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Levy C, Dickey AK, Wang B, Thapar M, Naik H, Keel SB, Saberi B, Beaven SW, Rudnick SR, Elmariah SB, Erwin AL, Goddu RJ, Hedstrom K, Leaf RK, Kazamel M, Mazepa M, Philpotts LL, Quigley J, Raef H, Ungar J, Anderson KE, Balwani M. Evidence-based consensus guidelines for the diagnosis and management of protoporphyria-related liver dysfunction in erythropoietic protoporphyria and X-linked protoporphyria. Hepatology 2024; 79:731-743. [PMID: 37505211 PMCID: PMC10818013 DOI: 10.1097/hep.0000000000000546] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, FL
| | - Amy K. Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Bruce Wang
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA
| | - Manish Thapar
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Hetanshi Naik
- Department of Genetics, Stanford University School of Medicine, Palo Alto, CA
| | - Siobán B. Keel
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
| | - Behnam Saberi
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Simon W. Beaven
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Sean R. Rudnick
- Department of Internal Medicine, Section on Gastroenterology and Hepatology, Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Sarina B. Elmariah
- Department of Dermatology, University of California San Francisco, San Francisco, CA
| | - Angelika L. Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic, Cleveland, OH
| | - Robert J. Goddu
- Division of Continuing Education, University of Colorado Boulder, Boulder, CO
| | - Karli Hedstrom
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rebecca Karp Leaf
- Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Marshall Mazepa
- Division of Hematology,Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | - John Quigley
- Division of Hematology/Oncology, Department of Medicine, University of Illinois Chicago, IL
| | - Haya Raef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
- Department of Dermatology, University of California San Francisco, San Francisco, CA
| | - Jonathan Ungar
- Department of Dermatology, Mount Sinai Hospital, New York, NY
| | - Karl E. Anderson
- Department of Internal Medicine (Division of Gastroenterology & Hepatology), University of Texas Medical Branch/UTMB Health, Galveston, TX
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
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2
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Dickey AK, Naik H, Keel SB, Levy C, Beaven SW, Elmariah SB, Erwin AL, Goddu RJ, Hedstrom K, Leaf RK, Kazamel M, Mazepa M, Philpotts LL, Quigley J, Raef H, Rudnick SR, Saberi B, Thapar M, Ungar J, Wang B, Balwani M. Evidence-based consensus guidelines for the diagnosis and management of erythropoietic protoporphyria and X-linked protoporphyria. J Am Acad Dermatol 2023; 89:1227-1237. [PMID: 36041558 PMCID: PMC9968824 DOI: 10.1016/j.jaad.2022.08.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/07/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022]
Abstract
Erythropoietic protoporphyria and X-linked protoporphyria are rare genetic photodermatoses. Limited expertise with these disorders among physicians leads to diagnostic delays. Here, we present evidence-based consensus guidelines for the diagnosis, monitoring, and management of erythropoietic protoporphyria and X-linked protoporphyria. A systematic literature review was conducted, and reviewed among subcommittees of experts, divided by topic. Consensus on guidelines was reached within each subcommittee and then among all members of the committee. The appropriate biochemical and genetic testing to establish the diagnosis is reviewed in addition to the interpretation of results. Prevention of symptoms, management of acute phototoxicity, and pharmacologic and nonpharmacologic treatment options are discussed. The importance of ongoing monitoring for liver disease, iron deficiency, and vitamin D deficiency is discussed with management guidance. Finally, management of pregnancy and surgery and the safety of other therapies are summarized. We emphasize that these are multisystemic disorders that require longitudinal monitoring. These guidelines provide a structure for evidence-based diagnosis and management for practicing physicians. Early diagnosis and management of these disorders are essential, particularly given the availability of new and emerging therapies.
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Affiliation(s)
- Amy K Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Siobán B Keel
- Division of Hematology, University of Washington School of Medicine, Seattle, Washington
| | - Cynthia Levy
- Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Simon W Beaven
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles Medical Center, Los Angeles, California
| | - Sarina B Elmariah
- Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Angelika L Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic, Cleveland, Ohio
| | - Robert J Goddu
- Division of Continuing Education, University of Colorado Boulder, Boulder, Colorado
| | - Karli Hedstrom
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rebecca K Leaf
- Harvard Medical School, Boston, Massachusetts; Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Mohamed Kazamel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marshall Mazepa
- Division of Hematology and Oncology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - John Quigley
- Division of Hematology/Oncology, Department of Medicine, University of Illinois Chicago, Chicago, Illinois
| | - Haya Raef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sean R Rudnick
- Department of Internal Medicine, Section on Gastroenterology and Hepatology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Behnam Saberi
- Harvard Medical School, Boston, Massachusetts; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Manish Thapar
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jonathan Ungar
- Department of Dermatology, Mount Sinai Hospital, New York, New York
| | - Bruce Wang
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York.
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Tumminelli C, Burlo F, Pastore S, Severini GM, Berti I, Marchini S, Zanon D, De Martino E, Tommasini A. Erythropoietic protoporphyria: case reports for clinical and therapeutic hints. Ital J Pediatr 2023; 49:156. [PMID: 37996925 PMCID: PMC10668413 DOI: 10.1186/s13052-023-01544-2] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/03/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Erythropoietic protoporphyria is a rare disorder which represents an important health problem in children, causing painful photosensitivity. Little is known on the correlation between genetic profile and clinical manifestations. The standard of care for Erythropoietic protoporphyria is based on avoiding sun and using sun protections, but recent literature has suggested that cimetidine may have a role in improving sun sensitivity. Herein we report our case series describing the successful use of cimetidine and analyzing potential phenotype-genotype correlations. CASE PRESENTATION This case series describes five patients presented to our Rheumatology Service complaining sun sensitivity. Blood exams and genetic analysis were consistent with the diagnosis of erythropoietic protoporphyria. Four of 5 patients received cimetidine in addition to standard therapies and the effect of treatment was evaluated by Erythropoietic Protoporphyria - Quality of Life questionnaire. CONCLUSIONS Erythropoietic protoporphyria usually manifests in early childhood after a short sun exposure. Skin manifestations are the main reason for investigations, although sometimes they can be more subtle, leading to a significant diagnostic delay. Skin diseases in children can have profound effects on their family and social relationships. A treatment with cimetidine appears to be an excellent therapeutic option in children with Erythropoietic protoporphyria.
