1
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Peterlin P, Bonnelye J, Garnier A, Le Bourgeois A, Guillaume T, Jullien M, Dutartre H, Le Moigne M, Schmitt C, Gouya L, Poli A, Barbarot S, Chevallier P. Successful treatment of congenital erythropoietic porphyria using matched unrelated hematopoietic stem cell transplantation in an adult: A case report. Skin Health Dis 2024; 4:e342. [PMID: 38577034 PMCID: PMC10988712 DOI: 10.1002/ski2.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/02/2024] [Accepted: 01/19/2024] [Indexed: 04/06/2024]
Abstract
Congenital erythropoietic porphyria (CEP), or Gunther disease, is a rare genetic disease responsible for severe dermatologic, hepatic and/or haematological damages related to the deficient activity of the uroporphyrinogen III synthase. Allogeneic stem cell transplantation (Allo-SCT) represents the only curative treatment and few allotransplanted cases have been reported in children but not in adults. Here we report for the first time the successful cure of a 46-year old man with CEP with a 5-year follow-up after Allo-SCT.
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Affiliation(s)
- Pierre Peterlin
- Clinical HematologyNantes University HospitalNantesFrance
- Equipe 12 CRCI2NA ‐ INSERM UMR1307CNRS UMR 6075CRCINA IRS‐UNUniversity of NantesNantesFrance
| | - Julia Bonnelye
- Dermatology DepartmentReference Center for Cutaneous PorphyriasNantes University HospitalNantesFrance
| | - Alice Garnier
- Clinical HematologyNantes University HospitalNantesFrance
| | | | - Thierry Guillaume
- Clinical HematologyNantes University HospitalNantesFrance
- Equipe 12 CRCI2NA ‐ INSERM UMR1307CNRS UMR 6075CRCINA IRS‐UNUniversity of NantesNantesFrance
| | - Maxime Jullien
- Clinical HematologyNantes University HospitalNantesFrance
| | - Hervé Dutartre
- Dermatology DepartmentReference Center for Cutaneous PorphyriasNantes University HospitalNantesFrance
| | - Marie Le Moigne
- Dermatology DepartmentReference Center for Cutaneous PorphyriasNantes University HospitalNantesFrance
| | - Caroline Schmitt
- Reference Center for Rare Diseases PorphyriasLouis Mourier HospitalAP‐HP, Colombes and Research Center of InflammationUMR1149 INSERMUniversité de ParisParisFrance
| | - Laurent Gouya
- Reference Center for Rare Diseases PorphyriasLouis Mourier HospitalAP‐HP, Colombes and Research Center of InflammationUMR1149 INSERMUniversité de ParisParisFrance
| | - Antoine Poli
- Reference Center for Rare Diseases PorphyriasLouis Mourier HospitalAP‐HP, Colombes and Research Center of InflammationUMR1149 INSERMUniversité de ParisParisFrance
| | - Sebastien Barbarot
- Dermatology DepartmentReference Center for Cutaneous PorphyriasNantes University HospitalNantesFrance
| | - Patrice Chevallier
- Clinical HematologyNantes University HospitalNantesFrance
- Equipe 12 CRCI2NA ‐ INSERM UMR1307CNRS UMR 6075CRCINA IRS‐UNUniversity of NantesNantesFrance
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2
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Desjardins MP, Naccache L, Hébert A, Auger I, Teira P, Pelland-Marcotte MC. Very Early Diagnosis and Management of Congenital Erythropoietic Porphyria. Clin Pediatr (Phila) 2023; 62:399-403. [PMID: 36217751 PMCID: PMC10170564 DOI: 10.1177/00099228221128661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Congenital erythropoietic porphyria (CEP), a rare form of porphyria, is caused by a defect in the heme biosynthesis pathway of the enzyme uroporphyrinogen III synthase (UROS). Uroporphyrinogen III synthase deficiency leads to an accumulation of nonphysiological porphyrins in bone marrow, red blood cells, skin, bones, teeth, and spleen. Consequently, the exposure to sunlight causes severe photosensitivity, long-term intravascular hemolysis, and eventually, irreversible mutilating deformities. Several supportive therapies such as strict sun avoidance, physical sunblocks, red blood cells transfusions, hydroxyurea, and splenectomy are commonly used in the management of CEP. Currently, the only available curative treatment of CEP is hematopoietic stem cell transplantation (HSCT). In this article, we present a young girl in which precocious genetic testing enabled early diagnosis and allowed curative treatment with HSCT for CEP at the age of 3 months of age, that is, the youngest reported case thus far.
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Affiliation(s)
- Marie-Pier Desjardins
- CHU de Québec, Centre Hospitalier de l’Université Laval, Department of Pediatrics, Université Laval, Québec City, QC, Canada
- Marie-Pier Desjardins, CHU de Québec, Centre Hospitalier de l’Université Laval, Department of Pediatrics, Université Laval, 2705 Boulevard Laurier, Quebec City, QC G1V 4G2, Canada.
| | - Lamia Naccache
- CHU de Québec, Centre Hospitalier de l’Université Laval, Department of Pediatrics, Université Laval, Québec City, QC, Canada
| | - Audrey Hébert
- CHU de Québec, Centre Hospitalier de l’Université Laval, Department of Pediatrics, Université Laval, Québec City, QC, Canada
| | - Isabelle Auger
- CHU de Québec, Centre Hospitalier de l’Université Laval, Division of Dermatology, Department of Medicine, Université Laval, Québec City, QC, Canada
| | - Pierre Teira
- CHU Sainte-Justine, Division of Hematology/Oncology, Department of Pediatrics, University of Montréal, Montréal, QC, Canada
| | - Marie-Claude Pelland-Marcotte
- CHU de Québec, Centre Hospitalier de l’Université Laval, Department of Pediatrics, Université Laval, Québec City, QC, Canada
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3
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Mickevicius T, Holtmann C, Draganov J, Prues-Hoelscher J, Geerling G, Borrelli M. Lagophthalmos-induced corneal perforation in a patient with congenital erythropoietic porphyria. Orbit 2023:1-7. [PMID: 36734461 DOI: 10.1080/01676830.2023.2169718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/12/2023] [Indexed: 06/18/2023]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder in which the activity of uroporphyrinogen III synthase (UROS) is decreased. This results in the accumulation of photoreactive porphyrinogens, primarily in the skin and bone marrow. We describe a case of a patient with CEP who initially presented with scarring and shortening of the anterior and posterior lid lamella, which led to the development of lagophthalmos. Vascularized hyperkeratotic plaques in both corneas were also present. Despite treatment with topical ocular surface lubricants, corneal perforation with iris and uvea prolapse developed and evisceration of the right eye under local anesthesia was performed. The presented case suggests that despite topical therapy, ocular complications may exacerbate requiring surgical intervention, especially in the presence of lagophthalmos.
