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Roberti R, Rocca M, Iannone LF, Gasparini S, Pascarella A, Neri S, Cianci V, Bilo L, Russo E, Quaresima P, Aguglia U, Di Carlo C, Ferlazzo E. Status epilepticus in pregnancy: a literature review and a protocol proposal. Expert Rev Neurother 2022; 22:301-312. [PMID: 35317697 DOI: 10.1080/14737175.2022.2057224] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Status epilepticus (SE) in pregnancy represents a life-threatening medical emergency for both mother and fetus. Pregnancy-related pharmacokinetic modifications and the risks for fetus associated with the use of antiseizure medications (ASMs) and anesthetic drugs complicate SE management. No standardized treatment protocol for SE in pregnancy is available to date. AREAS COVERED In this review, we provide an overview of the current literature on the management of SE in pregnancy and we propose a multidisciplinary-based protocol approach. EXPERT OPINION Literature data are scarce (mainly anecdotal case reports or small case series). Prompt treatment of SE during pregnancy is paramount and a multidisciplinary team is needed. Benzodiazepines are the drugs of choice for SE in pregnancy. Levetiracetam and phenytoin represent the most suitable second-line agents. Valproic acid should be administered only if other ASMs failed and preferably avoided in the first trimester of pregnancy. For refractory SE, anesthetic drugs are needed, with propofol and midazolam as preferred drugs. Magnesium sulfate is the first-line treatment for SE in eclampsia. Termination of pregnancy, via delivery or abortion, is recommended in case of failure of general anesthetics. Further studies are needed to identify the safest and most effective treatment protocol.
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Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Morena Rocca
- Obstetrics and Gynecology Unit, "Pugliese-ciaccio" Hospital of Catanzaro, Catanzaro, Italy
| | | | - Sara Gasparini
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Angelo Pascarella
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Sabrina Neri
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy
| | - Leonilda Bilo
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Paola Quaresima
- Department of Experimental and Clinical Medicine, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Umberto Aguglia
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Costantino Di Carlo
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, Federico II University, Naples, Italy
| | - Edoardo Ferlazzo
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
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Gerischer LM, Scheibe F, Nümann A, Köhnlein M, Stölzel U, Meisel A. Acute porphyrias - A neurological perspective. Brain Behav 2021; 11:e2389. [PMID: 34661997 PMCID: PMC8613433 DOI: 10.1002/brb3.2389] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/21/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023] Open
Abstract
Acute hepatic porphyrias (AHP) can cause severe neurological symptoms involving the central, autonomic, and peripheral nervous system. Due to their relative rarity and their chameleon-like presentation, delayed diagnosis and misdiagnosis are common. AHPs are genetically inherited disorders that result from heme biosynthesis enzyme deficiencies and comprise four forms: acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), and ALA-dehydratase porphyria (ALADP). Depending on the clinical presentation, the main differential diagnoses are Guillain-Barré syndrome and autoimmune encephalitis. Red flags that could raise the suspicion of acute porphyria are neurological symptoms starting after severe (abdominal) pain, in association with reddish urine, hyponatremia or photodermatitis, and the presence of encephalopathy and/or axonal neuropathy. We highlight the diagnostic difficulties by presenting three cases from our neurological intensive care unit and give a comprehensive overview about the diagnostic findings in imaging, electrophysiology, and neuropathology.