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Affiliation(s)
- Cristina Tumminelli
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Francesca Burlo
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Serena Pastore
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy.
| | - Giovanni Maria Severini
- Department of Medical Genetics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Irene Berti
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy
| | - Stefano Marchini
- Department of Surgical and Medical Sciences for Children and Adults, Internal Medicine Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41124, Italy
| | - Davide Zanon
- Pharmacy and Clinical Pharmacology Department, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Eleonora De Martino
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy
| | - Alberto Tommasini
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health "IRCCS Burlo Garofolo", Via dell'Istria, 65, Trieste, 34137, Italy
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Portich JP, Ribeiro AS, Rodrigues Taniguchi AN, Backes A, de Souza CFM, Kieling CO, Scherer FF, de Oliveira Poswar F, Leipnitz I, Doederlein Schwartz IV, Sekine L, Rigoni LDC, Marquardt da Silveira L, de Almeida Furlanetto M, Adami MR, Breunig RC, Guedes RR, do Amaral SN, Gonçalves Vieira SM, de Brum Soares T, Silva TO, da Rocha Silla LM, Astigarraga CC, Paz AA, Daudt LE. Consecutive Liver and Bone Marrow Transplantation for Erythropoietic Protoporphyria: Case Report and Literature Review. J Pediatr Hematol Oncol 2023; 45:416-422. [PMID: 37539993 DOI: 10.1097/mph.0000000000002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/19/2023] [Accepted: 06/22/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited disease of heme biosynthesis resulting in the accumulation of protoporphyrin, characterized by liver failure in a minority of cases. Although liver transplant (LT) is the therapeutic strategy for advanced hepatic disease, it does not correct the primary defect, which leads to recurrence in liver graft. Thus, hematopoietic stem cell transplantation (HSCT) is an approach for treating EPP. METHODS We aim to describe the first sequential LT and HSCT for EPP performed in Latin America, besides reviewing the present-day literature. RESULTS The patient, a 13-year-old female with a history of photosensitivity, presented with symptoms of cholestatic and hepatopulmonary syndrome and was diagnosed with EPP. Liver biopsy demonstrated cirrhosis. She was submitted to a successful LT and showed improvement of respiratory symptoms. However, she had disease recurrence on the liver graft. She underwent a myeloablative HSCT using a matched unrelated donor, conditioning with BuCy (busulfan and cyclophosphamide), and GvHD (graft vs. host disease) prophylaxis with ATG (thymoglobulin), tacrolimus and methotrexate. Neutrophil engraftment occurred on D+18. She has presented mixed chimerism, but normalization of PP levels, being 300 days after HSCT, in good state of health and normal liver function. CONCLUSIONS Consecutive LT and HSCT for EPP is a procedure that has been described in 10 cases in the literature and, even though these patients are a highly diversified population, studies have shown favorable results. This concept of treatment should be considered in patients with established liver disease.
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Affiliation(s)
| | | | | | | | | | - Carlos Oscar Kieling
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | | | | | - Ian Leipnitz
- Hemotherapy
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | | | - Leo Sekine
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Luciana Marquardt da Silveira
- Departments of Bone Marrow Transplantation
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Marina Rossato Adami
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
| | - Raquel Cristine Breunig
- Post-Graduation Program in Child's Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Renata Rostirola Guedes
- Children Liver Transplantation Program
- Digestive Surgery Service, Hospital de Clínicas de Porto Alegre
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5
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Hussain Z, Qi Q, Zhu J, Anderson KE, Ma X. Protoporphyrin IX-induced phototoxicity: Mechanisms and therapeutics. Pharmacol Ther 2023; 248:108487. [PMID: 37392940 PMCID: PMC10529234 DOI: 10.1016/j.pharmthera.2023.108487] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Abstract
Protoporphyrin IX (PPIX) is an intermediate in the heme biosynthesis pathway. Abnormal accumulation of PPIX due to certain pathological conditions such as erythropoietic protoporphyria and X-linked protoporphyria causes painful phototoxic reactions of the skin, which can significantly impact daily life. Endothelial cells in the skin have been proposed as the primary target for PPIX-induced phototoxicity through light-triggered generation of reactive oxygen species. Current approaches for the management of PPIX-induced phototoxicity include opaque clothing, sunscreens, phototherapy, blood therapy, antioxidants, bone marrow transplantation, and drugs that increase skin pigmentation. In this review, we discuss the present understanding of PPIX-induced phototoxicity including PPIX production and disposition, conditions that lead to PPIX accumulation, symptoms and individual differences, mechanisms, and therapeutics.