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Affiliation(s)
- Tomas Mickevicius
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Christoph Holtmann
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Jutta Draganov
- Department of Anesthesiology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | | | - Gerd Geerling
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
| | - Maria Borrelli
- Department of Ophthalmology, University Hospital of Düsseldorf, Düsseldorf, Germany
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4
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Abstract
The porphyrias are a group of eight rare genetic disorders, each caused by the deficiency of one of the enzymes in the heme biosynthetic pathway, resulting in the excess accumulation of heme precursors and porphyrins. Depending on the tissue site as well as the chemical characteristics of the accumulating substances, the clinical features of different porphyrias vary substantially. Heme precursors are neurotoxic, and their accumulation results in acute hepatic porphyria, while porphyrins are photoactive, and excess amounts cause cutaneous porphyrias, which present with photosensitivity. These disorders are clinically heterogeneous but can result in severe clinical manifestations, long-term complications and a significantly diminished quality of life. Medical management consists mostly of the avoidance of triggering factors and symptomatic treatment. With an improved understanding of the underlying pathophysiology and disease mechanisms, new treatment approaches have become available, which address the underlying defects at a molecular or cellular level, and promise significant improvement, symptom prevention and more effective treatment of acute and chronic disease manifestations.
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Affiliation(s)
- Angelika L. Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic & Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
- Correspondence: ; Tel.: +1-216-444-9249
| | - Manisha Balwani
- Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
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5
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Mohamed ZA, Pelletier S, Vintze-Geoffrion A, Lagacé-Nadon S, Olney HJ, Adam JP. Autologous Stem Cell Transplant for Treatment of Multiple Myeloma in a Patient with Concomitant Porphyria Cutanea Tarda. Clin Lymphoma Myeloma Leuk 2021; 21:e264-e266. [PMID: 33390349 DOI: 10.1016/j.clml.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/27/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Sarah Pelletier
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | | | | | - Harold J Olney
- Division of Hematology-Oncology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Research Center of Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Jean-Philippe Adam
- Research Center of Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Pharmacy, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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6
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Abkowitz JL. A simple Rx for congenital erythropoietic porphyria. Blood 2020; 136:2371-2372. [DOI: 10.1182/blood.2020007968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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7
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Prat F, Toutain J, Boutin J, Amintas S, Cullot G, Lalanne M, Lamrissi-Garcia I, Moranvillier I, Richard E, Blouin JM, Dabernat S, Moreau-Gaudry F, Bedel A. Mutation-Specific Guide RNA for Compound Heterozygous Porphyria On-target Scarless Correction by CRISPR/Cas9 in Stem Cells. Stem Cell Reports 2020; 15:677-693. [PMID: 32795423 PMCID: PMC7486222 DOI: 10.1016/j.stemcr.2020.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 01/31/2023] Open
Abstract
CRISPR/Cas9 is a promising technology for gene correction. However, the edition is often biallelic, and uncontrolled small insertions and deletions (indels) concomitant to precise correction are created. Mutation-specific guide RNAs were recently tested to correct dominant inherited diseases, sparing the wild-type allele. We tested an original approach to correct compound heterozygous recessive mutations. We compared editing efficiency and genotoxicity by biallelic guide RNA versus mutant allele-specific guide RNA in iPSCs derived from a congenital erythropoietic porphyria patient carrying compound heterozygous mutations resulting in UROS gene invalidation. We obtained UROS function rescue and metabolic correction with both guides with the potential of use for porphyria clinical intervention. However, unlike the biallelic one, the mutant allele-specific guide was free of on-target collateral damage. We recommend this design to avoid genotoxicity and to obtain on-target scarless gene correction for recessive disease with frequent cases of compound heterozygous mutations.
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Affiliation(s)
- Florence Prat
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France
| | - Jérôme Toutain
- Medical Genetic Laboratory, CHU Bordeaux, Bordeaux 33000, France
| | - Julian Boutin
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France
| | - Samuel Amintas
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France; Laboratory of Tumor Biology, CHU Bordeaux, Pessac 33604, France
| | - Grégoire Cullot
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France
| | - Magalie Lalanne
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France
| | - Isabelle Lamrissi-Garcia
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France
| | | | - Emmanuel Richard
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France; Biochemistry Laboratory, CHU Bordeaux, Bordeaux 33000, France; Laboratory of Excellence, GR-Ex, Imagine Institute, Paris 75015, France
| | - Jean-Marc Blouin
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France; Biochemistry Laboratory, CHU Bordeaux, Bordeaux 33000, France; Laboratory of Excellence, GR-Ex, Imagine Institute, Paris 75015, France
| | - Sandrine Dabernat
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France; Biochemistry Laboratory, CHU Bordeaux, Bordeaux 33000, France; Laboratory of Excellence, GR-Ex, Imagine Institute, Paris 75015, France
| | - François Moreau-Gaudry
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France; Biochemistry Laboratory, CHU Bordeaux, Bordeaux 33000, France; Laboratory of Excellence, GR-Ex, Imagine Institute, Paris 75015, France
| | - Aurélie Bedel
- Univ Bordeaux, Bordeaux 33000, France; INSERM U1035, Biotherapy of Genetic Diseases, Inflammatory Disorders and Cancers, Bordeaux 33000, France; Biochemistry Laboratory, CHU Bordeaux, Bordeaux 33000, France; Laboratory of Excellence, GR-Ex, Imagine Institute, Paris 75015, France.