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Affiliation(s)
- Lea M. Gerischer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| | - Franziska Scheibe
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| | - Astrid Nümann
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
| | - Martin Köhnlein
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
| | - Ulrich Stölzel
- Department of Internal Medicine II, Porphyria Center SaxoniaKlinikum Chemnitz gGmbHChemnitzGermany
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
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Oliveira Santos M, Leal Rato M. Neurology of the acute hepatic porphyrias. J Neurol Sci 2021; 428:117605. [PMID: 34375916 DOI: 10.1016/j.jns.2021.117605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/01/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Abstract
Porphyrias are a set of rare inherited metabolic disorders, each of them representing a defect in one of the eight enzymes in the haem biosynthetic pathway resulting in the accumulation of organic compounds called porphyrins. Acute hepatic porphyrias (AHP) are those in which the enzyme deficiency occurs in the liver, of which acute intermittent porphyria is by far the most common subtype. Neurology of the AHP is still challenging in practice, and patients rarely receive the correct diagnosis early in the disease course. For AHP, which primarily affects the central and peripheral nervous system, the cause of symptoms seems to be the increased production of neurotoxic precursors, in particular delta-aminolaevulinic acid and porphobilinogen. Neurological complications usually result from severe episodes of acute attacks. The neurologic hallmark of porphyrias is an acute predominantly motor axonal neuropathy resembling a Guillain-Barré syndrome that generally occurs after the onset of other clinical features such as abdominal pain and central nervous system manifestations. Neuropsychiatric syndromes, seizures, encephalopathy, and cerebrovascular disorders are among the possible central nervous system presentations. Therapeutic approach to AHP is divided into management and prophylaxis of an acute attack, including long standing options such as intravenous hematin and new therapeutic agents such as givosiran.
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Affiliation(s)
- Miguel Oliveira Santos
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Institute of Physiology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
| | - Miguel Leal Rato
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Institute of Pharmacology and Neurosciences, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Rajiv KR, Radhakrishnan A. Status epilepticus in pregnancy - Can we frame a uniform treatment protocol? Epilepsy Behav 2019; 101:106376. [PMID: 31303443 DOI: 10.1016/j.yebeh.2019.06.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 06/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND There is lack of uniform treatment protocol for status epilepticus (SE) in pregnancy, with majority of data being limited to individual cases or case series. Devising a uniform treatment protocol will facilitate prompt control of SE in pregnancy and reduce adverse maternal and fetal outcomes. METHODS Literature search was done in various databases including PubMed, CINAHL, EMBASE, TRIP, and the gray literature, including relevant organizational websites, for the topics "Status Epilepticus" and "Pregnancy". English language original research articles, case reports, and systematic reviews that were published in the last 18 years (2000-2018) and addressed SE in relation to pregnancy (i.e., antepartum, labor, or postpartum) were considered for inclusion. RESULTS Over the past 15 years, a total of seven articles reporting 29 cases of SE related to pregnancy, satisfying the inclusion criteria were analyzed. The most common cause of SE was posterior reversible encephalopathy syndrome (PRES)/reversible cerebral vasoconstriction syndrome (RCVS) spectrum (n = 11, 38%), followed by cortical venous sinus thrombosis (CVT) and autoimmune encephalitis (n = 5, 17%). Twenty-three out of 29 cases (79%) had good maternal outcomes in terms of recovery to baseline. Seventeen fetuses (58%) were delivered at term and seven at preterm (2.4%). First-line agent used was lorazepam in 15 patients (52%) and midazolam in two patients (7%). The most common antiepileptic drug (AED) and anesthesia used for treatment of SE and refractory SE were phenytoin/fosphenytoin (n = 21, 72%) and midazolam (n = 12, 52%), respectively. In all cases due to eclampsia (n = 5), magnesium sulfate was the preferred first-line drug. CONCLUSION Management of SE in pregnancy is influenced by etiology of SE and duration of pregnancy. It carries a good prognosis if detected early and treated appropriately. Large-scale multicentric studies are warranted for formulating definite guidelines for management of SE in pregnancy. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Keni Ravish Rajiv