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Affiliation(s)
- Zahir Hussain
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Qian Qi
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Karl E Anderson
- Porphyria Laboratory and Center, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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6
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Leaf RK, Dickey AK. How I treat erythropoietic protoporphyria and X-linked protoporphyria. Blood 2023; 141:2921-2931. [PMID: 36898083 PMCID: PMC10646811 DOI: 10.1182/blood.2022018688] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) is an inherited cutaneous porphyria caused by reduced expression of ferrochelatase, the enzyme that catalyzes the final step in heme biosynthesis. The resultant accumulation of protoporphyrin IX leads to severe, painful cutaneous photosensitivity, as well as potentially life-threatening liver disease in a small percentage of patients. X-linked protoporphyria (XLP) is clinically similar to EPP but results from increased activity of δ-aminolevulinic acid synthase 2, the first step in heme biosynthesis in the bone marrow, and also causes protoporphyrin accumulation. Although historically the management of EPP and XLP (collectively termed protoporphyria) centered around avoidance of sunlight, novel therapies have recently been approved or are in development, which will alter the therapeutic landscape for these conditions. We present 3 patient cases, highlighting key treatment considerations in patients with protoporphyria, including (1) approach to photosensitivity, (2) managing iron deficiency in protoporphyria, and (3) understanding hepatic failure in protoporphyria.
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Affiliation(s)
- Rebecca Karp Leaf
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Amy K. Dickey
- Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA
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7
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Wensink D, Wagenmakers MAEM, Qi H, Wilson JHP, Langendonk JG. Objective light exposure measurements and circadian rhythm in patients with erythropoietic protoporphyria: A case-control study. Mol Genet Metab 2022; 135:215-220. [PMID: 35034844 DOI: 10.1016/j.ymgme.2021.12.017] [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] [Received: 10/15/2021] [Revised: 11/26/2021] [Accepted: 12/25/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) patients suffer from painful phototoxicity. Sunlight-avoiding behaviour has not yet been quantified objectively in EPP patients. OBJECTIVE To study total white light exposure obtained with an actigraph device, before and during afamelanotide treatment, in EPP patients compared to healthy controls. Effects on circadian rhythm, pain and sleep were also investigated. METHODS Adult EPP patients visiting the Porphyria Center Rotterdam of the Erasmus MC were included in this single-center longitudinal case-control open-label intervention study. Controls were age and place of residence matched. Participants wore an actigraph (Actiwatch Pro) during two weeks for multiple periods. Afamelanotide was given to EPP patients as part of standard care. RESULTS Twenty-six EPP patients and 23 matched controls participated. Controls were statistically significantly more exposed to white light than EPP patients off treatment during autumn (95.4%), spring (69.9%), and summer (105.4%; p = 0.01). EPP patients on afamelanotide treatment had 71.6% more light exposure during spring compared to EPP patients off treatment (p < 0.01). Afamelanotide treatment resulted in a reduction of painful moments in the morning (6.5% decrease) and the evening (8.1% decrease; p < 0.05). Bedtime differed between EPP patients off treatment, controls and EPP patients on treatment (23:45 h ± 1:51 versus 23:02 ± 1:41 and 23:14 ± 1:29, respectively; p < 0.0001). CONCLUSION Actigraphy is a useful method to objectively measure white light exposure and treatment effects in EPP. In EPP patients afamelanotide treatment is associated with increased white light exposure during spring, and overall less pain. Treatment with afamelanotide is also associated with normalization of circadian rhythm.
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Affiliation(s)
- Debby Wensink
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - Margreet A E M Wagenmakers
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - Hongchao Qi
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - J H Paul Wilson
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
| | - Janneke G Langendonk
- Porphyria Expertcenter Rotterdam, Center for Lysosomal and Metabolic Disease, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands.
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Linenberger M, Fertrin KY. Updates on the diagnosis and management of the most common hereditary porphyrias: AIP and EPP. Hematology Am Soc Hematol Educ Program 2020; 2020:400-410. [PMID: 33275677 PMCID: PMC7727547 DOI: 10.1182/hematology.2020000124] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
The porphyrias are a family of metabolic disorders caused by defects in the activity of one of the enzymes in the heme biosynthetic pathway. Acute intermittent porphyria (AIP), caused by autosomal dominant mutations in the gene encoding hydroxymethylbilane synthase, can lead to hepatocyte overaccumulation and systemic distribution of the proximal porphyrin precursors, 5-aminolevulinic acid (ALA) and porphobilinogen (PBG). ALA and PBG are toxic to neurons and extrahepatic tissue and cause the neurovisceral clinical manifestations of AIP. Management of AIP includes awareness and avoidance of triggering factors, infusions of hemin for severe acute attacks, and, if indicated for chronic suppressive therapy, maintenance treatment with hemin or givosiran, a small interfering RNA molecule that antagonizes ALA synthase 1 transcripts. Erythropoietic protoporphyria (EPP) is most commonly caused by autosomal recessive mutations in the gene encoding ferrochelatase (FECH), the heme pathway terminal enzyme. FECH deficiency leads to erythrocyte overaccumulation and high plasma levels of lipophilic protoporphyrins that photoactivate in the skin, causing burning pain and erythema. Protoporphyrins excreted in the bile can cause gallstones, cholestasis, fibrosis, and ultimately liver failure. Management of EPP includes skin protection and afamelanotide, an α-melanocyte stimulating hormone analog that increases melanin pigment and reduces photoactivation. Liver transplantation may be necessary for severe EPP-induced liver complications. Because AIP and EPP arise from defects in the heme biosynthetic pathway, hematologists are often consulted to evaluate and manage suspected or proven porphyrias. A working knowledge of these disorders increases our confidence and effectiveness as consultants and medical providers.