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8
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Besnard C, Schmitt C, Galmiche-Rolland L, Debray D, Fabre M, Molina T, Gouya L, Ged C, Castelle M, Cavazzana M, Magrin E, Neven B, Moshous D, Blanche S, Frémond ML. Bone Marrow Transplantation in Congenital Erythropoietic Porphyria: Sustained Efficacy but Unexpected Liver Dysfunction. Biol Blood Marrow Transplant 2019; 26:704-711. [PMID: 31843562 DOI: 10.1016/j.bbmt.2019.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare disease characterized by erosive photosensitivity and chronic hemolysis due to a defect of the enzyme uroporphyrinogen-III-synthase (UROS). To date, hematopoietic stem cell transplantation (HSCT) is the only curative therapy for the devastating early and severe form of the disease. We describe 6 patients with CEP treated with HSCT (3 of them twice after failure of a first graft) between 1994 and 2016 in our center, including 2 of the very first living patients treated more than 20 years ago. Four patients are doing well at 6 to 25 years post-HSCT, with near-normal biochemical parameters of porphyrin metabolism without the cutaneous or hematologic features of CEP. One patient died within the first year after HSCT from severe graft-versus-host disease (GVHD), and 1 child died of unexplained acute hepatic failure at 1 year after HSCT, despite full donor chimerism. Retrospectively, it appears that all but 1 child had increased transaminase activity with onset from the early postnatal period, which was significantly more marked in the child who died of liver failure. In contrast, liver function values progressively normalized after engraftment in all other children. Liver pathology before HSCT for 3 patients revealed varying degrees of portal, centrilobular, and perisinusoidal fibrosis; clarification of hepatocytes; and cytosolic porphyrin deposits. The liver porphyrin content in biopsy specimens was >60 times the normal values. Despite difficult engraftment, the long-term efficacy of HSCT in CEP appears to be favorable and reinforces its benefits for the severe form of CEP. Hepatic involvement requires careful evaluation before and after HSCT and further investigation into its pathophysiology and care.
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Affiliation(s)
- Caroline Besnard
- Pediatric Immuno-Hematology and Rheumatology Unit, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
| | - Caroline Schmitt
- French Center of Porphyrias, Louis Mourier Hospital, AP-HP, Colombes and Research Center of Inflammation, UMR1149 INSERM, Université de Paris, Paris, France
| | | | - Dominique Debray
- Pediatric Hepatology Unit, Necker Enfants Malades Hospital, AP-HP, Paris, France
| | - Monique Fabre
- Pathology Department, Necker Enfants Malades Hospital, AP-HP, Paris, France
| | - Thierry Molina
- Pathology Department, Necker Enfants Malades Hospital, AP-HP, Paris, France
| | - Laurent Gouya
- French Center of Porphyrias, Louis Mourier Hospital, AP-HP, Colombes and Research Center of Inflammation, UMR1149 INSERM, Université de Paris, Paris, France
| | - Cécile Ged
- Biotherapy of Genetic Diseases, Inflammatory Disorders, and Cancers, U1035 INSERM, Bordeaux University, Bordeaux, France
| | - Martin Castelle
- Pediatric Immuno-Hematology and Rheumatology Unit, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
| | - Marina Cavazzana
- Biotherapy Unit, Necker Enfants Malades Hospital, AP-HP, Paris, France
| | - Elisa Magrin
- Biotherapy Unit, Necker Enfants Malades Hospital, AP-HP, Paris, France
| | - Bénédicte Neven
- Pediatric Immuno-Hematology and Rheumatology Unit, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
| | - Despina Moshous
- Pediatric Immuno-Hematology and Rheumatology Unit, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
| | - Stéphane Blanche
- Pediatric Immuno-Hematology and Rheumatology Unit, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France.
| | - Marie-Louise Frémond
- Pediatric Immuno-Hematology and Rheumatology Unit, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, AP-HP, Paris, France
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9
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Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder characterized by photosensitivity and by hematologic abnormalities in affected individuals. CEP is caused by mutations in the uroporphyrinogen synthase (UROS) gene. In three reported cases, CEP has been associated with a specific X-linked GATA1 mutation. Disease-causing mutations in either gene result in absent or markedly reduced UROS enzymatic activity. This in turn leads to the accumulation of the non-physiologic and photoreactive porphyrinogens, uroporphyrinogen I and coproporphyrinogen I, which damage erythrocytes and elicit a phototoxic reaction upon light exposure. The clinical spectrum of CEP depends on the level of residual UROS activity, which is determined by the underlying pathogenic loss-of-function UROS mutations. Disease severity ranges from non-immune hydrops fetalis in utero to late-onset disease with only mild cutaneous involvement. The clinical characteristics of CEP include exquisite photosensitivity to visible light resulting in bullous vesicular lesions which, when infected lead to progressive photomutilation of sun-exposed areas such as the face and hands. In addition, patients have erythrodontia (brownish discoloration of teeth) and can develop corneal scarring. Chronic transfusion-dependent hemolytic anemia is common and leads to bone marrow hyperplasia, which further increases porphyrin production. Management of CEP consists of strict avoidance of exposure to visible light with sun-protective clothing, sunglasses, and car and home window filters. Adequate care of ruptured vesicles and use of topical antibiotics is indicated to prevent superinfections and osteolysis. In patients with symptomatic hemolytic anemia, frequent erythrocyte cell transfusions may be necessary to suppress hematopoiesis and decrease marrow production of the phototoxic porphyrins. In severe transfection-dependent cases, bone marrow or hematopoietic stem cell transplantation has been performed, which is curative. Therapeutic approaches including gene therapy, proteasome inhibition, and pharmacologic chaperones are under investigation.
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Affiliation(s)
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Address all Correspondence to: R. J. Desnick, PhD, MD, Dean for Genetic and Genomic Medicine Professor and Chairman Emeritus, Department of Genetic and Genomic Sciences Icahn School of Medicine at Mount Sinai New York, NY 10029, Phone: (212) 659-6700 Fax: (212) 360-1809
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Ciftci V, Kılavuz S, Bulut FD, Mungan HN, Bisgin A, Dogan MC. Congenital erythropoietic porphyria with erythrodontia: A case report. Int J Paediatr Dent 2019; 29:542-548. [PMID: 30706587 DOI: 10.1111/ipd.12473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/02/2019] [Accepted: 01/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The causes for intrinsic tooth discoloration can be separated into two categories as systemic and local. Systemic causes are either genetic or drug-induced effects. The development of dentition can also be affected by a number of systemic factors and metabolic diseases such as porphyria. Congenital erythropoietic porphyria (CEP), also known as Gunther's disease, is a metabolic disease caused by a transformation in the gene that codifies uroporphyrinogen-3 synthesis, leading to porphyrin aggregation in urine, skin, bone, and dentin. CASE REPORT A 21-month-old girl with erythrodontia was referred to Paediatric Dentistry Department in September 2017. A physical examination revealed blisters on her face, nose, hands, and feet. Laboratory findings showed highly elevated urine total uroporphyrin and total coproporphyrin I and III levels. Next-generation sequencing multigene panel testing for porphyria demonstrated a homozygous c.10C>T (p.L4F) mutation in the UROS gene. For curative therapy, the patient was admitted to the allogeneic bone marrow transplantation program. CONCLUSION Congenital erythropoietic porphyria most commonly presents in the first few years of life. Manifestations can include reddish-colored urine, skin blistering, scarring, and erythrodontia. A timely diagnosis can prevent undesirable skin findings of the disease and death due to hematological involvement before a curative allogeneic bone marrow transplantation is performed.
