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Anderson HB, Storandt MH, Kallamadi R, Bande D, Matta A. Iatrogenic Iron Overload Causing Porphyria Cutanea Tarda in a Patient With a Rare Nonsense Heterozygous UROD Gene Mutation. Cureus 2021; 13:e16215. [PMID: 34367815 PMCID: PMC8341219 DOI: 10.7759/cureus.16215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 01/07/2023] Open
Abstract
Porphyria cutanea tarda (PCT) is a rare dermatologic condition characterized by blistering of sun-exposed surfaces and elevated hepatic enzymes. It may infrequently occur as the primary presentation of underlying hemochromatosis. A 61-year-old female with anemia caused by chronic kidney disease and end-stage renal disease on hemodialysis presented with a bullous rash on her hands with associated pruritus. The rash worsened despite conservative treatment. An initial biopsy demonstrated a pauci-inflammatory cell-poor subepidermal cleft. Subsequent workup revealed elevated serum and urine porphyrins, confirming a diagnosis of PCT. Additionally, her skin was darkened and ferritin was elevated. MRI of the liver demonstrated iron overload with genetic testing negative for C282Y or H63D mutations, supporting a diagnosis of secondary hemochromatosis. Further genetic testing revealed that the patient had a rare heterozygous nonsense mutation of the uroporphyrinogen decarboxylase (UROD) gene, for a sequence variant designated c.616C>T, which is predicted to result in premature protein termination (p.Gln206*). PCT occurs due to decreased function of UROD, leading to accumulation of porphyrins causing dermatologic manifestations and liver injury. UROD is inactivated in an iron-dependent process, explaining the mechanistic link between hemochromatosis and PCT.
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Affiliation(s)
- Hallie B Anderson
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | - Michael H Storandt
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | | | - Dinesh Bande
- Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
| | - Abhishek Matta
- Hospital Medicine, Sanford Health, Fargo, USA.,Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, USA
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2
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Singal AK. Porphyria cutanea tarda: Recent update. Mol Genet Metab 2019; 128:271-281. [PMID: 30683557 DOI: 10.1016/j.ymgme.2019.01.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/05/2019] [Accepted: 01/05/2019] [Indexed: 12/13/2022]
Abstract
Porphyria cutanea tarda (PCT) is the most common human porphyria, due to hepatic deficiency of uroporphyrinogen decarboxylase (UROD), which is acquired in the presence of iron overload and various susceptibility factors, such as alcohol abuse, smoking, hepatitis C virus (HCV) infection, HIV infection, iron overload with HFE gene mutations, use of estrogens, and UROD mutation. Patients with familial or type II PCT due to autosomal dominant UROD mutation also require other susceptibility factors, as the disease phenotype requires hepatic UROD deficiency to below 20% of normal. PCT clinically manifests with increased skin fragility and blistering skin lesions on sun exposed areas. The common age of presentation is 5th to 6th decade and occurs slightly more commonly in males. Although mild liver biochemical profile are common, advanced fibrosis and cirrhosis with hepatocellular carcinoma (HCC) can occasionally develop. Screening for HCC using ultrasound examination is recommended in PCT patients, especially with cirrhosis and advanced fibrosis. PCT is effectively and readily treatable with the use of either repeated phlebotomy or use of 100 mg hydroxychloroquine orally twice a week, and both the treatments are equally effective and safe. With the advent of new or direct antiviral agents for HCV infection, treatment of concomitant HCV has become safer and effective. Data are emerging on the benefit of these drugs as monotherapy for both PCT and HCV. After the achievement of remission of PCT, there remains a potential for relapse, especially when the susceptibility factors are not adequately controlled. Scanty data from retrospective and observational studies shows the relapse rate to be somewhat higher after remission with low-dose hydroxychloroquine as compared to phlebotomy induced remission. Future studies are needed on exploring mechanism of action of 4-aminoquinolines, understanding interaction of HCV and PCT, and relapse of PCT on long-term follow-up.
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Affiliation(s)
- Ashwani K Singal
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL, United States.
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3
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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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Pallet N, Karras A, Thervet E, Gouya L, Karim Z, Puy H. Porphyria and kidney diseases. Clin Kidney J 2018; 11:191-197. [PMID: 29644058 PMCID: PMC5888040 DOI: 10.1093/ckj/sfx146] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/20/2017] [Indexed: 01/03/2023] Open
Abstract
The kidneys, after the bone marrow and liver, are third in terms of the amounts of haem synthesized daily. Haem is incorporated into haemoproteins that are critical to renal physiology. In turn, disturbances in haem metabolism interfere with renal physiology and are tightly interrelated with kidney diseases. Acute intermittent porphyria causes kidney injury, whereas medical situations associated with end-stage renal disease, such as porphyrin accumulation, iron overload and hepatitis C, participate in the inhibition of uroporphyrinogen decarboxylase and predispose the individual to porphyria cutanea tarda. Even if some of these interactions have been known for a long time, the clinical situations associated with these interrelations have strikingly evolved over time with the advent of new therapeutic strategies for dialysis therapy and a better understanding of the pathophysiological mechanisms of porphyria-associated kidney disease. Physicians should be aware of these interactions. The aim of this review is to summarize the complex interactions between kidney physiology and pathology in the settings of porphyria and to emphasize their often-underestimated importance.