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9
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Barman-Aksözen J, Halloy F, Iyer PS, Schümperli D, Minder AE, Hall J, Minder EI, Schneider-Yin X. Delta-aminolevulinic acid synthase 2 expression in combination with iron as modifiers of disease severity in erythropoietic protoporphyria. Mol Genet Metab 2019; 128:304-308. [PMID: 31076252 DOI: 10.1016/j.ymgme.2019.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 10/17/2018] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 11/30/2022]
Abstract
Deficiency in ferrochelatase (FECH), the last enzyme in the heme biosynthetic pathway, leads to an accumulation of protoporphyrin IX (PPIX) that causes a severely painful phototoxic reaction of the skin in patients with erythropoietic protoporphyria (EPP). Besides phototoxicity of the skin, EPP patients often present with symptoms of iron deficiency in form of a microcytic and hypochromic anemia with low serum iron and ferritin. In addition, elevated aminolevulinic acid synthase 2 (ALAS2) both at the mRNA and protein levels have been observed among EPP patients. ALAS is the first enzyme in the pathway and exists in two isoforms, whereby the isoform 2 (ALAS2) is expressed exclusively in erythropoiesis. The mRNA of ALAS2 contains an iron response element (IRE) at its 5'UTR. When iron is limited, iron response element binding protein 2 (IRP2) binds to the IRE of ALAS2 mRNA and suppresses its translation. In this study, we demonstrated that iron deprivation increased the amount of ALAS2 mRNA as well as the ratio of ALAS2 to FECH mRNAs in cultured erythroleukemic K562 cells. At the protein level, however, iron deprivation in the cell line caused reductions in both enzymes as shown by the Western blot analysis. A comparable increase in the ratio of ALAS2 to FECH mRNAs was also found in EPP patients indicating an imbalance in heme biosynthesis. As iron cannot be completely missing from an organism, we assume that in EPP patients, a certain amount of ALAS2 mRNA is translated despite a partial deficiency of FECH. The increase in ALAS2 enzyme contributes to the accumulation in PPIX in the patients. Targeted inhibition of ALAS2 could therefore be a treatment option for EPP.
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Affiliation(s)
| | - Francois Halloy
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, The Federal Institute of Technology (ETH), Zürich, Switzerland
| | - Pavithra S Iyer
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, The Federal Institute of Technology (ETH), Zürich, Switzerland
| | - Daniel Schümperli
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, The Federal Institute of Technology (ETH), Zürich, Switzerland
| | - Anna Elisabeth Minder
- Division of Endocrinology, Department of Internal Medicine, Municipal Hospital Triemli, Zurich, Switzerland
| | - Jonathan Hall
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, The Federal Institute of Technology (ETH), Zürich, Switzerland
| | - Elisabeth I Minder
- Division of Endocrinology, Department of Internal Medicine, Municipal Hospital Triemli, Zurich, Switzerland
| | - Xiaoye Schneider-Yin
- Institute of Laboratory Medicine, Municipal Hospital Triemli, Zürich, Switzerland.
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10
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Balwani M. Erythropoietic Protoporphyria and X-Linked Protoporphyria: pathophysiology, genetics, clinical manifestations, and management. Mol Genet Metab 2019; 128:298-303. [PMID: 30704898 PMCID: PMC6656624 DOI: 10.1016/j.ymgme.2019.01.020] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 11/18/2022]
Abstract
Erythropoietic Protoporphyria (EPP) and X-linked Protoporphyria (XLP) are rare, genetic photodermatoses resulting from defects in enzymes of the heme-biosynthetic pathway. EPP results from the partial deficiency of ferrochelatase, and XLP results from gain-of-function mutations in erythroid specific ALAS2. Both disorders result in the accumulation of erythrocyte protoporphyrin, which is released in the plasma and taken up by the liver and vascular endothelium. The accumulated protoporphyrin is activated by sunlight exposure, generating singlet oxygen radical reactions leading to tissue damage and excruciating pain. About 2-5% of patients develop clinically significant liver dysfunction due to protoporphyrin deposition in bile and/or hepatocytes which can advance to cholestatic liver failure requiring transplantation. Clinically these patients present with acute, severe, non-blistering phototoxicity within minutes of sun-exposure. Anemia is seen in about 47% of patients and about 27% of patients will develop abnormal serum aminotransferases. The diagnosis of EPP and XLP is made by detection of markedly increased erythrocyte protoporphyrin levels with a predominance of metal-free protoporphyrin. Genetic testing by sequencing the FECH or ALAS2 gene confirms the diagnosis. Treatment is limited to sun-protection and there are no currently available FDA-approved therapies for these disorders. Afamelanotide, a synthetic analogue of α-melanocyte stimulating hormone was found to increase pain-free sun exposure and improve quality of life in adults with EPP. It has been approved for use in the European Union since 2014 and is not available in the U.S. In addition to the development of effective therapeutics, future studies are needed to establish the role of iron and the risks related to the development of hepatopathy in these patients.
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MESH Headings
- 5-Aminolevulinate Synthetase/genetics
- Anemia/etiology
- Clinical Trials as Topic
- Dermatitis, Phototoxic
- Disease Management
- Genes, X-Linked
- Heme/metabolism
- Humans
- Liver Diseases/etiology
- Liver Diseases/physiopathology
- Porphyrias, Hepatic/complications
- Porphyrias, Hepatic/genetics
- Porphyrias, Hepatic/physiopathology
- Porphyrias, Hepatic/therapy
- Protoporphyria, Erythropoietic/complications
- Protoporphyria, Erythropoietic/genetics
- Protoporphyria, Erythropoietic/physiopathology
- Protoporphyria, Erythropoietic/therapy
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences and Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
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Naik H, Shenbagam S, Go AM, Balwani M. Psychosocial issues in erythropoietic protoporphyria - the perspective of parents, children, and young adults: A qualitative study. Mol Genet Metab 2019; 128:314-319. [PMID: 30711301 PMCID: PMC6660424 DOI: 10.1016/j.ymgme.2019.01.023] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 12/21/2022]
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are rare photodermatoses, generally presenting in childhood with severe and painful phototoxicity. EPP has been reported to negatively affect quality of life (QoL), but there is limited information on the psychosocial issues faced by patients and families. To address this, an online focus group study was conducted to explore the perspective of parents of children with EPP, and young adults and children with EPP. Five focus groups were conducted in a semi-structured format, with moderator-led discussions exploring the impact on QoL. Three focus groups included parents of children with EPP, one with children aged 10-11 years, and another with young adults aged 24-25 years, for a total of 24 participants. Thematic data analysis showed that parents experience guilt for being unable to protect their children and frustration with the current state of knowledge of EPP. Parents also admitted that the disease can lead to stress within family members which is difficult to manage. Young adults expressed embarrassment over having to explain the disease to others. They reported that the teenage years were the most difficult to navigate; however, they learned to adapt to their disease as they grew older. Children expressed that they had limited understanding of their disease and wished they were told what symptoms to expect by physicians earlier in life. Our findings emphasize the significant impact on QoL for these families and a lack of age appropriate information for children with EPP. These findings can help improve counseling and support resources for patients and caregivers.