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, SreeChitraTirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ashalatha Radhakrishnan
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, SreeChitraTirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
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Rajiv KR, Radhakrishnan A. Status epilepticus in pregnancy: Etiology, management, and clinical outcomes. Epilepsy Behav 2017; 76:114-119. [PMID: 28899640 DOI: 10.1016/j.yebeh.2017.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 07/03/2017] [Accepted: 07/03/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Status epilepticus (SE) in pregnancy carries significant risk to both mother and fetus. There is limited literature available on SE occurring in pregnancy world-over, with majority being from obstetric centers. METHODS All women who developed SE related to pregnancy (gestation, labor, or puerperium) between January 2000 and December 2016 were included in the study. Data were collected from our SE registry, maintained, and archived in the institute. The variables influencing the maternal and fetal outcome were compared using Student's t-test for continuous variables and Fisher's exact test for discrete variables. RESULTS During the 16-year study period, a total of 348 SE events were recorded in 294 patients. Among these, there were 138 women, of which 17 had SE related to pregnancy. The etiology of SE was remote symptomatic in two and acute symptomatic in 15 patients. The various causes detected after initial evaluation for acute symptomatic SE were eclampsia (n=4), posterior reversible encephalopathy syndrome due to various causes other than eclampsia (n=6), cortical venous thrombosis (n=3), subarachnoid hemorrhage (n=1), and NMDA receptor antibody-mediated encephalitis (n=1).13 of 17 women with SE (76%) had good outcome. Majority of the fetuses had good outcomes, i.e., Category 1 (n=9, 57%). Duration of intensive care unit stay (p=0.029) and Status Epilepticus Severity Score (p=0.0324) at admission, were found to be significantly associated with poor outcomes. CONCLUSION In any patient presenting with SE occurring in pregnancy, though eclampsia is presumed to be the most common overall cause; it is relevant to consider other etiologies such as posterior reversible encephalopathy syndrome, cortical venous thrombosis, and autoimmune encephalitis especially in cases presenting with refractory SE. Posterior reversible encephalopathy may occur in pregnancy due to diverse etiologies other than eclampsia.
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Affiliation(s)
- Keni Ravish Rajiv
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ashalatha Radhakrishnan
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
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Zhang J, Hu Y, Zheng J, Gao J, Hou H, Liu N, Wang Y. Treatment of acute intermittent porphyria during pregnancy and posterior reversible encephalopathy syndrome after delivery: A case report. Exp Ther Med 2017; 14:5554-5556. [PMID: 29285091 DOI: 10.3892/etm.2017.5212] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/23/2017] [Indexed: 11/05/2022] Open
Abstract
Acute intermittent porphyria (AIP) is a rare inherited disorder of heme metabolism. It has the ability to trigger posterior reversible encephalopathy syndrome (PRES), a rare acute neurologic condition that is characterized by acute neurological symptoms. Pregnancy may induce AIP attacks. The present report describes the case of a pregnant woman with AIP. The patient was treated with heme-arginate during pregnancy and successfully delivered a healthy baby. Following delivery, the patient presented with PRES and experienced generalized seizures. Treatment including arginine hemoglobin, calcium gluconate and sodium chloride was administered. The symptoms of epilepsy did not recur. Magnetic resonance imaging of the head demonstrated that the bilateral occipital lobe lesions were significantly reduced in size following the treatment. In the present report, it was demonstrated that administration of heme-arginate for AIP during pregnancy is safe. Timely administration of arginine hemoglobin, calcium gluconate and sodium chloride may more efficiently improve the clinical status in AIP patients diagnosed with PRES who experience generalized seizures.