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Affiliation(s)
- Volkan Ciftci
- Department of Pediatric Dentistry, Faculty of Dentistry, Cukurova University, Adana, Turkey
| | - Sebile Kılavuz
- Division of Pediatric Metabolism and Nutrition, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Fatma Derya Bulut
- Division of Pediatric Metabolism and Nutrition, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Halise Neslihan Mungan
- Division of Pediatric Metabolism and Nutrition, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Atil Bisgin
- Medical Genetics Department of Balcali Hospital and Clinics, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Muharrem Cem Dogan
- Department of Pediatric Dentistry, Faculty of Dentistry, Cukurova University, Adana, Turkey
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Luo E, Liu H, Zhao Q, Shi B, Chen Q. Dental-craniofacial manifestation and treatment of rare diseases. Int J Oral Sci 2019; 11:9. [PMID: 30783081 PMCID: PMC6381182 DOI: 10.1038/s41368-018-0041-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/22/2018] [Accepted: 10/28/2018] [Indexed: 02/05/2023] Open
Abstract
Rare diseases are usually genetic, chronic and incurable disorders with a relatively low incidence. Developments in the diagnosis and management of rare diseases have been relatively slow due to a lack of sufficient profit motivation and market to attract research by companies. However, due to the attention of government and society as well as economic development, rare diseases have been gradually become an increasing concern. As several dental-craniofacial manifestations are associated with rare diseases, we summarize them in this study to help dentists and oral maxillofacial surgeons provide an early diagnosis and subsequent management for patients with these rare diseases.
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Affiliation(s)
- En Luo
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hanghang Liu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Qiucheng Zhao
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Bing Shi
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
| | - Qianming Chen
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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Abstract
Congenital erythropoietic porphyria (CEP) is a rare genetic disease resulting from the remarkable deficient activity of uroporphyrinogen III synthase, the fourth enzyme of the haem biosynthetic pathway. This enzyme defect results in overproduction of the non-physiological and pathogenic porphyrin isomers, uroporphyrin I and coproporphyrin I. The predominant clinical characteristics of CEP include bullous cutaneous photosensitivity to visible light from early infancy, progressive photomutilation and chronic haemolytic anaemia. The severity of clinical manifestations is markedly heterogeneous among patients; and interdependence between disease severity and porphyrin amount in the tissues has been pointed out. A more pronounced endogenous production of porphyrins concomitant to activation of ALAS2, the first and rate-limiting of the haem synthesis enzymes in erythroid cells, has also been reported. CEP is inherited as autosomal recessive or X-linked trait due to mutations in UROS or GATA1 genes; however an involvement of other causative or modifier genes cannot be ruled out.
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Affiliation(s)
- Elena Di Pierro
- U.O. di Medicina Interna, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milano, Italy
| | - Valentina Brancaleoni
- U.O. di Medicina Interna, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milano, Italy
| | - Francesca Granata
- U.O. di Medicina Interna, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milano, Italy
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Egan DN, Yang Z, Phillips J, Abkowitz JL. Inducing iron deficiency improves erythropoiesis and photosensitivity in congenital erythropoietic porphyria. Blood 2015; 126:257-61. [PMID: 25972160 DOI: 10.1182/blood-2014-07-584664] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 04/17/2015] [Indexed: 01/08/2023] Open
Abstract
Congenital erythropoietic porphyria (CEP) is an autosomal recessive disorder of heme synthesis characterized by reduced activity of uroporphyrinogen III synthase and the accumulation of nonphysiologic isomer I porphyrin metabolites, resulting in ineffective erythropoiesis and devastating skin photosensitivity. Management of the disease primarily consists of supportive measures. Increased activity of 5-aminolevulinate synthase 2 (ALAS2) has been shown to adversely modify the disease phenotype. Herein, we present a patient with CEP who demonstrated a remarkable improvement in disease manifestations in the setting of iron deficiency. Hypothesizing that iron restriction improved her symptoms by decreasing ALAS2 activity and subsequent porphyrin production, we treated the patient with off-label use of deferasirox to maintain iron deficiency, with successful results. We confirmed the physiology of her response with marrow culture studies.
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Abstract
The porphyrias are diverse in pathophysiology, clinical presentation, severity, and prognosis, presenting a diagnostic and therapeutic challenge. Although not easily curable, the dermatological manifestations of these diseases, photosensitivity and associated cutaneous pathology, can be effectively prevented and managed. Sun avoidance is essential, and patient education regarding the irreversibility of photocutaneous damage is a necessary corollary. Beyond preventative measures, the care of fragile, vulnerable skin, and pain management, each of the porphyrias has a limited number of unique additional therapeutic options. Many of the treatments have been published only in small case series or anecdotal reports and do not have well-understood nor proven mechanisms of action. This article presents a comprehensive review of available therapeutic options and long-term management recommendations for the cutaneous porphyrias.
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Affiliation(s)
- Suzanne Tintle
- Department of Dermatology, Tufts Medical Center, Boston, MA, USA
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Martinez Peinado C, Díaz de Heredia C, To-Figueras J, Arias-Santiago S, Nogueras P, Elorza I, Olivé T, Bádenas C, Moreno MJ, Tercedor J, Herrero C. Successful treatment of congenital erythropoietic porphyria using matched unrelated hematopoietic stem cell transplantation. Pediatr Dermatol 2013; 30:484-9. [PMID: 23557135 DOI: 10.1111/pde.12117] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Congenital erythropoietic porphyria (CEP), or Günther's disease, is an inborn error of metabolism produced by a deficiency of uroporphyrinogen III synthase (UROS), the fourth enzyme of the heme biosynthesis pathway. This enzymatic defect induces the accumulation of isomer I porphyrins in erythrocytes, skin, and tissues, producing various clinical manifestations. Severe cases are characterized by extreme photosensitivity, causing scarring and mutilations, and by hemolytic anemia, reducing life expectancy. CEP is caused by mutations in the UROS gene, and one of the most severe forms of the disease is associated with a cysteine to arginine substitution at residue 73 of the protein (C73R). CEP has been successfully treated only by the transplantation of hematopoietic precursors. We report the case of a male infant with severe postdelivery symptoms diagnosed with CEP and found to be homozygous for the C73R mutation. He underwent successful allogeneic bone marrow transplantation from a matched unrelated donor at 7 months of age. The hemolytic anemia was corrected and the porphyrin overproduction was significantly reduced. The patient remained asymptomatic after 1 year. This new case confirms that patients with severe CEP can benefit from early postnatal hematopoietic stem cell transplantation.
