[ERYTHROPOIETIC PROTOPORPHYRIA. PROTOPORPHYRINEMIC PHOTODERMATOSIS]

The histopathology and ultrastructure of liver disease in erythropoietic protoporphyria

The light, polarization and electron microscopic changes in the liver of four cases of erythropoietic protoporphyria (EPP) are described. In one of these cases liver involvement resulted in death, whereas in the other three there were no symptoms of referable to hepatic disease. In two cases hepatic pigment was readily visible on light and polarization microscopy and corresponded to characteristic crystalline aggregates seen ultrastructurally. Pronounced micronodular cirrhosis and cholestasis were present in the fatal case, while in the other only mild periportal fibrosis and mononuclear inflammatory cell infiltrate occurred. The third and fourth cases showed no evidence of hepatic involvement on light microscopy. Electron microscopy, however, revealed characteristic crystal-containing vacuoles indicative of protoporphyrin deposition. The need for early detection of the hepatic lesion is emphasized.

Oral carotenoids for photohypersensitivity in patients with erythrohepatic protoporphyria, polymorphous light eruptions and lupus erythematodes discoides

beta-Carotene and canthaxanthin in a dose of 75--250 mg a day by mouth reduced the symptons of exposure to the sun in all 7 treated patients with erythrohepatic protoporphyria (EPP), in 15 of 18 with polymorphous light eruptions (PMLE) and in 3 of 4 with lupus erythematodes discoides. In the EPP group the protoporphyrin level tended to vary inversely with that of the serum carotenoids. The level of retinol-binding protein in plasma remained unchanged despite a substantial rise in the concentration of the serum carotenoids. Estimation of the minimal erythema dose for unfiltered light from a Xenon lamp in 7 patients with PMLE showed an increase in only 1 patient. Neither clinical examination nor repeated laboratory studies revealed any serious side effects of the treatment.

Hepato-erythropoietic porphyria presenting as scleroderma and acrosclerosis in a sibling pair

Clinical and biochemical data are reported on a sibling pair with clinical and biochemical features of both erythropoietic protoporphyria and hepatic cutaneous porphyria. After many years of photosensitivity the clinical picture resembles systemic sclerosis.

[Erythropoietic protoporphyria: porphyrin content of a gall-stone (author's transl)]

In the case of a 48 year old woman with characteristic signs of erythropoetic protoporphyria, a solitary gall-stone which had persisted over a period of 10 years was removed. Porphyrin-concentration of this gall-stone was found to be 22.6 mcg/g, which is almost twenty times the concentration of other cholestrol-stones. Besides protoporphyrin, porphyrins with a higher degree of carboxylation were discovered in four different samples by thin layer chromatography. It is postulated that the increased bile-concentration of protoporphyrin in the liver causes the cristallisation of cholestrol and the formation and growth of gall-stones. The biochemical finding of porphyrins with a higher degree of carboxylation indicates that the porphyrins of the gall-stone may not only come from hemolysed erythrocytes but possibly also from metabolites of disturbed hepatic porphyrin biosynthesis.

Erythropoietic protoporphyria. Hepatic implications

The terminal stages of erythropoietic protoporphyria are recorded. The observations are related to the site of the fundamental lesion and the nature of the biochemical defect. The possibly ominous prognosis in this usually mild condition is emphasized. Apart from congenital porphyria, the porphyrias do not usually confer severe cutaneous lesions. These diseases present to dermatologists because of moderate photosensitivity and are not usually regarded as a risk to life. Dangerous central nervous system involvement may occur, however, in acute intermittent, variegate and hereditary coproporphyrias, while in acquired symptomatic porphyria severe underlying liver dysfunction may occur. Probably the most common familial photosensitizing porphyria is erythropoietic protoporphyria. Recently some deaths from severe liver involvement have been reported in this disease.

'Erythropoietic' protoporphyria and cirrhosis in sisters

The clinical and histopathological features of two sisters with erythropoietic protoporphyria and liver disease are described. They had unusually severe photosensitivity with blistering, and both died at the age of 31 from cirrhosis. The association of erythropoietic protoporphyria with several hepatic abnormalities is discussed.