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Affiliation(s)
- Jian Zhang
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Yiting Hu
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Jimin Zheng
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Juncha Gao
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Hongtao Hou
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Na Liu
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Yuzhen Wang
- Department of Gastroenterology and Hepatology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
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Lu YT, Hsu CW, Tsai WC, Cheng MY, Shih FY, Fu TY, Chuang YC, Tsai MH. Status epilepticus associated with pregnancy: A cohort study. Epilepsy Behav 2016; 59:92-7. [PMID: 27116537 DOI: 10.1016/j.yebeh.2016.03.034] [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: 11/16/2015] [Revised: 03/23/2016] [Accepted: 03/25/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a neurological emergency associated with a high mortality rate and long-term cognitive sequelae. Status epilepticus in pregnancy poses a tremendous threat to both mother and fetus, making a correct diagnosis and treatment a challenging task for clinicians. The prevalence, underlying etiology, and outcomes of pregnancy-related SE remain largely unknown. METHODS We retrospectively studied all SE episodes (n=366) in patients admitted to our neurological ICU over a period of 8.5years. The patients who developed SE during pregnancy and within 6months after delivery were considered to have pregnancy-related SE. Patients with eclampsia were not included as they were usually cared for in our obstetric unit. RESULTS Seven patients with pregnancy-related SE were identified (2.1% of all cases of SE), with the majority (85%) occurring de novo except for one patient who had a previous history of epilepsy-related SE due to withdrawal of antiepileptic medication. In terms of etiology, limbic encephalitis and cerebral venous sinus thrombosis were the two main etiologies of de novo SE associated with pregnancy. The overall mortality rate was 28.5% at discharge, and poor outcomes were especially noted in the patients with limbic encephalitis compared to other etiologies. CONCLUSIONS Pregnancy-associated SE is rare and predominantly occurs in patients without a history of epilepsy. An autoimmune etiology should be considered in pregnant patients with de novo SE, which was associated with poor outcomes. Thorough investigations and prompt treatment according to the etiology may be required to improve the final outcomes of both mother and fetus.
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Affiliation(s)
- Yan-Ting Lu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Che-Wei Hsu
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wan-Chen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Mei-Yun Cheng
- Department of Neurology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Fu-Yuan Shih
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ting-Ying Fu
- Department of Pathology and Laboratory Medicine, Kaohsiung Veteran General Hospital, Kaohsiung, Taiwan
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Center for Translational Research in Biomedical Sciences, Kaohsiung, Taiwan; Department of Biological Science, National Sun Yet-Sen University, Kaohsiung, Taiwan; Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Nursing, Meiho University, Pingtung, Taiwan.
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Electroencephalography of encephalopathy in patients with endocrine and metabolic disorders. J Clin Neurophysiol 2014; 30:505-16. [PMID: 24084183 DOI: 10.1097/wnp.0b013e3182a73db9] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with acute alteration in mental status from encephalopathy because of underlying metabolic-toxic or endocrine abnormalities are frequently seen in the acute hospital setting. A rapid diagnosis and correction of the underlying cause is essential as a prolonged state of encephalopathy portends a poor outcome. Correct diagnosis and management remain challenging because several encephalopathies may present similarly, and further laboratory, imaging, or other testing may not always reveal the underlying cause. EEG provides rapid additional information on the encephalopathic patient. It may help establish the diagnosis and is indispensable for identifying nonconvulsive status epilepticus, an important possible complication in this context. The EEG may assist the clinician in gauging the severity of brain dysfunction and may aid in predicting outcome. This review summarizes the current knowledge on EEG findings in selected metabolic and endocrine causes of encephalopathy and highlights distinct EEG features associated with particular etiologies.
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Tran TPY, Leduc K, Savard M, Dupré N, Rivest D, Nguyen DK. Acute porphyria presenting as epilepsia partialis continua. Case Rep Neurol 2013; 5:116-24. [PMID: 23898283 PMCID: PMC3724138 DOI: 10.1159/000353279] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Purpose The porphyrias are a defect in the biosynthesis of heme which can be associated with different neurological symptoms during acute attacks such as peripheral neuropathy, mental disturbance and seizures. So far, there have only been a few case reports of status epilepticus, none of which were of epilepsia partialis continua (EPC). We present here two cases of hereditary coproporphyria (HCP) manifesting EPC as part of the clinical presentation. Method The patients’ medical charts, EEG and imaging studies were carefully reviewed. Results Case 1 is a 49-year-old male who first presented a tonic-clonic seizure. Case 2 is a 30-year-old male who came to the emergency room for a convulsive status epilepticus. Both evolved to EPC over the next days. EPC persisted despite several antiepileptic drug trials. Diagnosis of HCP was confirmed by a high level of urine, fecal and serum porphyrins in both cases and by genetic testing in one. Over the last 3 years, the first patient has continued to present non-disabling EPC and has had four tonic-clonic seizures associated with alcohol consumption. The second patient died from brain edema one month and half after admission. Conclusion Acute porphyrias should be included in the differential diagnosis of new onset status epilepticus, including EPC. Their recognition is important as it modifies significantly patient management, since many anticonvulsants are porphyrogenic.