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Affiliation(s)
- Nicolas Pallet
- INSERM U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France.,Service de Néphrologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Biochimie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Karras
- INSERM U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France.,Service de Néphrologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Thervet
- INSERM U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France.,Service de Néphrologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Gouya
- Centre Francais des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France.,INSERM U1149, CNRS ERL 8252, Centre de Recherche sur l'inflammation, Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Zoubida Karim
- INSERM U1149, CNRS ERL 8252, Centre de Recherche sur l'inflammation, Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Hervé Puy
- Centre Francais des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France.,INSERM U1149, CNRS ERL 8252, Centre de Recherche sur l'inflammation, Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
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5
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Yoshida A, Hagiwara S, Watanabe T, Nishida N, Ida H, Sakurai T, Komeda Y, Yamao K, Takenaka M, Enoki E, Kimura M, Miyake M, Kawada A, Kudo M. Erythropoietic Protoporphyria-related Hepatopathy Successfully Treated with Phlebotomy. Intern Med 2018; 57:2505-2509. [PMID: 30175727 PMCID: PMC6172546 DOI: 10.2169/internalmedicine.0673-17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 27-year-old man bearing an erythropoietic protoporphyria (EPP)-associated ferrochelatase (FECH) mutation was admitted to our hospital for general malaise and marked elevation of the serum levels of hepatobiliary enzymes and bilirubin. Initial treatment with plasma exchange did not reduce the blood protoporphyrin or serum liver enzyme levels, so phlebotomy was started. Surprisingly, weekly phlebotomy normalized the serum levels of liver enzymes, accompanied by a marked reduction in the blood protoporphyrin levels. The clinical course of this case strongly suggests that phlebotomy may be a suitable treatment option for EPP-related hepatopathy.
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Affiliation(s)
- Akihiro Yoshida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Satoru Hagiwara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Hiroshi Ida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Toshiharu Sakurai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Yoriaki Komeda
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
| | - Eisuke Enoki
- Department of Pathology, Kindai University Faculty of Medicine, Japan
| | - Masatomo Kimura
- Department of Pathology, Kindai University Faculty of Medicine, Japan
| | - Masako Miyake
- Department of Dermatology, Kindai University Faculty of Medicine, Japan
| | - Akira Kawada
- Department of Dermatology, Kindai University Faculty of Medicine, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Japan
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6
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Abstract
This is an overview of the cutaneous porphyrias. It is a narrative review based on the published literature and my personal experience; it is not based on a formal systematic search of the literature. The cutaneous porphyrias are a diverse group of conditions due to inherited or acquired enzyme defects in the porphyrin-haem biosynthetic pathway. All the cutaneous porphyrias can have (either as a consequence of the porphyria or as part of the cause of the porphyria) involvement of other organs as well as the skin. The single commonest cutaneous porphyria in most parts of the world is acquired porphyria cutanea tarda, which is usually due to chronic liver disease and liver iron overload. The next most common cutaneous porphyria, erythropoietic protoporphyria, is an inherited disorder in which the accumulation of bile-excreted protoporphyrin can cause gallstones and, rarely, liver disease. Some of the porphyrias that cause blistering (usually bullae) and fragility (clinically and histologically identical to porphyria cutanea tarda) can also be associated with acute neurovisceral porphyria attacks, particularly variegate porphyria and hereditary coproporphyria. Management of porphyria cutanea tarda mainly consists of visible-light photoprotection measures while awaiting the effects of treating the underlying liver disease (if possible) and treatments to reduce serum iron and porphyrin levels. In erythropoietic protoporphyria, the underlying cause can be resolved only with a bone marrow transplant (which is rarely justifiable in this condition), so management consists particularly of visible-light photoprotection and, in some countries, narrowband ultraviolet B phototherapy. Afamelanotide is a promising and newly available treatment for erythropoietic protoporphyria and has been approved in Europe since 2014.