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Affiliation(s)
- Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
| | - Shruti Shenbagam
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Allysa Marie Go
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
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Abstract
Erythropoietic protoporphyria is a photodermatosis presenting in childhood with severe pain on sun exposure. The diagnosis is often delayed because of the lack of awareness among pediatricians. We describe the diagnostic odyssey of 2 children presenting with symptoms of erythropoietic protoporphyria and report results of a survey of 129 affected individuals.
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Affiliation(s)
- Sajel M Lala
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY.
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Teramura T, Mizuno M, Asano H, Naru E, Kawara S, Kamide R, Kawada A. Prevention of photosensitivity with action spectrum adjusted protection for erythropoietic protoporphyria. J Dermatol 2018; 45:145-149. [PMID: 29266358 PMCID: PMC5814858 DOI: 10.1111/1346-8138.14175] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 05/01/2017] [Accepted: 11/08/2017] [Indexed: 12/24/2022]
Abstract
Erythropoietic protoporphyria is a genetic disease characterized by sensitivity to sunlight caused by the accumulation of protoporphyrin IX. Photoprotection against ultraviolet A and visible light is necessary for erythropoietic porphyria patients because the absorption spectrum of protoporphyrin IX lies in both ultraviolet A and visible light region. We developed a novel index, in vitro porphyrin protection factor, based on the protoporphyrin IX absorbance spectrum. We also selected appropriate photoprotective products designed according to protoporphyrin IX absorbance. The porphyrin protection factors of a combination of make-up base with a powder as well as with a liquid foundation were significantly higher than those of a conventional sunscreen product, even at a small application dose. An in-use test carried out for 6 months showed that the efficacy of these products was 78.3%, and no adverse reactions were observed. Male subjects preferred liquid foundation, whereas all female subjects used powder foundation. The preference of the subjects could lead to the long-term use of the tested products. In conclusion, this study provided a new approach to improve photoprotection in erythropoietic protoporphyria patients.
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Affiliation(s)
| | - Makoto Mizuno
- Fundamental Research LaboratoriesKOSÉ CorporationTokyoJapan
| | - Hajime Asano
- Fundamental Research LaboratoriesKOSÉ CorporationTokyoJapan
| | - Eiji Naru
- Fundamental Research LaboratoriesKOSÉ CorporationTokyoJapan
| | - Shigeru Kawara
- Department of DermatologyJapanese Red Cross Kanazawa HospitalIshikawaJapan
| | - Ryoichi Kamide
- Hihuno Clinic NingyochoTokyoJapan
- Department of DermatologyDaisan HospitalThe Jikei University School of MedicineTokyoJapan
| | - Akira Kawada
- Department of DermatologyKindai University Faculty of MedicineOsakaJapan
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Affiliation(s)
- D Montgomery Bissell
- From the Department of Medicine, Division of Gastroenterology and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Departments of Preventive Medicine and Community Health and Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston (K.E.A.); and the Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC (H.L.B.)
| | - Karl E Anderson
- From the Department of Medicine, Division of Gastroenterology and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Departments of Preventive Medicine and Community Health and Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston (K.E.A.); and the Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC (H.L.B.)
| | - Herbert L Bonkovsky
- From the Department of Medicine, Division of Gastroenterology and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Departments of Preventive Medicine and Community Health and Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston (K.E.A.); and the Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, NC (H.L.B.)
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Oustric V, Manceau H, Ducamp S, Soaid R, Karim Z, Schmitt C, Mirmiran A, Peoc'h K, Grandchamp B, Beaumont C, Lyoumi S, Moreau-Gaudry F, Guyonnet-Dupérat V, de Verneuil H, Marie J, Puy H, Deybach JC, Gouya L. Antisense oligonucleotide-based therapy in human erythropoietic protoporphyria. Am J Hum Genet 2014; 94:611-7. [PMID: 24680888 PMCID: PMC3980518 DOI: 10.1016/j.ajhg.2014.02.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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: 12/05/2013] [Accepted: 02/18/2014] [Indexed: 01/05/2023] Open
Abstract
In 90% of people with erythropoietic protoporphyria (EPP), the disease results from the inheritance of a common hypomorphic FECH allele, encoding ferrochelatase, in trans to a private deleterious FECH mutation. The activity of the resulting FECH enzyme falls below the critical threshold of 35%, leading to the accumulation of free protoporphyrin IX (PPIX) in bone marrow erythroblasts and in red cells. The mechanism of low expression involves a biallelic polymorphism (c.315-48T>C) localized in intron 3. The 315-48C allele increases usage of the 3' cryptic splice site between exons 3 and 4, resulting in the transcription of an unstable mRNA with a premature stop codon, reducing the abundance of wild-type FECH mRNA, and finally reducing FECH activity. Through a candidate-sequence approach and an antisense-oligonucleotide-tiling method, we identified a sequence that, when targeted by an antisense oligonucleotide (ASO-V1), prevented usage of the cryptic splice site. In lymphoblastoid cell lines derived from symptomatic EPP subjects, transfection of ASO-V1 reduced the usage of the cryptic splice site and efficiently redirected the splicing of intron 3 toward the physiological acceptor site, thereby increasing the amount of functional FECH mRNA. Moreover, the administration of ASO-V1 into developing human erythroblasts from an overtly EPP subject markedly increased the production of WT FECH mRNA and reduced the accumulation of PPIX to a level similar to that measured in asymptomatic EPP subjects. Thus, EPP is a paradigmatic Mendelian disease in which the in vivo correction of a common single splicing defect would improve the condition of most affected individuals.