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Chantorn R, Lim HW, Shwayder TA. Photosensitivity disorders in children: part I. J Am Acad Dermatol 2012; 67:1093.e1-18; quiz 1111-2. [PMID: 23158621 DOI: 10.1016/j.jaad.2012.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 07/25/2012] [Accepted: 07/29/2012] [Indexed: 11/18/2022]
Abstract
Photosensitivity disorders in children encompass a diverse group of diseases. Compared to adult patients, underlying systemic disorders, including genetic or metabolic defects, are common causes in pediatric photosensitivity disorders. Photosensitivity in a child should be suspected if the child develops a sunburn reaction in sun-exposed sites after limited sun exposure. Diagnosis of a photodermatosis is made based on careful history taking and a physical examination. Early recognition and prompt diagnosis are essential to minimize long-term complications associated with inadequate photoprotection. In part I of this continuing medical education article, immunologically mediated photodermatoses, photodermatoses caused by exogenous photosensitizers, and the cutaneous porphyrias will be covered.
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Affiliation(s)
- Rattanavalai Chantorn
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Katugampola RP, Anstey AV, Finlay AY, Whatley S, Woolf J, Mason N, Deybach JC, Puy H, Ged C, de Verneuil H, Hanneken S, Minder E, Schneider-Yin X, Badminton MN. A management algorithm for congenital erythropoietic porphyria derived from a study of 29 cases. Br J Dermatol 2012; 167:888-900. [PMID: 22804244 DOI: 10.1111/j.1365-2133.2012.11154.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Congenital erythropoietic porphyria (CEP) is an autosomal recessive photomutilating porphyria with onset usually in childhood, where haematological complications determine prognosis. Due to its extreme rarity and clinical heterogeneity, management decisions in CEP are often difficult. OBJECTIVES To develop a management algorithm for patients with CEP based on data from carefully characterized historical cases. METHODS A single investigator collated data related to treatments and their outcomes in 29 patients with CEP from the U.K., France, Germany and Switzerland. RESULTS Six children were treated with bone marrow transplantation (BMT); five have remained symptomatically cured up to 11.5 years post-transplantation. Treatments such as oral charcoal, splenectomy and chronic hypertransfusion were either of no benefit or were associated with complications and negative impact on health-related quality of life. Lack of consistent genotype-phenotype correlation meant that this could not be used to predict disease prognosis. The main poor prognostic factors were early age of disease onset and severity of haematological manifestations. CONCLUSIONS A management algorithm is proposed where every patient, irrespective of disease severity at presentation, should receive a comprehensive, multidisciplinary clinical assessment and should then be reviewed at intervals based on their predicted prognosis, and the rate of onset of complications. A BMT should be considered in those with progressive, symptomatic haemolytic anaemia and/or thrombocytopenia. Uroporphyrinogen III synthase genotypes associated with poor prognosis would additionally justify consideration for a BMT. Rigorous photoprotection of the skin and eyes from visible light is essential in all patients.
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Affiliation(s)
- R P Katugampola
- Department of Dermatology and Wound Healing, Cardiff University, UK.
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Bedel A, Taillepierre M, Guyonnet-Duperat V, Lippert E, Dubus P, Dabernat S, Mautuit T, Cardinaud B, Pain C, Rousseau B, Lalanne M, Ged C, Duchartre Y, Richard E, de Verneuil H, Moreau-Gaudry F. Metabolic correction of congenital erythropoietic porphyria with iPSCs free of reprogramming factors. Am J Hum Genet 2012; 91:109-21. [PMID: 22795135 DOI: 10.1016/j.ajhg.2012.05.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 04/18/2012] [Accepted: 05/31/2012] [Indexed: 11/24/2022] Open
Abstract
Congenital erythropoietic porphyria (CEP) is due to a deficiency in the enzymatic activity of uroporphyrinogen III synthase (UROS); such a deficiency leads to porphyrin accumulation and results in skin lesions and hemolytic anemia. CEP is a candidate for retrolentivirus-mediated gene therapy, but recent reports of insertional leukemogenesis underscore the need for safer methods. The discovery of induced pluripotent stem cells (iPSCs) has opened up new horizons in gene therapy because it might overcome the difficulty of obtaining sufficient amounts of autologous hematopoietic stem cells for transplantation and the risk of genotoxicity. In this study, we isolated keratinocytes from a CEP-affected individual and generated iPSCs with two excisable lentiviral vectors. Gene correction of CEP-derived iPSCs was obtained by lentiviral transduction of a therapeutic vector containing UROS cDNA under the control of an erythroid-specific promoter shielded by insulators. One iPSC clone, free of reprogramming genes, was obtained with a single proviral integration of the therapeutic vector in a genomic safe region. Metabolic correction of erythroblasts derived from iPSC clones was demonstrated by the disappearance of fluorocytes. This study reports the feasibility of porphyria gene therapy with the use of iPSCs.
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Moghbeli M, Maleknejad M, Arabi A, Abbaszadegan MR. Mutational analysis of uroporphyrinogen III cosynthase gene in Iranian families with congenital erythropoietic porphyria. Mol Biol Rep 2012; 39:6731-5. [PMID: 22350154 DOI: 10.1007/s11033-012-1497-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 01/24/2012] [Indexed: 10/28/2022]
Abstract
Porphyrias are rare metabolic hereditary diseases originating from defects in specific enzymes involved in the heme biosynthesis pathway. Congenital erythropoietic porphyria (CEP) is the rarest autosomal recessive porphyria resulting from a deficiency of uroporphyrinogen III cosynthase (UROS), the fourth enzyme in heme biosynthesis. CEP leads to an excessive production and accumulation of type Ι porphyrins in bone marrow, skin and several other tissues. Clinical manifestations are presented in childhood with severe cutaneous photosensitivity, blistering, scarring and deformation of the hands and the loss of eyebrows and eyelashes. Less than 200 cases of CEP have been reported to date. Four CEP patients and their family members were studied for the first time in Iran. A missense mutation in the UROS gene was identified in this family. A, T to C change at nucleotide 34313, leading to a substitution of Leucine by Proline at codon 237, was observed in the homozygous state in these 4 patients and heterozygous state in their parents. Our data from the Iranian population emphasizes the importance of codon 237 alone, given the rarity of this disease. This fact can be taken into consideration in the mutational analysis of UROS. This work emphasizes the advantages of molecular genetic techniques as diagnostic tools for the detection of clinically asymptomatic heterozygous mutation carriers as well as CEP within families.