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Affiliation(s)
- Robert Dawe
- Scottish Cutaneous Porphyria Service, Scottish Photodiagnostic Unit, Department of Dermatology, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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7
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Franzon VAZ, Mikilita ES, Camelo FH, Camargo R. Porphyria cutanea tarda in a HIV- positive patient. An Bras Dermatol 2017; 91:520-3. [PMID: 27579753 PMCID: PMC4999116 DOI: 10.1590/abd1806-4841.20163808] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/13/2015] [Indexed: 11/22/2022] Open
Abstract
This is a case report about Porphyria cutanea tarda (PCT) and its relationship with the infection caused by the human immunodeficiency virus (HIV). Cutaneous porphyria is an illness caused by enzymatic modification that results in partial deficiency of uroporphyrinogen decarboxylase (Urod), which may be hereditary or acquired. Several studies suggest that HIV infection associated with cofactors might trigger the development of porphyria cutanea tarda. In this case report, we present a patient infected with HIV, who after the introduction of antiretroviral therapy (ART) enjoyed clinical improvement of porphyria cutanea tarda symptoms.
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Affiliation(s)
| | | | | | - Rosana Camargo
- Pontifícia Universidade Católica do Paraná (PUCPR) - Curitiba (PR), Brazil.,Hospital Oswaldo Cruz - Curitiba (PR), Brazil
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Porphyria Cutanea Tarda in a Patient with End-Stage Renal Disease: A Case of Successful Treatment with Deferoxamine and Ferric Carboxymaltose. Case Rep Nephrol 2017; 2017:4591871. [PMID: 28210512 PMCID: PMC5292176 DOI: 10.1155/2017/4591871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/05/2017] [Indexed: 11/24/2022] Open
Abstract
Porphyria cutanea tarda (PCT) is a rare disease, with a strong association with hepatitis C virus. PCT is particularly problematic in end-stage renal disease patients as they have no renal excretion of porphyrins and these are poorly dialyzed. Also, conventional treatment of PCT is compromised in these patients as hydroxychloroquine is contraindicated, phlebotomies with the stipulated frequency are poorly tolerated in already anaemia-prone patients, and iron-chelating agents are less efficient in removing iron and contribute to worsening anaemia. The authors report a patient on haemodialysis, with hepatitis C infection, that is diagnosed with PCT. Despite the good clinical results with deferoxamine, she became dependent on blood transfusions because of her ferropenic state. Every time oxide iron was started, the patient developed clinical features of the disease, resolving after the suspension of the drug. A decision was made to start the patient on ferric carboxymaltose, which was well tolerated without disease symptoms and need of further blood transfusions. This case suggests that deferoxamine is efficient in treatment of porphyria cutanea tarda. Also, ferric carboxymaltose may be a valuable option for refractory anaemia in patients with this disease and end-stage renal disease, as it seems to provide iron without clinical relapse of the disease.
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Arora S, Young S, Kodali S, Singal AK. Hepatic porphyria: A narrative review. Indian J Gastroenterol 2016; 35:405-418. [PMID: 27796941 DOI: 10.1007/s12664-016-0698-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 09/15/2016] [Indexed: 02/04/2023]
Abstract
Porphyrias are a group of metabolic disorders, which result from a specific abnormality in one of the eight enzymes of the heme biosynthetic pathway. These have been subdivided based on the predominant site of enzyme defect into hepatic and erythropoietic types and based on clinical presentation into acute neurovisceral and cutaneous blistering porphyrias. This review focuses on hepatic porphyrias, which include acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), aminolevulinic acid dehydratase deficiency porphyria (ADP), and porphyria cutanea tarda (PCT). Of these, AIP and ADP are classified as acute porphyria, PCT as cutaneous, while VP and HCP present with both acute and cutaneous clinical manifestations. Porphobilinogen levels in a spot urine sample is the initial screening test for the diagnosis of acute hepatic porphyria, and plasma with spot urine porphyrin levels is the initial screening test to approach patients suspected of cutaneous porphyria. Specific biochemical porphyrin profile for each porphyria helps in determining the specific diagnosis. Pain relief and elimination of triggering agents are the initial steps in managing a patient presenting with an acute attack. Intravenous glucose administration terminates the mild episode of acute porphyria, with intravenous hemin needed for management of moderate to severe episodes. Liver transplantation is curative and may be needed for patients with a life-threatening acute porphyria attack or for patients with recurrent acute attacks refractory to prophylactic treatment. Of the cutaneous porphyrias, PCT is the most common and is frequently associated with a combination of multiple susceptibility factors such as alcohol use, smoking, hepatitis C virus infection, HIV infection, estrogen use, and mutations of the hemochromatosis gene. Regular phlebotomy schedule and low-dose hydroxychloroquine are effective and safe treatment options for management of PCT.
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Affiliation(s)
- Sumant Arora
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA
| | - Steven Young
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA
| | - Sudha Kodali
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA.,Division of Gastroenterology and Hepatology, UAB University of Alabama in Birmingham, Birmingham, AL, USA
| | - Ashwani K Singal
- Department of Internal Medicine, UAB University of Alabama in Birmingham, Birmingham, AL, USA. .,Division of Gastroenterology and Hepatology, UAB University of Alabama in Birmingham, Birmingham, AL, USA.
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