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Affiliation(s)
- Vincent Oustric
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France
| | - Hana Manceau
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France
| | - Sarah Ducamp
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France
| | - Rima Soaid
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France
| | - Zoubida Karim
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université Paris Diderot, F-75018 Paris, France
| | - Caroline Schmitt
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université Paris Diderot, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France
| | - Arienne Mirmiran
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France
| | - Katell Peoc'h
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France
| | - Bernard Grandchamp
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université Paris Diderot, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Hormonale et Génétique, Hôpital Bichat, F-75018 Paris, France
| | - Carole Beaumont
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université Paris Diderot, F-75018 Paris, France
| | - Said Lyoumi
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université de Versailles Saint Quentin en Yvelines, F-78035 Versailles, France
| | - François Moreau-Gaudry
- Institut National de la Santé et de la Recherche Médicale, U1035, Biothérapies des Maladies Génétiques et Cancers, Laboratoire d'Excellence du Globule Rouge, F-33000 Bordeaux, France; Université Bordeaux Segalen, F-33000 Bordeaux, France
| | - Véronique Guyonnet-Dupérat
- Institut National de la Santé et de la Recherche Médicale, U1035, Biothérapies des Maladies Génétiques et Cancers, Laboratoire d'Excellence du Globule Rouge, F-33000 Bordeaux, France; Université Bordeaux Segalen, F-33000 Bordeaux, France
| | - Hubert de Verneuil
- Institut National de la Santé et de la Recherche Médicale, U1035, Biothérapies des Maladies Génétiques et Cancers, Laboratoire d'Excellence du Globule Rouge, F-33000 Bordeaux, France; Université Bordeaux Segalen, F-33000 Bordeaux, France
| | - Joëlle Marie
- Centre de Génétique Moléculaire, Centre National de la Recherche Scientifique, UPR 3404, Avenue de Terrasse, 91198 Gif-sur-Yvette, Université Paris-Sud, 91400 Orsay, France
| | - Herve Puy
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université Paris Diderot, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Hormonale et Génétique, Hôpital Bichat, F-75018 Paris, France
| | - Jean-Charles Deybach
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Université Paris Diderot, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Hormonale et Génétique, Hôpital Bichat, F-75018 Paris, France.
| | - Laurent Gouya
- Institut National de la Santé et de la Recherche Médicale, U1149, Centre de Recherches sur l'Inflammation, F-75018 Paris, France; Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, 178 Rue des Renouillers, F-92701 Colombes, France; Université de Versailles Saint Quentin en Yvelines, F-78035 Versailles, France; Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Hormonale et Génétique, Hôpital Ambroise Paré, F-92100 Boulogne Billancourt, France; Laboratory of Excellence GR-Ex, 75000 Paris, France
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Kasper DA, Centilli M, Silverton K. Erythematous patches on the hands. J Fam Pract 2012; 61:101-104. [PMID: 22312615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Our patient's history of obsessive-compulsive disorder may have masked the true diagnosis for years.
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Dowman JK, Gunson BK, Mirza DF, Badminton MN, Newsome PN. UK experience of liver transplantation for erythropoietic protoporphyria. J Inherit Metab Dis 2011; 34:539-45. [PMID: 21301964 PMCID: PMC3101349 DOI: 10.1007/s10545-010-9272-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 12/02/2010] [Accepted: 12/23/2010] [Indexed: 01/25/2023]
Abstract
Erythropoietic protoporphyria (EPP) is characterised by excess production of free protoporphyrin from the bone marrow, most commonly due to deficiency of the enzyme ferrochelatase. Excess protoporphyrin gives rise to the cutaneous photosensitivity characteristic of the disease, and in a minority of patients leads to end-stage liver disease necessitating liver transplantation (LT). There is limited information regarding the timing, impact and long-term outcome of LT in such patients, thus we aimed to identify the indications and outcomes of all transplants performed for EPP in the UK using data from the UK Transplant Registry. Between 1987 and 2009, five patients underwent LT for EPP liver disease. Median follow-up was 60 months, and there were two deaths at 44 and 95 months from causes unrelated to liver disease. The remaining recipients are alive at 22.4 years, 61 months and 55 months after transplant. A high rate of postoperative biliary stricturing requiring multiple biliary interventions was observed. Recurrent EPP-liver disease occurred in 4/5 (80%) of patients but graft failure has not been observed. Given the role of biliary obstruction in inducing EPP-mediated liver damage, we suggest that consideration should be given for construction of a Roux loop at the time of transplant. Thus we demonstrate that although EPP liver transplant recipients have a good long-term survival, comparable to patients undergoing LT for other indications, biliary complications and disease recurrence are almost universal, and bone marrow transplantation should be considered where possible.