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Affiliation(s)
- Meysam Moghbeli
- Division of Human Genetics, Avicenna Research Institute, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran
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Fortian A, Castaño D, Gonzalez E, Laín A, Falcon-Perez JM, Millet O. Structural, thermodynamic, and mechanistical studies in uroporphyrinogen III synthase: molecular basis of congenital erythropoietic porphyria. Adv Protein Chem Struct Biol 2012; 83:43-74. [PMID: 21570665 DOI: 10.1016/b978-0-12-381262-9.00002-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal disease ultimately related to deleterious mutations in uroporphyrinogen III synthase (UROIIIS), the fourth enzyme of the biosynthetic route of the heme group. UROIIIS catalyzes the cyclization of the linear tetrapyrrol hydroxymethylbilane (HMB), inverting the configuration in one of the aromatic rings. In the absence of the enzyme (or when ill-functioning), HMB spontaneously degrades to the by-product uroporphyrinogen I, which cannot lead to the heme group and accumulates in the body, producing some of the symptoms observed in CEP patients. In the present chapter, clinical, biochemical, and biophysical information has been compiled to provide an integrative view on the molecular basis of CEP. The high-resolution structure of UROIIIS sheds light on the enzyme reaction mechanism while thermodynamic analysis revealed that the protein is thermolabile. Pathogenic missense mutations are found throughout the primary sequence of the enzyme. All but one of these is rarely found in patients, whereas C73R is responsible for more than one-third of the reported cases. Most of the mutant proteins (C73R included) retain partial catalytic activity but the mutations often reduce the enzyme's stability. The stabilization of the protein in vivo is discussed in the context of a new line of intervention to complement existing treatments such as bone marrow transplantation and gene therapy.
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Abstract
Congenital erythropoietic porphyria is a rare form of porphyria, presenting during the neonatal period or during infancy. Clinical features include photosensitive blistering and severe anemia. Wood's lamp fluorescence of the diaper is a useful screening test. We describe a severely affected neonate with systemic involvement due to a homozygous mutation. Because of ongoing severe hemolytic anemia and severe photosensitivity, bone-marrow transplantation was performed, but the patient ultimately succumbed to chemotherapy-induced lung damage, as well as severe pulmonary hypertension, likely due to his chronic hemolytic anemia.
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Affiliation(s)
- Marcia Hogeling
- Department of Dermatology, University of California, San Francisco, California, USA.
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Bishop DF, Clavero S, Mohandas N, Desnick RJ. Congenital erythropoietic porphyria: characterization of murine models of the severe common (C73R/C73R) and later-onset genotypes. Mol Med 2011; 17:748-56. [PMID: 21365124 DOI: 10.2119/molmed.2010.00258] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 02/24/2011] [Indexed: 11/06/2022] Open
Abstract
Congenital erythropoietic porphyria (CEP) is an autosomal recessive disorder due to the deficient activity of uroporphyrinogen III synthase (UROS). Knock-in mouse models were generated for the common, hematologically severe human genotype, C73R/C73R, and milder genotypes (C73R/V99L and V99L/V99L). The specific activities of the UROS enzyme in the livers and erythrocytes of these mice averaged approximately 1.2%, 11% and 19% of normal, respectively. C73R/C73R mice that survived fetal life to weaning age (~12%) had a severe microcytic hypochromic anemia (hemoglobin 7.9 g/dL, mean cellular volume 26.6 fL, mean cellular hemoglobin content 27.4 g/dL, red cell distribution width 37.7%, reticulocytes 19%) and massively accumulated isomer I porphyrins (95, 183 and 44 μmol/L in erythrocytes, spleen and liver, respectively), but a nearly normal lifespan. In adult C73R/C73R mice, spleen and liver weights were 8.2- and 1.5-fold increased, respectively. C73R/V99L mice were mildly anemic (hemoglobin was 14.0 g/dL and mean cellular hemoglobin was 13.3), with minimally accumulated porphyrins (0.10, 5.54 and 0.58 μmol/L in erythrocytes, spleen and liver, respectively), whereas adult V99L/V99L mice were normal. Of note, even the mildest genotype, V99L/V99L, exhibited porphyria in utero, which disappeared by 2 months of age. These severe and mild mouse models inform therapeutic interventions and permit further investigation of the porphyrin-induced hematopathology, which leads to photo-induced cutaneous lesions. Of significance for therapeutic intervention, these mouse models suggest that only 11% of wild-type activity might be needed to reverse the pathology in CEP patients.
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Affiliation(s)
- David F Bishop
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, New York, USA.
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Robert-Richard E, Lalanne M, Lamrissi-Garcia I, Guyonnet-Duperat V, Richard E, Pitard V, Mazurier F, Moreau-Gaudry F, Ged C, de Verneuil H. Modeling of congenital erythropoietic porphyria by RNA interference: a new tool for preclinical gene therapy evaluation. J Gene Med 2010; 12:637-46. [PMID: 20586119 DOI: 10.1002/jgm.1478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Congenital erythropoietic porphyria (CEP) is a severe autosomal recessive disorder characterized by a deficiency in uroporphyrinogen III synthase (UROS), the fourth enzyme of the heme biosynthetic pathway. We recently demonstrated the definitive cure of a murine model of CEP by lentiviral vector-mediated hematopoietic stem cell (HSC) gene therapy. In the perspective of a gene therapy clinical trial, human cellular models are required to evaluate the therapeutic potential of lentiviral vectors in UROS-deficient cells. However, the rare incidence of the disease makes difficult the availability of HSCs derived from patients. METHODS RNA interference (RNAi) has been used to develop a new human model of the disease from normal cord blood HSCs. Lentivectors were developed for this purpose. RESULTS We were able to down-regulate the level of human UROS in human cell lines and primary hematopoietic cells. A 97% reduction of UROS activity led to spontaneous uroporphyrin accumulation in human erythroid bone marrow cells of transplanted immune-deficient mice, recapitulating the phenotype of cells derived from patients. A strong RNAi-induced UROS inhibition allowed us to test the efficiency of different lentiviral vectors with the aim of selecting a safer vector. Restoration of UROS activity in these small hairpin RNA-transduced CD34(+) cord blood cells by therapeutic lentivectors led to a partial correction of the phenotype in vivo. CONCLUSIONS The RNAi strategy is an interesting new tool for preclinical gene therapy evaluation.
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Abstract
Porphyrias are a group of eight rare inherited metabolic disorders of heme biosynthesis pathway. Porphyrias are still underdiagnosed, although examinations of urine and plasma are first-line tests for detecting excess of porphyrins or heme precursors in suspected patients. Diagnosis, particularly for the acute forms, is essential to avoid precipitating factors and the use of triggering drugs. Mutation screening of family members is recommended to identify presymptomatic carriers and to prevent acute attacks. The therapeutic approach should be appropriate regarding specific forms of porphyria and treatment should be started promptly.
