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Moghe A, Dickey A, Erwin A, Leaf RK, O'Brien A, Quigley JG, Thapar M, Anderson KE. Acute hepatic porphyrias: Recommendations for diagnosis and management with real-world examples. Mol Genet Metab 2023; 140:107670. [PMID: 37542766 DOI: 10.1016/j.ymgme.2023.107670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Abstract
Acute hepatic porphyria (AHP) is a group of four rare inherited diseases, each resulting from a deficiency in a distinct enzyme in the heme biosynthetic pathway. Characterized by acute neurovisceral symptoms that may mimic other medical and psychiatric conditions, lack of recognition of the disease often leads to a delay in diagnosis and initiation of effective treatment. Biochemical testing for pathway intermediates that accumulate when the disease is active forms the basis for screening and establishing a diagnosis. Subsequent genetic analysis identifies the pathogenic variant, supporting screening of family members and genetic counseling. Management of AHP involves avoidance of known exogenous and hormonal triggers, symptomatic treatment, and prevention of recurrent attacks. Here we describe six case studies from our own real-world experience to highlight current recommendations and challenges associated with the diagnosis and long-term management of the disease.
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Affiliation(s)
- Akshata Moghe
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States of America.
| | - Amy Dickey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Angelika Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, OH, United States of America
| | - Rebecca K Leaf
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, United States of America
| | - Alan O'Brien
- Service de Médecine Génique, Département de Médecine, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - John G Quigley
- Department of Medicine, University of Illinois College of Medicine, Chicago, IL, United States of America
| | - Manish Thapar
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA, United States of America
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, United States of America
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Herrera PM, Vélez Van Meerbeke A, Bonnot O. Psychiatric Disorders Secondary to Neurometabolic Disorders. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2018; 47:244-251. [PMID: 30286847 DOI: 10.1016/j.rcp.2017.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 05/06/2017] [Indexed: 12/11/2022]
Abstract
Some diseases secondary to inborn errors of metabolism are associated with psychiatric disorders or minor neurological symptoms. The existence of some cases with exclusively psychiatric symptoms represents a diagnostic and therapeutic challenge. The aim of this article is to describe seven treatable neurometabolic disorders that should be taken into account in the psychiatric consultation as they manifest with psychiatric symptoms that mask the organic origin of the disorder. Homocysteine metabolism and urea cycle disorders, Wilson's disease, Niemann-Pick disease Type C, acute porphyria and cerebrotendinous xanthomatosis are described. Following an analysis of the literature, a list of psychiatric symptoms associated with these disorders are proposed, ranging from insidious changes in affective state and thought to atypical symptoms such as visual hallucinations, as well as paradoxical effects of antipsychotics or behavioural disorders in children and adolescents associated with loss of autonomy. The most frequently associated neurological signs, such as alterations in the state of consciousness, motor behaviour and balance disorders, catatonia or progressive cognitive deficit are also listed. Emphasis is placed on the importance of considering resistance to antipsychotic treatment as a warning sign to suspect organicity, as well as the significant improvement in psychiatric impairment when effective and early treatment is established.
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Affiliation(s)
- Paula M Herrera
- Departamento de Psiquiatría, Facultad de Medicina y Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira, Colombia; Grupo de investigación en neurociencias (NeURos), Universidad del Rosario, Bogotá, Colombia; Consciousness and Cognition lab, Department of Psychology, University of Cambridge, Cambridge, Reino Unido.
| | | | - Olivier Bonnot
- Service Universitaire de Psychiatrie de l'Enfant et de l'Adolescent, Université de Nantes, Nantes, Francia
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Bonnot O, Herrera P, Kuster A. [Treatable neurometabolic diseases. Association with schizophrenia spectrum disorders]. Presse Med 2015; 44:889-97. [PMID: 26248708 DOI: 10.1016/j.lpm.2015.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 02/10/2015] [Accepted: 02/17/2015] [Indexed: 11/18/2022] Open
Abstract
Schizophrenia spectrum disorders are presented on 1% of subjects over general population. Organic pathologies prevalence in schizophrenia spectrum patients is not well determined, and it is probably underestimated. In the present update review, we are going to highlight seven treatable neurometabolic diseases (NMD) associated to sub-clinic neurological symptoms. It is not infrequent to witness the absence of any clinical neurological signs going along with the NMD. Psychiatric symptoms may be the only clinical alarm that can guide physicians to an acute diagnosis. This is why it is a challenging pathology, defying our clinical accuracy as psychiatrist or any other practitioners confronted to this population. Hereby we are going to expose a literature review and comprehensive tables in order to present in a glance the essential clinical features of disorders of homocysteine metabolism, urea cycle disorders, Niemann-Pick disease type C, acute porphyria, cerebrotendinous-xanthomatosis. These conditions are sensible to major improvement strongly correlated to the accuracy of diagnosis. Literature analysis led us to propose a comprehensive list of atypical psychiatric symptoms including highly predominant visual hallucinations, compared to auditory ones, as well as confusion, catatonia or progressive cognitive decline. We highlight the importance of considering antipsychotic treatment resistance as a crucial sign leading to suspect an organic factor beneath the psychiatric features.
