) and later-onset genotypes. Mol Med 2011; 17:748-56. [PMID: 21365124 DOI: 10.2119/molmed.2010.00258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 02/24/2011] [Indexed: 11/06/2022] Open
Abstract
Congenital erythropoietic porphyria (CEP) is an autosomal recessive disorder due to the deficient activity of uroporphyrinogen III synthase (UROS). Knock-in mouse models were generated for the common, hematologically severe human genotype, C73R/C73R, and milder genotypes (C73R/V99L and V99L/V99L). The specific activities of the UROS enzyme in the livers and erythrocytes of these mice averaged approximately 1.2%, 11% and 19% of normal, respectively. C73R/C73R mice that survived fetal life to weaning age (~12%) had a severe microcytic hypochromic anemia (hemoglobin 7.9 g/dL, mean cellular volume 26.6 fL, mean cellular hemoglobin content 27.4 g/dL, red cell distribution width 37.7%, reticulocytes 19%) and massively accumulated isomer I porphyrins (95, 183 and 44 μmol/L in erythrocytes, spleen and liver, respectively), but a nearly normal lifespan. In adult C73R/C73R mice, spleen and liver weights were 8.2- and 1.5-fold increased, respectively. C73R/V99L mice were mildly anemic (hemoglobin was 14.0 g/dL and mean cellular hemoglobin was 13.3), with minimally accumulated porphyrins (0.10, 5.54 and 0.58 μmol/L in erythrocytes, spleen and liver, respectively), whereas adult V99L/V99L mice were normal. Of note, even the mildest genotype, V99L/V99L, exhibited porphyria in utero, which disappeared by 2 months of age. These severe and mild mouse models inform therapeutic interventions and permit further investigation of the porphyrin-induced hematopathology, which leads to photo-induced cutaneous lesions. Of significance for therapeutic intervention, these mouse models suggest that only 11% of wild-type activity might be needed to reverse the pathology in CEP patients.
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Affiliation(s)
- David F Bishop
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, USA.
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Abstract
Hereditary porphyrias are a group of eight metabolic disorders of the haem biosynthesis pathway that are characterised by acute neurovisceral symptoms, skin lesions, or both. Every porphyria is caused by abnormal function of a separate enzymatic step, resulting in a specific accumulation of haem precursors. Seven porphyrias are the result of a partial enzyme deficiency, and a gain of function mechanism has been characterised in a new porphyria. Acute porphyrias present with acute attacks, typically consisting of severe abdominal pain, nausea, constipation, confusion, and seizure, and can be life-threatening. Cutaneous porphyrias present with either acute painful photosensitivity or skin fragility and blisters. Rare recessive porphyrias usually manifest in early childhood with either severe cutaneous photosensitivity and chronic haemolysis or chronic neurological symptoms with or without photosensitivity. Porphyrias are still underdiagnosed, but when they are suspected, and dependent on clinical presentation, simple first-line tests can be used to establish the diagnosis in all symptomatic patients. Diagnosis is essential to enable specific treatments to be started as soon as possible. Screening of families to identify presymptomatic carriers is crucial to decrease risk of overt disease of acute porphyrias through counselling about avoidance of potential precipitants.
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Affiliation(s)
- Hervé Puy
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
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Erupciones inflamatorias y purpúricas. DERMATOLOGÍA NEONATAL 2009. [PMCID: PMC7161408 DOI: 10.1016/b978-84-8086-390-2.50019-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Effective gene therapy of mice with congenital erythropoietic porphyria is facilitated by a survival advantage of corrected erythroid cells. Am J Hum Genet 2008; 82:113-24. [PMID: 18179890 DOI: 10.1016/j.ajhg.2007.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 09/04/2007] [Accepted: 09/21/2007] [Indexed: 11/23/2022] Open
Abstract
Achieving long-term expression of a therapeutic gene in a given hematopoietic lineage remains an important goal of gene therapy. Congenital erythropoietic porphyria (CEP) is a severe autosomal-recessive disorder characterized by a deficiency in uroporphyrinogen III synthase (UROS), the fourth enzyme of the heme biosynthetic pathway. We used a recently obtained murine model to check the feasibility of gene therapy in this disease. Lentivirus-mediated transfer of the human UROS cDNA into hematopoietic stem cells (HSCs) from Uros(mut248) mice resulted in a complete and long-term enzymatic, metabolic, and phenotypic correction of the disease, favored by a survival advantage of corrected red blood cells. These results demonstrate that the cure of this mouse model of CEP at a moderate transduction level supports the proof of concept of a gene therapy in this disease by transplantation of genetically modified hematopoietic stem cells.
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Baselga E, Torrelo A. Inflammatory and Purpuric Eruptions. NEONATAL DERMATOLOGY 2008. [PMCID: PMC7315339 DOI: 10.1016/b978-1-4160-3432-2.50022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
Recent advances in the molecular understanding of the porphyrias now offer specific diagnosis and precise definition of the types of genetic mutations involved in the disease. Molecular diagnostic testing is powerful and very useful in kindred evaluation and genetic counselling when a disease-responsible mutation has been identified in the family. It is also the only way to properly screen asymptomatic gene carriers, facilitating correct treatment and appropriate genetic counselling of family members at risk. However, it should be noted that DNA-based testing is for the diagnosis of the gene carrier status, but not for the diagnosis of clinical syndrome or severity of the disease, e.g. an acute attack. For the diagnosis of clinically expressed porphyrias, a logical stepwise approach including the analysis of porphyrins and their precursors should not be underestimated, as it is still very useful, and is often the best from the cost-effective point of view.