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Affiliation(s)
- Maria Domenica Cappellini
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Università degli Studi di Milano, Via F. Sforza 35, 20122, Milan, Italy.
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Lebreuilly-Sohyer I, Morice A, Acher A, Dompmartin A, Clement C, de Verneuil H, Ged C, Leroy D, Verneuil L. Porphyrie érythropoïétique congénitale traitée par allogreffe de cellules souches hématopoïétiques. Ann Dermatol Venereol 2010; 137:635-9. [DOI: 10.1016/j.annder.2010.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 04/25/2010] [Accepted: 06/22/2010] [Indexed: 11/25/2022]
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Clavero S, Bishop DF, Giger U, Haskins ME, Desnick RJ. Feline congenital erythropoietic porphyria: two homozygous UROS missense mutations cause the enzyme deficiency and porphyrin accumulation. Mol Med 2010; 16:381-8. [PMID: 20485863 DOI: 10.2119/molmed.2010.00038] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 05/11/2010] [Indexed: 02/02/2023] Open
Abstract
The first feline model of human congenital erythropoietic porphyria (CEP) due to deficient uroporphyrinogen III synthase (URO-synthase) activity was identified by its characteristic clinical phenotype, and confirmed by biochemical and molecular genetic studies. The proband, an adult domestic shorthair cat, had dark-red urine and brownish discolored teeth with red fluorescence under ultraviolet light. Biochemical studies demonstrated markedly increased uroporphyrinogen I in urine and plasma (2,650- and 10,700-fold greater than wild type, respectively), whereas urinary 5-aminolevulinic acid and porphobilinogen were lower than normal. Erythrocytic URO-synthase activity was <1% of mean wild-type activity, confirming the diagnosis and distinguishing it from feline phenocopies having acute intermittent porphyria. Sequencing of the affected cat's UROS gene revealed two missense mutations, c.140C>T (p.S47F) in exon 3 and c.331G>A (p.G111S) in exon 6, both of which were homozygous, presumably owing to parental consanguinity. Neither was present in 100 normal cat alleles. Prokaryotic expression and thermostability studies of the purified monomeric wild-type, p.S47F, p.G111S, and p.S47F/G111S enzymes showed that the p.S47F enzyme had 100% of wild-type specific activity but ~50% decreased thermostability, whereas the p.G111S and p.S47F/G111S enzymes had about 60% and 20% of wild-type specific activity, respectively, and both were markedly thermolabile. Molecular modeling results indicated that the less active/less stable p.G111S enzyme was further functionally impaired by a structural interaction induced by the presence of the S47F substitution. Thus, the synergistic interaction of two rare amino acid substitutions in the URO-synthase polypeptide caused the feline model of human CEP.
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Affiliation(s)
- Sonia Clavero
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, NY, USA
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Abstract
Hereditary porphyrias are a group of eight metabolic disorders of the haem biosynthesis pathway that are characterised by acute neurovisceral symptoms, skin lesions, or both. Every porphyria is caused by abnormal function of a separate enzymatic step, resulting in a specific accumulation of haem precursors. Seven porphyrias are the result of a partial enzyme deficiency, and a gain of function mechanism has been characterised in a new porphyria. Acute porphyrias present with acute attacks, typically consisting of severe abdominal pain, nausea, constipation, confusion, and seizure, and can be life-threatening. Cutaneous porphyrias present with either acute painful photosensitivity or skin fragility and blisters. Rare recessive porphyrias usually manifest in early childhood with either severe cutaneous photosensitivity and chronic haemolysis or chronic neurological symptoms with or without photosensitivity. Porphyrias are still underdiagnosed, but when they are suspected, and dependent on clinical presentation, simple first-line tests can be used to establish the diagnosis in all symptomatic patients. Diagnosis is essential to enable specific treatments to be started as soon as possible. Screening of families to identify presymptomatic carriers is crucial to decrease risk of overt disease of acute porphyrias through counselling about avoidance of potential precipitants.
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Affiliation(s)
- Hervé Puy
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, Colombes, France
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Kim SE, Lee HK. Ocular Manifestation of Compound Heterozygotic Mutation in Congenital Erythropoietic Porphyria. J Korean Ophthalmol Soc 2009. [DOI: 10.3341/jkos.2009.50.3.477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sung Eun Kim
- The Institute of Vision Research, Department of Ophthalmology, College of Medicine, Yonsei University, Seoul, Korea
| | - Hyung Keun Lee
- The Institute of Vision Research, Department of Ophthalmology, College of Medicine, Yonsei University, Seoul, Korea
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Baselga E, Torrelo A. Erupciones inflamatorias y purpúricas. Dermatología neonatal 2009. [DOI: 10.1016/b978-84-8086-390-2.50019-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Robert-Richard E, Moreau-Gaudry F, Lalanne M, Lamrissi-Garcia I, Cario-André M, Guyonnet-Dupérat V, Taine L, Ged C, de Verneuil H. Effective gene therapy of mice with congenital erythropoietic porphyria is facilitated by a survival advantage of corrected erythroid cells. Am J Hum Genet 2008; 82:113-24. [PMID: 18179890 DOI: 10.1016/j.ajhg.2007.09.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Revised: 09/04/2007] [Accepted: 09/21/2007] [Indexed: 11/23/2022] Open
Abstract
Achieving long-term expression of a therapeutic gene in a given hematopoietic lineage remains an important goal of gene therapy. Congenital erythropoietic porphyria (CEP) is a severe autosomal-recessive disorder characterized by a deficiency in uroporphyrinogen III synthase (UROS), the fourth enzyme of the heme biosynthetic pathway. We used a recently obtained murine model to check the feasibility of gene therapy in this disease. Lentivirus-mediated transfer of the human UROS cDNA into hematopoietic stem cells (HSCs) from Uros(mut248) mice resulted in a complete and long-term enzymatic, metabolic, and phenotypic correction of the disease, favored by a survival advantage of corrected red blood cells. These results demonstrate that the cure of this mouse model of CEP at a moderate transduction level supports the proof of concept of a gene therapy in this disease by transplantation of genetically modified hematopoietic stem cells.