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Affiliation(s)
- Olivier Bonnot
- Service universitaire de psychiatrie de l'enfant et de l'adolescent, CHU de Nantes, université de Nantes, 44093 Nantes, France.
| | - Paula Herrera
- Service universitaire de psychiatrie de l'enfant et de l'adolescent, CHU de Nantes, université de Nantes, 44093 Nantes, France; Service de pédiatrie, centre hospitalier universitaire de Nantes, Nantes, France
| | - Alice Kuster
- Service de pédiatrie, centre hospitalier universitaire de Nantes, Nantes, France
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Bonnot O, Herrera PM, Tordjman S, Walterfang M. Secondary psychosis induced by metabolic disorders. Front Neurosci 2015; 9:177. [PMID: 26074754 PMCID: PMC4436816 DOI: 10.3389/fnins.2015.00177] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 04/30/2015] [Indexed: 11/13/2022] Open
Abstract
Metabolic disorders are not well-recognized by psychiatrists as a possible source of secondary psychoses. Inborn errors of metabolism (IEMs) are not frequent. Although their prompt diagnosis may lead to suitable treatments. IEMs are well-known to pediatricians, in particular for their most serious forms, having an early expression most of the time. Recent years discoveries have unveiled later expression forms, and sometimes very discreet first physical signs. There is a growing body of evidence that supports the hypothesis that IEMs can manifest as atypical psychiatric symptoms, even in the absence of clear neurological symptoms. In the present review, we propose a detailed overview at schizophrenia-like and autism-like symptoms that can lead practitioners to bear in mind an IEM. Other psychiatric manifestations are also found, as behavioral, cognitive, learning, and mood disorders. However, they are less frequent. Ensuring an accurate IEM diagnosis, in front of these psychiatric symptoms should be a priority, in order to grant suitable and valuable treatment for these pathologies.
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Affiliation(s)
- Olivier Bonnot
- Psychology Laboratory of Pays de la Loire (LPPL), U2PEA Department of Child and Adolescent Psychiatry, Centre Hospitalier Universitaire de Nantes, University of Angers Nantes, France
| | - Paula M Herrera
- Psychology Laboratory of Pays de la Loire (LPPL), U2PEA Department of Child and Adolescent Psychiatry, Centre Hospitalier Universitaire de Nantes, University of Angers Nantes, France ; Grupo de Investigación en Neurociencias NeURos, Universidad del Rosario Bogota, Colombia
| | - Sylvie Tordjman
- Department of Child an Adolescent Psychiatry, Centre Hospitalier Guillaume Regnier, University of Rennes Rennes, France
| | - Mark Walterfang
- Neuropsychiatry Unit, Royal Melbourne Hospital Melbourne, VIC, Australia ; Melbourne Neuropsychiatry Centre, University of Melbourne Melbourne, VIC, Australia
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Bonnot O, Klünemann HH, Sedel F, Tordjman S, Cohen D, Walterfang M. Diagnostic and treatment implications of psychosis secondary to treatable metabolic disorders in adults: a systematic review. Orphanet J Rare Dis 2014; 9:65. [PMID: 24775716 PMCID: PMC4043981 DOI: 10.1186/1750-1172-9-65] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 03/24/2014] [Indexed: 12/18/2022] Open
Abstract
Objective It is important for psychiatrists to be aware of certain inborn errors of metabolism (IEMs) as these rare disorders can present as psychosis, and because definitive treatments may be available for treating the underlying metabolic cause. A systematic review was conducted to examine IEMs that often present with schizophrenia-like symptoms. Data sources Published literature on MEDLINE was assessed regarding diseases of homocysteine metabolism (DHM; cystathionine beta-synthase deficiency [CbS-D] and homocysteinemia due to methyltetrahydrofolate reductase deficiency [MTHFR-D]), urea cycle disorders (UCD), acute porphyria (POR), Wilson disease (WD), cerebrotendinous-xanthomatosis (CTX) and Niemann-Pick disease type C (NP-C). Study selection Case reports, case series or reviews with original data regarding psychiatric manifestations and cognitive impairment published between January 1967 and June 2012 were included based on a standardized four-step selection process. Data extraction All selected articles were evaluated for descriptions of psychiatric signs (type, severity, natural history and treatment) in addition to key disease features. Results A total of 611 records were identified. Information from CbS-D (n = 2), MTHFR-D (n = 3), UCD (n = 8), POR (n = 12), WD (n = 11), CTX (n = 14) and NP-C publications (n = 9) were evaluated. Six non-systematic literature review publications were also included. In general, published reports did not provide explicit descriptions of psychiatric symptoms. The literature search findings are presented with a didactic perspective, showing key features for each disease and psychiatric signs that should trigger psychiatrists to suspect that psychotic symptoms may be secondary to an IEM. Conclusion IEMs with a psychiatric presentation and a lack of, or sub-clinical, neurological signs are rare, but should be considered in patients with atypical psychiatric symptoms.
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Affiliation(s)
- Olivier Bonnot
- Department of Child and Adolescent Psychiatry, Centre Hospitalier Universitaire de Nantes, Hôpital Mère-Enfant, 7 quai Moncousu, 44 000 Nantes, France.
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Kim DHT, Hino R, Adachi Y, Kobori A, Taketani S. The enzyme engineering of mutant homodimer and heterodimer of coproporphyinogen oxidase contributes to new insight into hereditary coproporphyria and harderoporphyria. J Biochem 2013; 154:551-9. [DOI: 10.1093/jb/mvt086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Anderson KE, Collins S. Open-label study of hemin for acute porphyria: clinical practice implications. Am J Med 2006; 119:801.e19-24. [PMID: 16945618 DOI: 10.1016/j.amjmed.2006.05.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 05/07/2006] [Accepted: 05/17/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The acute porphyrias are rare inherited diseases characterized by acute episodes of life-threatening symptoms. Hemin was approved for treating these disorders in 1983. This open-label study of hemin therapy, conducted to demonstrate the safety of hemin manufactured in a new facility, is the largest to date and provides an overview of the use of hemin in clinical practice in the United States. METHODS During 8 months when hemin was available only through study participation, 130 patients with a clinical diagnosis of acute porphyria received hemin as regularly prescribed by their doctor. Laboratory information and data on use of hemin for acute and prophylactic treatment were analyzed from case report forms. RESULTS Hemin was administered to 111 patients for treatment of 305 acute attacks and to 40 patients for prophylaxis (usually by weekly or biweekly infusions). Diagnostic laboratory findings reported for 69 patients were confirmatory in only 26. Hemin was regarded as effective for all attacks in 73% of patients. Doses for acute attacks were less than the recommended 3-4 mg/kg/day in 20% of patients. Among 31 patients who received hemin prophylaxis for >1 month, 68% did not require subsequent hemin treatment for acute attacks. Most adverse events were attributed to porphyria and not treatment, and were more common in patients treated for acute attacks rather than prophylaxis. CONCLUSIONS Safety and perceived efficacy of hemin were consistent with previous studies. Physician education is needed regarding use of diagnostic tests and recommended dosing. Preventive regimens are common and deserve further study.
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Affiliation(s)
- Karl E Anderson
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston 77555-1109, USA.