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MESH Headings
- Acute Disease
- Chronic Disease
- Coproporphyria, Hereditary/diagnosis
- Coproporphyria, Hereditary/therapy
- Heme/biosynthesis
- Humans
- Porphobilinogen Synthase/metabolism
- Porphyria Cutanea Tarda/diagnosis
- Porphyria Cutanea Tarda/therapy
- Porphyria, Erythropoietic/diagnosis
- Porphyria, Erythropoietic/therapy
- Porphyria, Hepatoerythropoietic/diagnosis
- Porphyria, Hepatoerythropoietic/therapy
- Porphyria, Variegate/diagnosis
- Porphyria, Variegate/therapy
- Porphyrias/classification
- Porphyrias/diagnosis
- Porphyrias/therapy
- Porphyrias, Hepatic/diagnosis
- Porphyrias, Hepatic/therapy
- Protoporphyria, Erythropoietic/diagnosis
- Protoporphyria, Erythropoietic/therapy
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Affiliation(s)
- Shigeru Sassa
- Laboratory of Biochemical Hematology, The Rockefeller University, New York 10021, USA.
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Anstey A. School in photodermatology: Smith-Lemli-Opitz syndrome. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2006; 22:200-4. [PMID: 16869869 DOI: 10.1111/j.1600-0781.2006.00231.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The Smith-Lemli-Opitz syndrome has only recently been added to the small number of congenital disorders characterized by photosensitivity. The clinical features of this disorder are distinct from other photosensitivity syndromes. Details on the patho-mechanism of photosensitivity in the Smith-Lemli-Opitz syndrome have yet to be fully determined. However, preliminary evidence points to the deranged cholesterol metabolism that characterizes the syndrome as causal in this UVA-mediated photosensitivity disorder.
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Affiliation(s)
- Alex Anstey
- Academic Department of Dermatology, College of Medicine, Cardiff University, Cardiff, UK.
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Bishop DF, Johansson A, Phelps R, Shady AA, Ramirez MCM, Yasuda M, Caro A, Desnick RJ. Uroporphyrinogen III synthase knock-in mice have the human congenital erythropoietic porphyria phenotype, including the characteristic light-induced cutaneous lesions. Am J Hum Genet 2006; 78:645-58. [PMID: 16532394 PMCID: PMC1424695 DOI: 10.1086/502667] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2006] [Accepted: 01/25/2006] [Indexed: 11/03/2022] Open
Abstract
Congenital erythropoietic porphyria (CEP), an autosomal recessive inborn error, results from the deficient but not absent activity of uroporphyrinogen III synthase (URO-synthase), the fourth enzyme in the heme biosynthetic pathway. The major clinical manifestations include severe anemia, erythrodontia, and disfiguring cutaneous involvement due to the accumulation of phototoxic porphyrin I isomers. Murine models of CEP could facilitate studies of disease pathogenesis and the evaluation of therapeutic endeavors. However, URO-synthase null mice were early embryonic lethals. Therefore, knock-in mice were generated with three missense mutations, C73R, V99A, and V99L, which had in vitro-expressed activities of 0.24%, 5.9%, and 14.8% of expressed wild-type activity, respectively. Homozygous mice for all three mutations were fetal lethals, except for mice homozygous for a spontaneous recombinant allele, V99A(T)/V99A(T), a head-to-tail concatemer of three V99A targeting constructs. Although V99A(T)/V99A(T) and C73R/V99A(T) mice had approximately 2% hepatic URO-synthase activity and normal hepatic microsomal heme and hemoprotein levels, they had 20% and 13% of wild-type activity in erythrocytes, respectively, which indicates that sufficient erythroid URO-synthase was present for fetal development and survival. Both murine genotypes showed marked porphyrin I isomer accumulation in erythrocytes, bone, tissues, and excreta and had fluorescent erythrodontia, hemolytic anemia with reticulocytosis and extramedullary erythropoiesis, and, notably, the characteristic light-induced cutaneous involvement. These mice provide insight into why CEP is an erythroid porphyria, and they should facilitate studies of the disease pathogenesis and therapeutic endeavors for CEP.
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Affiliation(s)
- David F Bishop
- Department of Human Genetics, Mount Sinai School of Medicine, New York, NY 10029, USA
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Abstract
Metabolic diseases are common diseases in the Western world. Many of these diseases, including diabetes mellitus, hyperlipoproteinemia, gout, calcinosis, and hemochromatosis, are associated with skin diseases or often present with specific cutaneous signs. A knowledge of cutaneous manifestations helps to identify patients at risk, establish the internal diagnosis, and monitor the adverse effects of therapy.
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Affiliation(s)
- Erich Köstler
- Department of Dermatology, Academic Teaching Hospital Dresden-Friedrichstadt, 01067 Dresden, Germany.
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