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Baselga E, Torrelo A. Inflammatory and Purpuric Eruptions. Neonatal Dermatology 2008. [PMCID: PMC7315339 DOI: 10.1016/b978-1-4160-3432-2.50022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Taibjee SM, Stevenson OE, Abdullah A, Tan CY, Darbyshire P, Moss C, Goodyear H, Heagerty A, Whatley S, Badminton MN. Allogeneic bone marrow transplantation in a 7-year-old girl with congenital erythropoietic porphyria: a treatment dilemma. Br J Dermatol 2007; 156:567-71. [PMID: 17300251 DOI: 10.1111/j.1365-2133.2006.07699.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Congenital erythropoietic porphyria (CEP, Günther's disease) has a very variable phenotype. In the more severely affected, bone marrow transplantation (BMT) is potentially curative, but is not without risks. We describe a 7-year-old girl with CEP characterized by severe photosensitivity but only mild anaemia, in whom the difficult decision to proceed with allogeneic BMT was made after discussion in a multidisciplinary team. She has shown successful engraftment, accompanied by biochemical and clinical resolution of her metabolic disease. She remains well 3 years later, the oldest patient with CEP receiving BMT to survive beyond 12 months. However, she has experienced significant morbidity including florid cutaneous graft-versus-host disease with postinflammatory hypopigmentation. Her case is important in highlighting the delay in diagnosis not uncommon in this condition and the complex decision-making process involved in proceeding with BMT.
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Affiliation(s)
- S M Taibjee
- Department of Haematology, Birmingham Children's Hospital, Birmingham, UK.
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Abstract
The porphyrias are a group of disorders involving enzymatic defects in heme synthesis. The porphyrias classically manifest neuro-visceral or photocutaneous symptoms based on which enzyme in the heme metabolic pathway is deficient. Although rare, the porphyrias would most likely be encountered in the emergency department in patients presenting with chronic unspecified abdominal or musculoskeletal pain and those with new onset of psychiatric complaints.
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Affiliation(s)
- Teague A Dombeck
- Department of Emergency Medicine, Synergy Medical Education Alliance, 1000 Houghton Avenue, Saginaw, MI 48602, USA
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36
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Abstract
Porphyria is a diverse group of diseases in which the biosynthesis of heme is disrupted by either genetic defects or environmental factors. This review gives an overview of the different types of porphyria and describes possible causes, clinical signs, diagnosis and therapy. In addition, the oral manifestations of porphyria and the potential implications of the disease for dental management are discussed.
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Dupuis-Girod S, Akkari V, Ged C, Galambrun C, Kebaïli K, Deybach JC, Claudy A, Geburher L, Philippe N, de Verneuil H, Bertrand Y. Successful match-unrelated donor bone marrow transplantation for congenital erythropoietic porphyria (Günther disease). Eur J Pediatr 2005; 164:104-7. [PMID: 15703981 DOI: 10.1007/s00431-004-1575-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2004] [Revised: 10/11/2004] [Accepted: 10/13/2004] [Indexed: 11/29/2022]
Abstract
UNLABELLED Congenital erythropoietic porphyria (CEP; Gunther disease; OMIM 263700) is a rare autosomal recessive disorder caused by a deficiency of uroporphyrinogen III synthase (UROS). The deficiency of this enzyme is associated with lifelong overproduction of series I porphyrins which circulate and are deposited in many tissues, causing light-sensitisation and severe damage to skin beginning in childhood. Blistering and scarring of exposed areas may lead to mutilating deformities. We describe two cases: a 4-year-old boy and his first cousin who were cured of CEP by matched unrelated donor bone marrow transplants. Both are alive and disease-free 3 and 2 years post-transplant, respectively. Cutaneous lesions improved dramatically. The correction of the enzyme deficiency was confirmed by measuring erythrocyte UROS activity and urinary porphyrin excretion. Chimerism was complete for both children. Both patients were homoallelic for a novel mutation of the UROS gene, the missense mutation A69T. CONCLUSION Considering the severity of the disease, if HLA-matched sibling donor is not available, haematopoietic stem cell transplantation using a matched unrelated donor should be strongly considered for treating congenital erythropoietic porphyria since this is currently the only known curative therapy.
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Affiliation(s)
- Sophie Dupuis-Girod
- Immuno-hématologie Pédiatrique et transplantation de moelle osseuse, Hôpital Debrousse, 29 rue Soeur Bouvier, 6932 Lyon Cedex 05, France.
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Abstract
The erythropoietic porphyrias are erythropoietic protoporphyria, and congenital erythropietic porphyria. Diagnosis is made based on clinical manifestations, and their characteristic porphyrin profiles. There are multiple treatment options for these two porphyrias, however, aside from bone marrow transplant for CEP, none is curative.
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Kontos AP, Ozog D, Bichakjian C, Lim HW. Congenital erythropoietic porphyria associated with myelodysplasia presenting in a 72-year-old man: report of a case and review of the literature. Br J Dermatol 2003; 148:160-4. [PMID: 12534613 DOI: 10.1046/j.1365-2133.2003.05040.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disease owing to the deficient activity of uroporphyrinogen III synthase, the fourth enzyme in the porphyrin-haem synthetic pathway. Of the porphyrias, it is the most mutilating type, usually presenting early in life. To date, 12 documented cases of adult onset CEP have been reported. We report the second oldest documented patient with late onset CEP with incidental findings of thrombocytopenia and myelodysplasia with bone-marrow sideroblasts. We further discuss several current and future treatment options for this therapeutically challenging disease.
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Affiliation(s)
- A P Kontos
- Department of Dermatology, Henry Ford Health System, Detroit, MI 48202, USA
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Affiliation(s)
- Robert J Desnick
- Department of Human Genetics, Mount Sinai School of Medicine, Box 1498, New York University, Fifth Avenue and 100th Street, New York, NY 10029, USA.
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Abstract
Bone marrow transplantation (BMT) has emerged as a major therapeutic option for a number of nonmalignant disorders affecting the bone marrow and leading to clinical manifestations most likely affecting distant organs. Disorders such as autoimmune diseases, metabolic disorders, hemoglobinopathies, immunodeficiencies, and others have been the target of high-dose therapy and autologous or allogeneic bone marrow, stem cell, or cord blood transplantation. Successful results have been reported in a large number of these disorders. In most instances the goal of transplantation is to provide sufficient degree of marrow engraftment to allow long-term amelioration of disease phenotype. For many of these disorders, early diagnosis is crucial in achieving the desired results as transplantation becomes difficult when significant end-organ damage sets in. Major unsolved problems, including toxicity of conditioning regimens, graft-versus-host disease, and donor availability, need to be addressed. We attempt to provide a comprehensive review of BMT and discuss unique features of this modality for treatment of nonmalignant disorders.
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Affiliation(s)
- Nabil Saba
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Hennepin County Medical Center, Minneapolis, MN 55403, USA.
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