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Schmitt C, Gouya L, Malonova E, Lamoril J, Camadro JM, Flamme M, Rose C, Lyoumi S, Da Silva V, Boileau C, Grandchamp B, Beaumont C, Deybach JC, Puy H. Mutations in human CPO gene predict clinical expression of either hepatic hereditary coproporphyria or erythropoietic harderoporphyria. Hum Mol Genet 2005; 14:3089-98. [PMID: 16159891 DOI: 10.1093/hmg/ddi342] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Hereditary coproporphyria (HCP), an autosomal dominant acute hepatic porphyria, results from mutations in the gene that encodes coproporphyrinogen III oxidase (CPO). HCP (heterozygous or rarely homozygous) patients present with an acute neurovisceral crisis, sometimes associated with skin lesions. Four patients (two families) have been reported with a clinically distinct variant form of HCP. In such patients, the presence of a specific mutation (K404E) on both alleles or associated with a null allele, produces a unifying syndrome in which hematological disorders predominate: 'harderoporphyria'. Here, we report the fifth case (from a third family) with harderoporphyria. In addition, we show that harderoporphyric patients exhibit iron overload secondary to dyserythropoiesis. To investigate the molecular basis of this peculiar phenotype, we first studied the secondary structure of the human CPO by a predictive method, the hydrophobic cluster analysis (HCA) which allowed us to focus on a region of the enzyme. We then expressed mutant enzymes for each amino acid of the region of interest, as well as all missense mutations reported so far in HCP patients and evaluated the amount of harderoporphyrin in each mutant. Our results strongly suggest that only a few missense mutations, restricted to five amino acids encoded by exon 6, may accumulate significant amounts of harderoporphyrin: D400-K404. Moreover, all other type of mutations or missense mutations mapped elsewhere throughout the CPO gene, lead to coproporphyrin accumulation and subsequently typical HCP. Our findings, reinforced by recent crystallographic results of yeast CPO, shed new light on the genetic predisposition to HCP. It represents a first monogenic metabolic disorder where clinical expression of overt disease is dependent upon the location and type of mutation, resulting either in acute hepatic or in erythropoietic porphyria.
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Affiliation(s)
- Caroline Schmitt
- INSERM U656 and Centre Français de Porphyries, Université Paris VII, Hôpital Louis Mourier, Colombes, France
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Allen KR, Whatley SD, Degg TJ, Barth JH. Hereditary coproporphyria: comparison of molecular and biochemical investigations in a large family. J Inherit Metab Dis 2005; 28:779-85. [PMID: 16151909 DOI: 10.1007/s10545-005-0092-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Accepted: 04/21/2005] [Indexed: 11/27/2022]
Abstract
Hereditary coproporphyria (HCP) is the least common of the three autosomal dominant acute porphyrias. To compare the sensitivity of metabolite measurements for the identification of asymptomatic HCP, we carried out a molecular and biochemical investigation of a large family in which HCP is caused by a previously unreported frameshift mutation (c.119delA). Thirteen of 19 asymptomatic family members, aged 10-72 years, were shown by mutational analysis to have HCP. The faecal coproporphyrin isomer III:I ratio was increased in all of these 13 family members; faecal total porphyrin concentration and urinary porphyrin excretion were increased in 11 and 8 of them, respectively. Plasma porphyrin concentrations were marginally increased in three individuals and plasma fluorescence emission scanning showed a porphyrin peak at 618 nm in two of these. Our results add to the evidence that an increased faecal porphyrin coproporphyrin III:I ratio is a highly sensitive test for the detection of clinically latent HCP in individuals over the age of 10 years; its sensitivity below this age remains uncertain. They also show that plasma fluorescence emission scanning is not useful for the investigation of families with HCP.
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Affiliation(s)
- K R Allen
- Department of Clinical Biochemistry, Leeds Teaching Hospitals, Leeds, UK.
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Gómez Moreno R, Monge Ropero N, Calvo Cebrián A, Fraga Campo S. Porfirias agudas. Ataques agudos de porfiria. Semergen 2004. [DOI: 10.1016/s1138-3593(04)74335-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gross U, Gerlach R, Kühnel A, Seifert V, Doss MO. A description of an HPLC assay of coproporphyrinogen III oxidase activity in mononuclear cells. J Inherit Metab Dis 2003; 26:565-70. [PMID: 14605502 DOI: 10.1023/a:1025952031660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Coproporphyrinogen III oxidase is deficient in hereditary coproporphyria. An activity assay for this enzyme in mononuclear cells, besides the preparation of the substrate, are presented. The separation conditions for the product of the test protoporphyrin IX by gradient, reversed-phase high-performance liquid chromatography are given. The normal value from mononuclear cells of healthy volunteers was 138 +/- 21 pkat/g total soluble protein (mean +/- SD). The enzyme activity of a family with hereditary coproporphyria was measured. The gene carriers exhibit a specific coproporphyrinogen III oxidase activity of 61-90 pkat/g total soluble protein.
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Affiliation(s)
- U Gross
- Department of Neurosurgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
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