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Affiliation(s)
- Joanna K. Dowman
- Centre for Liver Research, 5th floor, Institute of Biomedical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH UK
| | - Briget K. Gunson
- Centre for Liver Research, 5th floor, Institute of Biomedical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH UK
| | - Darius F. Mirza
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH UK
| | - Mike N. Badminton
- Department of Infection, Immunity and Biochemistry, School of Medicine, Cardiff University, Cardiff, CF14 4XN UK
| | - Philip N. Newsome
- Centre for Liver Research, 5th floor, Institute of Biomedical Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2TH UK
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Lecluse ALY, Kuck-Koot VCM, van Weelden H, Sigurdsson V, Russel IM, Frank J, Pasmans SGMA. Erythropoietic protoporphyria without skin symptoms-you do not always see what they feel. Eur J Pediatr 2008; 167:703-6. [PMID: 17710435 PMCID: PMC2292482 DOI: 10.1007/s00431-007-0557-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Accepted: 06/18/2007] [Indexed: 10/27/2022]
Abstract
Erythropoietic protoporphyria (EPP) is an inherited disorder of the porphyrin metabolism that often remains undiagnosed in children. We report on a 4-year-old girl who had been suffering for 1 year from recurrent painful crises affecting her hands, feet, and nose following sun exposure. Objective skin lesions were absent until the age of 6. Porphyrin analysis revealed elevated free erythrocyte protoporphyrin (FEP) levels confirming the diagnosis of EPP. This illustrates that skin lesions might be completely absent in children affected with EPP, a fact that has only been reported once previously. Because EPP can manifest with few and unspecific cutaneous symptoms or no skin lesions at all, like in this patient, the diagnosis of EPP might be delayed or missed. EPP should be excluded in all photosensitive children, especially when discomfort is disproportionate to the extent of the cutaneous lesions. The clinic, pathophysiology, diagnosis, complications, and therapy of EPP are discussed.
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Affiliation(s)
- Anne L. Y. Lecluse
- Department of Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Centre, G02.124, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Veronica C. M. Kuck-Koot
- Department of Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Centre, G02.124, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Huib van Weelden
- Department of Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Centre, G02.124, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Vigfus Sigurdsson
- Department of Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Centre, G02.124, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ingrid M. Russel
- Department of Pediatrics, Wilhelmina Children’s Hospital, University Medical Centre, G02.124, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Jorge Frank
- Department of Dermatology, University Hospital Maastricht, Maastricht, The Netherlands
- Maastricht University Centre for Molecular Dermatology (MUCMD), University Hospital Maastricht, Maastricht, The Netherlands
- Euregional Porphyria Centre Maastricht-Aachen (EPCMA), University Hospital Maastricht, Maastricht, The Netherlands
| | - Suzanne G. M. A. Pasmans
- Department of Dermatology and Allergology, Wilhelmina Children’s Hospital, University Medical Centre, G02.124, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Abstract
Erythropoietic protoporphyria (EPP) is a disease of the heme metabolism due to a deficiency of ferrochelatase, leading to accumulation of protoporphyrin (PPIX) in the erythrocyte (red blood cell [RBC]). The major clinical manifestation in EPP is photosensitivity; however, in a small number of patients liver failure is a significant complication and liver transplantation is the only treatment option. Damage to both abdominal skin and organs occurs when exposed to operating light; however, this problem can be ameliorated by the use of filters that block the transmission of light with wavelength below 470 nm. A more unusual but very serious complication postoperatively is severe motor neuropathy, with few or no known acute available precautions. An effective treatment option is needed to manage EPP crises and to prevent complications after liver transplantation. We successfully treated a patient with EPP-induced liver failure with the molecular adsorbents recirculating system (MARS) and Prometheus in independent sessions. Following treatment with MARS we found a 9.1% reduction of the RBC-PPIX concentration and a 5.9% reduction after treatment with the Prometheus system. Plasmapheresis made a reduction in RBC-PPIX concentration of 0.8%. Following treatment sessions with MARS and Prometheus, the clinical condition was markedly improved and orthotopic liver transplantation was performed without further complications. In conclusion, extracorporeal therapy with MARS or Prometheus seems to be efficient in reducing RBC-PPIX concentration in comparison to plasma exchange.
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Affiliation(s)
- Martin Eefsen
- Department of Hepatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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Affiliation(s)
- A E Madu
- Department of Obstetrics and Gynaecology, The Horton Hospital, Oxford Radcliffe Hospital NHS Trust, UK.
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Abstract
Recent advances in the molecular understanding of the porphyrias now offer specific diagnosis and precise definition of the types of genetic mutations involved in the disease. Molecular diagnostic testing is powerful and very useful in kindred evaluation and genetic counselling when a disease-responsible mutation has been identified in the family. It is also the only way to properly screen asymptomatic gene carriers, facilitating correct treatment and appropriate genetic counselling of family members at risk. However, it should be noted that DNA-based testing is for the diagnosis of the gene carrier status, but not for the diagnosis of clinical syndrome or severity of the disease, e.g. an acute attack. For the diagnosis of clinically expressed porphyrias, a logical stepwise approach including the analysis of porphyrins and their precursors should not be underestimated, as it is still very useful, and is often the best from the cost-effective point of view.
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MESH Headings
- Acute Disease
- Chronic Disease
- Coproporphyria, Hereditary/diagnosis
- Coproporphyria, Hereditary/therapy
- Heme/biosynthesis
- Humans
- Porphobilinogen Synthase/metabolism
- Porphyria Cutanea Tarda/diagnosis
- Porphyria Cutanea Tarda/therapy
- Porphyria, Erythropoietic/diagnosis
- Porphyria, Erythropoietic/therapy
- Porphyria, Hepatoerythropoietic/diagnosis
- Porphyria, Hepatoerythropoietic/therapy
- Porphyria, Variegate/diagnosis
- Porphyria, Variegate/therapy
- Porphyrias/classification
- Porphyrias/diagnosis
- Porphyrias/therapy
- Porphyrias, Hepatic/diagnosis
- Porphyrias, Hepatic/therapy
- Protoporphyria, Erythropoietic/diagnosis
- Protoporphyria, Erythropoietic/therapy
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Affiliation(s)
- Shigeru Sassa
- Laboratory of Biochemical Hematology, The Rockefeller University, New York 10021, USA.
