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Peoc'h K, Manceau H, Karim Z, Wahlin S, Gouya L, Puy H, Deybach JC. Hepatocellular carcinoma in acute hepatic porphyrias: A Damocles Sword. Mol Genet Metab 2019; 128:236-241. [PMID: 30413387 DOI: 10.1016/j.ymgme.2018.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/05/2018] [Accepted: 10/05/2018] [Indexed: 02/08/2023]
Abstract
Porphyrias are inherited diseases with low penetrance affecting the heme biosynthesis pathway. Acute intermittent porphyria (AIP), variegate porphyria (VP) and hereditary coproporphyria (HCP) together constitute the acute hepatic porphyrias (AHP). These diseases have been identified as risk factors for primary liver cancers (PLC), mainly hepatocellular carcinoma (HCC: range 87-100%) but also cholangiocarcinoma, alone or combination with HCC. In AHP, HCC annual incidence rates range from 0.16 to 0.35% according to the populations studied. Annual incidence rates are higher in Swedish and Norwegian patients, due to a founder effect. It increases above age 50. The pathophysiology could include both direct toxic effects of heme precursors, particularly δ-aminolevulinic acid (ALA), compound heterozygosity for genes implied in heme biosynthesis pathway or the loss of oxidative stress homeostasis due to a relative lack of heme. The high HCC incidence justifies radiological surveillance in AHP patients above age 50. Efforts are made to find new biological non-invasive markers. In this respect, we describe here the first report of PIVKA-II clinical utility in the follow-up of an AIP patient that develop an HCC. In this manuscript we reviewed the epidemiology, the physiopathology, and the screening strategy of HCC in AHP.
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Affiliation(s)
- Katell Peoc'h
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS, Biochimie Clinique, Hôpital Beaujon, F-92110 Clichy, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Hana Manceau
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS, Biochimie Clinique, Hôpital Beaujon, F-92110 Clichy, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Zoubida Karim
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Staffan Wahlin
- Department of Gastroenterology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; Department of Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Laurent Gouya
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
| | - Hervé Puy
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France.
| | - Jean-Charles Deybach
- UMRs 1149, Centre de Recherche sur l'Inflammation, Institut National de la Santé et de la Recherche Médicale, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, HUPNVS Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Laboratory of Excellence Gr-Ex, France; Université Paris Diderot, UFR de Médecine Xavier Bichat, F-75018 Paris, France
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Corden MH, Frediani J, Xu F, Liu QY, Chen SYE, Bissell DM, Ostrom K. An 18-Year-Old With Acute-on-Chronic Abdominal Pain. Pediatrics 2018; 141:peds.2017-1332. [PMID: 29636397 DOI: 10.1542/peds.2017-1332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 11/24/2022] Open
Abstract
An 18-year-old woman with a complex past medical history presented with 2 days of vomiting and lower abdominal pain. She had been admitted for the majority of the previous 5 months for recurrent pancreatitis and had undergone a cholecystectomy. Additional symptoms included nausea, anorexia, constipation, and a 40-lb weight loss over 4 months. She appeared uncomfortable, and an examination was remarkable for tachycardia, hypertension, and diffuse abdominal tenderness to light palpation. Her initial laboratory test results revealed mildly elevated liver enzymes (aspartate aminotransferase 68 U/L, alanine aminotransferase 80 U/L) and a normal lipase. She was admitted for pain control and nutritional support. Over the next few days, the lipase increased to 1707 U/L. Despite optimizing her management for acute pancreatitis, the patient's symptoms persisted. Further history gathering and laboratory testing ultimately revealed her diagnosis. Our expert panel reviews her hospital course and elucidates the management of our eventual diagnosis.
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Affiliation(s)
- Mark H Corden
- Division of Hospital Medicine and .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jamie Frediani
- Children's Center for Cancer and Blood Diseases, Department of Pediatrics, and
| | - Frank Xu
- The Pediatric Group of Southern California, Agoura Hills, California
| | - Quin Y Liu
- Division of Gastroenterology, Digestive Diseases Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Shiu-Yi Emily Chen
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - D Montgomery Bissell
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Kathleen Ostrom
- Division of Hospital Medicine and.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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Acute intermittent porphyria after right hemi-colectomy. Int J Surg Case Rep 2017; 40:116-119. [PMID: 28988019 PMCID: PMC5633257 DOI: 10.1016/j.ijscr.2017.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/17/2017] [Accepted: 09/17/2017] [Indexed: 11/24/2022] Open
Abstract
Acute intermittent porphyria is rare. High index of suspicion is needed to diagnose acute intermittent porphyria in a patient with abdominal pain, neuro-psychiatric manifestations and hyponatremia after surgery. Once suspected, prompt intensive care management should include high calorie intake, symptomatic treatment of hyponatremia, use of safe medications and careful fluid-electrolyte monitoring in order to avoid serious complications and mortality.