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Affiliation(s)
- Thi Phuoc Yen Tran
- Service de Neurologie, Hôpital Notre-Dame, Centre Hospitalier Universitaire de Montréal, Montréal, Qué., Canada
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Tollånes MC, Aarsand AK, Sandberg S. Excess risk of adverse pregnancy outcomes in women with porphyria: a population-based cohort study. J Inherit Metab Dis 2011; 34:217-23. [PMID: 20978938 PMCID: PMC3026662 DOI: 10.1007/s10545-010-9231-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 10/01/2010] [Accepted: 10/07/2010] [Indexed: 12/19/2022]
Abstract
The porphyrias comprise a heterogeneous group of rare, primarily hereditary, metabolic diseases caused by a partial deficiency in one of the eight enzymes involved in the heme biosynthesis. Our aim was to assess whether acute or cutaneous porphyria has been associated with excess risks of adverse pregnancy outcomes. A population-based cohort study was designed by record linkage between the Norwegian Porphyria Register, covering 70% of all known porphyria patients in Norway, and the Medical Birth Registry of Norway, based on all births in Norway during 1967-2006. The risks of the adverse pregnancy outcomes preeclampsia, delivery by caesarean section, low birth weight, premature delivery, small for gestational age (SGA), perinatal death, and congenital malformations were compared between porphyric mothers and the rest of the population. The 200 mothers with porphyria had 398 singletons during the study period, whereas the 1,100,391 mothers without porphyria had 2,275,317 singletons. First-time mothers with active acute porphyria had an excess risk of perinatal death [adjusted odds ratio (OR) 4.9, 95% confidence interval (CI) 1.5-16.0], as did mothers with the hereditable form of porphyria cutanea tarda (PCT) (3.0, 1.2-7.7). Sporadic PCT was associated with an excess risk of SGA [adjusted relative risk (RR) 2.0, 1.2-3.4], and for first-time mothers, low birth weight (adjusted OR 3.4, 1.2-10.0) and premature delivery (3.5, 1.2-10.5) in addition. The findings suggest women with porphyria should be monitored closely during pregnancy.
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Affiliation(s)
- Mette Christophersen Tollånes
- The Norwegian Porphyria Centre (NAPOS), Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway.
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Siegesmund M, van Tuyll van Serooskerken AM, Poblete-Gutiérrez P, Frank J. The acute hepatic porphyrias: current status and future challenges. Best Pract Res Clin Gastroenterol 2010; 24:593-605. [PMID: 20955962 DOI: 10.1016/j.bpg.2010.08.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 08/26/2010] [Accepted: 08/28/2010] [Indexed: 01/31/2023]
Abstract
The porphyrias are predominantly inherited metabolic disorders, which result from a specific deficiency of one of the eight enzymes along the pathway of haem biosynthesis. Historically, they have been classified into hepatic and erythropoietic forms, based on the primary site of expression of the prevailing dysfunctional enzyme. From a clinical point of view, however, it is more convenient to subdivide them into acute and non-acute porphyrias, thereby primarily considering the potential occurrence of life-threatening acute neurovisceral attacks. Unrecognised or untreated, such an acute porphyric attack is associated with a significant mortality of up to 10%. The acute hepatic porphyrias comprise acute intermittent porphyria, variegate porphyria, hereditary coproporphyria, and δ-aminolevulinic acid dehydratase deficiency porphyria. Making a precise diagnosis may be difficult because the different types of porphyrias may show overlapping clinical and biochemical characteristics. To date, the therapeutic possibilities are limited and mainly symptomatic. In this overview we report on what is currently known about pathogenesis, clinic, diagnostics, and therapy of the acute hepatic porphyrias. We further point out actual and future challenges in the management of these diseases.