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Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited photodermatosis that causes lifelong painful photosensitivity. Neither its full clinical spectrum nor its impact on quality of life (QoL) has been investigated in a large cohort of patients. OBJECTIVES To document the clinical features of EPP and its impact on QoL in a high proportion of all patients with EPP resident in the U.K. METHODS Patients with EPP were identified from U.K. clinical databases and assessed by the same clinical investigator over a 7-month period using a standardized proforma and validated adult (Dermatology Life Quality Index, DLQI) and children's (Children's Dermatology Life Quality Index, CDLQI) QoL questionnaires. RESULTS Three hundred and eighty-nine living patients with EPP were identified, of whom 223 [114 females, 109 males; median age 34 years (range: 5-87), from 193 families] were investigated. Total erythrocyte porphyrin (TEP) was higher in males (median: 25.3 micromol L1) than females (median: 19.3 micromol L1). The median ages at onset and diagnosis were 1 and 12 years, respectively. Median times for onset of symptoms after sun exposure, onset of signs (oedema, erythema) and resolution of symptoms were 20 min, 6 h and 3 days, respectively. Most patients reported absence of protection by glass (92%), priming (85%), exacerbation by wind (68%), no family history of photosensitivity (56%), no symptoms during winter (56%) and had chronic skin lesions (79%). Symptoms changed little with age but improved during pregnancy in 47% of gravid women. Most patients used protective clothing and a sunscreen; 28% were taking beta-carotene and a further 56% had taken it; 29% were not under regular medical care. Two patients (1%) had liver failure and 8% reported gallstone disease. QoL was markedly impaired, with scores similar to those in severe dermatological disease (mean DLQI score 14.0, n = 176; mean CDLQI score 12.8, n = 44), indicating a large effect on patients' lives. DLQI scores correlated weakly with TEP (rs = 0.228; P = 0.002) and time to onset of symptoms (rs = -0.233; P = 0.002) but not with age at onset. CONCLUSIONS EPP is a persistent, severely painful, socially disabling disease with a marked impact on QoL. Its diagnosis is often overlooked. None of TEP, age at onset nor time to onset of symptoms is a useful predictor of impaired QoL in individual patients.
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Affiliation(s)
- S A Holme
- Department of Dermatology, Cardiff University, Heath Park, Cardiff CF14 4XN, UK.
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Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare, autosomal dominant genetic disorder caused by the decreased or absent activity of ferrochelatase, the final enzyme in the heme biosynthetic pathway. This enzyme defect in peripheral blood progenitor cells leads to the accumulation of protoporphyrin deposits in multiple tissues. Plasmapheresis has been previously reported as an adjunctive therapy for patients with advanced hepatic EPP. Because the concentration of protoporphyrins is severalfold higher inside the red blood cell (RBC) compared to plasma, it was hypothesized that RBC exchange therapy might absorb excess protoporphyrins from the plasma and serve as an effective therapy to reduce protoporphyrin load in patients with advanced hepatic EPP. The effectiveness of RBC exchange plus hematin versus plasmapheresis plus hematin in two patients with advanced hepatic EPP is reported. STUDY DESIGN AND METHODS Two patients with advanced hepatic EPP were treated with RBC exchange and plasmapheresis in the setting of recurrent disease in the graft (Patient 1) or preparation for liver transplantation (Patient 2). In vitro studies were performed to test transport of protoporphyrins from patients' plasma to normal RBCs. RESULTS Compared with plasmapheresis, RBC exchange was more effective, for the duration of the therapy, in reducing blood levels of protoporphyrins. Liver function tests, however, showed only a modest improvement during therapy. In vitro extracellular protoporphyrin were rapidly adsorbed into normal RBCs. CONCLUSION Neither RBC exchange nor plasmapheresis prevented progressive hepatic deterioration in advanced hepatic EPP despite a significant decrease in protoporphyrin levels.
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Affiliation(s)
- Quentin G Eichbaum
- Department of Pathology, Division of Laboratoty Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Richard E, Robert E, Cario-André M, Ged C, Géronimi F, Gerson SL, de Verneuil H, Moreau-Gaudry F. Hematopoietic stem cell gene therapy of murine protoporphyria by methylguanine-DNA-methyltransferase-mediated in vivo drug selection. Gene Ther 2005; 11:1638-47. [PMID: 15284838 DOI: 10.1038/sj.gt.3302335] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [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: 01/17/2023]
Abstract
Erythropoietic protoporphyria (EPP) is an inherited defect of the ferrochelatase (FECH) gene characterized by the accumulation of toxic protoporphyrin in the liver and bone marrow resulting in severe skin photosensitivity. We previously described successful gene therapy of an animal model of the disease with erythroid-specific lentiviral vectors in the absence of preselection of corrected cells. However, the high-level of gene transfer obtained in mice is not translatable to large animal models and humans if there is no selective advantage for genetically modified hematopoietic stem cells (HSCs) in vivo. We used bicistronic SIN-lentiviral vectors coexpressing EGFP or FECH and the G156A-mutated O6-methylguanine-DNA-methyltransferase (MGMT) gene, which allowed efficient in vivo selection of transduced HSCs after O6-benzylguanine and BCNU treatment. We demonstrate for the first time that the correction and in vivo expansion of deficient transduced HSC population can be obtained by this dual gene therapy, resulting in a progressive increase of normal RBCs in EPP mice and a complete correction of skin photosensitivity. Finally, we developed a novel bipromoter SIN-lentiviral vector with a constitutive expression of MGMT gene to allow the selection of HSCs and with an erythroid-specific expression of the FECH therapeutic gene.
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Affiliation(s)
- E Richard
- INSERM E0217, Federative Research Institute 66, Université Victor Segalen Bordeaux 2, Bordeaux France
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