Introduction Acute intermittent porphyria is a rare autosomal dominant metabolic disease. It is caused by a genetic mutation that results in deficiency of porphobilinogen deaminase enzyme, the third enzyme in heme biosynthesis. Acute intermittent porphyria precipitated by surgery is very rare. Case presentation We present a 24 year-old woman who developed acute intermittent porphyria five days after right hemi-colectomy. Her presentation included neuro-visceral and psychiatric manifestations, and severe hyponatremia. She received critical care symptomatic management including mechanical ventilation. The diagnosis was based on a positive urine test for porphobilinogen and confirmed by the presence of a heterozygous mutation in the hydroxyrmethylbilane synthase (HMBS) gene (c.760delC p Leu254). Discussion Acute intermittent porphyria is the most common and life threatining type of acute porphyrias. It is more common in women and usually presents after puberty with acute abdominal pain and diverse neuro-psychiatric manifestations that can be confused with several surgical and medical diseases. Acute intermittent porphyria after surgery is most likely due to postoperative pain and low-calorie intake. Once suspected, prompt ICU management including high calorie intake are necessary to avoid serious complications and mortality before starting definitive treatment with hematin. Conclusion Acute intermittent porphyria should be suspected in any patient, particularly young women, who develop diverse neuro-visceral and psychiatric manifestations and hyponatremia after surgery.
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Alfadhel M, Saleh N, Alenazi H, Baffoe-Bonnie H. Acute intermittent porphyria caused by novel mutation in HMBS gene, misdiagnosed as cholecystitis. Neuropsychiatr Dis Treat 2014; 10:2135-7. [PMID: 25419136 PMCID: PMC4235503 DOI: 10.2147/ndt.s73070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Acute intermittent porphyria (AIP) is an autosomal dominant neurovisceral inherited disorder due to a defect in the heme biosynthesis pathway. Misdiagnosis of the porphyrias is not uncommon. CASE REPORT We present a case of a 26-year-old female with suspected acute cholecystitis, mental status changes, and seizures. Biochemical and molecular investigations confirmed the diagnosis of AIP by findings of elevated urinary porphobilinogen, 5-aminolevulinic acid, and total porphyrins. DNA molecular testing showed a novel heterozygous mutation (c. 760delC p.L254X) in the exon11 of the HMBS gene. To the best of our knowledge, this is the first report of a misdiagnosis of AIP presenting with acute cholecystitis. CONCLUSION Clinicians are alerted to consider the possibility of AIP in an adult presenting with an acute abdomen, features of cholecystitis, and neuropsychiatric manifestations.
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Affiliation(s)
- Majid Alfadhel
- Division of Genetics, Department of Pediatrics, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia ; College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Neam Saleh
- Division of General Medicine, Department of Medicine, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Helal Alenazi
- Division of General Medicine, Department of Medicine, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Henry Baffoe-Bonnie
- Division of General Medicine, Department of Medicine, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
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González Estrada A, García-Morillo S, Gómez Morales L, Stiefel García-Junco P. Chronic elevation of liver enzymes in acute intermittent porphyria initially misdiagnosed as autoimmune hepatitis. Int J Hepatol 2011; 2011:392049. [PMID: 22007312 PMCID: PMC3190104 DOI: 10.4061/2011/392049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 12/03/2010] [Accepted: 12/27/2010] [Indexed: 11/20/2022] Open
Abstract
Autoimmune hepatitis is a disease characterized by an elevation of liver enzymes, as well as specific autoantibodies. It is more common in women than men. We describe a 32-year-old woman with elevated transaminases, autoantibodies, and a liver biopsy result suggestive of autoimmune hepatitis. The indicated treatment was administered without showing a satisfactory response. The patient had a family history of acute intermittent porphyria (AIP) so we decided to begin treatment with hematin, achieving a complete remission of the symptoms. Acute intermittent porphyria is a rare condition characterized by neurovisceral symptoms, abdominal pain being the most common of them. The disease has a higher prevalence among young women and certain European countries such as Sweden, Great Britain, and Spain. A correct diagnosis and prompt treatment are essential because patients affected by AIP must have a strict followup due to the fatal outcome of the outbreaks.
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Affiliation(s)
- A. González Estrada
- Internal Medicine, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain,*A. González Estrada:
| | - S. García-Morillo
- Internal Medicine, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain
| | - L. Gómez Morales
- Internal Medicine, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain
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Raigal Martín MY, Lledó Navarro JL, Raigal Martín JM, Muriel Patino E, Pérez Pérez E, Moreno Prat M. [Acute intermittent porphyria and chronic transaminase elevation]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:225-8. [PMID: 18405488 DOI: 10.1157/13117900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Acute intermittent porphyria is an autosomal dominant inherited disorder resulting from a deficiency of porphobilinogen deaminase activity, the third enzyme in the heme biosynthesis pathway. This disease is uncommon, although the prevalence is higher in asymptomatic heterozygotic carriers; however, this prevalence is difficult to establish because of the absence of symptoms. Although acute intermittent porphyria is a multisystemic disease, its most common form of presentation is abdominal pain and neurological or mental symptoms, which can sometimes be due to precipitating factors such as reduced energy intake, smoking, alcohol, some drugs, and stress. Diagnosis can be made by testing urinary porphobilinogen levels, with subsequent measurement of enzyme activity and DNA testing. Treatment is based on prevention of porphyria attacks by avoiding precipitating factors and early administration of intravenous glucose or hemin therapy. We present the case of a patient diagnosed with acute intermittent porphyria based on study of chronic mild alanine aminotransferase (ALT) elevation.
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