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Affiliation(s)
- Marko Siegesmund
- Department of Dermatology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Aladdin Y, Gross DW. Refractory status epilepticus during pregnancy secondary to cavernous angioma. Epilepsia 2008; 49:1627-9. [DOI: 10.1111/j.1528-1167.2008.01639.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pischik E, Kazakov V, Kauppinen R. Is screening for urinary porphobilinogen useful among patients with acute polyneuropathy or encephalopathy? J Neurol 2008; 255:974-9. [PMID: 18574620 DOI: 10.1007/s00415-008-0779-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Revised: 10/02/2007] [Accepted: 10/16/2007] [Indexed: 11/30/2022]
Abstract
Acute porphyrias are a group of inherited metabolic disorders representing overproduction syndromes with the formation of neurotoxic haem precursors. Clinical manifestations consist of acute attacks, which include abdominal pain, dysautonomia, mental symptoms, polyneuropathy and seizures mimicking many other acute neurological disorders.Porphyrin metabolites were screened in 108 patients with acute polyneuropathy or encephalopathy associated with pain and/or dysautonomia, who attended neurological wards, in order to evaluate the number of patients with acute porphyria.Urinary porphyrins and their precursors were increased in 21% of the cases. Surprisingly many patients (11%) had previously undiagnosed acute porphyria. Half of these patients had had mild to moderate symptoms of acute porphyria previously. Secondary porphyrinuria, which was mainly transient coproporphyrinuria because of hepatopathy, was also common (10%). Of the 108 patients studied, the levels of urinary porphyrins or their precursors were normal in the majority (79%) of the cases, who commonly had Guillain-Barré syndrome (40%). Epileptic seizures were also frequent (18%), but none of the patients with acute porphyria had solely epileptic seizures without prolonged confusion (>or= 1 day).Based on our findings, acute inherited porphyria is not infrequent among the selected group of neurological patients and screening of urinary PBG is cost-beneficial. Since the correct diagnosis of a hereditary disease is essential, genetic screening should be performed whenever possible for patients with clinically and biochemically confirmed acute porphyria.
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Affiliation(s)
- Elena Pischik
- Research Program in Molecular Medicine, Porphyria Research Centre, Biomedicum-Helsinki, C427a, University of Helsinki, 700, Haartmaninkatu 8, 00029 HUS Helsinki, Finland.
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Arméstar F, Catalán B, Pérez Picañol E, Mesalles E. Hiponatremia grave secundaria a secreción inadecuada de hormona antidiurética en un paciente con porfiria aguda intermitente. Med Clin (Barc) 2007; 128:757-8. [PMID: 17565885 DOI: 10.1157/13106135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Weinzierl A, Brezinka C, Engelhardt K. Unusual Manifestation of Acute Hepatic Porphyria in Pregnancy. Fetal Diagn Ther 2006; 22:136-8. [PMID: 17139171 DOI: 10.1159/000097113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 04/18/2006] [Indexed: 11/19/2022]
Abstract
A 22-year-old para I/gravida II developed psychiatric symptoms at 8 weeks of gestation. Subsequently neurological symptoms with seizures developed leading to a status epilepticus with continuing seizures at week 14. Anticonvulsive therapy had little effect in alleviating the seizures and the condition of the patient rapidly deteriorated. A sudden reddening of her urine lead to the diagnosis of acute hepatic porphyria confirmed by laboratory tests. After extensive discussion with the patient's family it was decided to terminate the pregnancy at week 16. Within hours after pregnancy termination the seizures stopped and the patient recovered without any neurological deficits. Acute hepatic porphyria can be triggered by pregnancy and usually presents with gastrointestinal symptoms and personality changes. In its rare neurological manifestation it can lead to untreatable convulsions which leave no option but to terminate the pregnancy.
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Affiliation(s)
- A Weinzierl
- Department of Gynecology and Obstetrics, University of Innsbruck, Innsbruck, Austria.
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