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Dickey AK, Berkovich J, Leaf RK, Jiang PY, Lopez-Galmiche G, Rebeiz L, Wheeden K, Kochevar I, Savage W, Zhao S, Campisi E, Heo SY, Trueb J, LaRochelle EPM, Rogers J, Banks A, Chang JK. Observational pilot study of multi-wavelength wearable light dosimetry for erythropoietic protoporphyria. Int J Dermatol 2024. [PMID: 38602089 DOI: 10.1111/ijd.17166] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) causes painful light sensitivity, limiting quality of life. Our objective was to develop and validate a wearable light exposure device and correlate measurements with light sensitivity in EPP to predict and prevent symptoms. METHODS A wearable light dosimeter was developed to capture light doses of UVA, blue, and red wavelengths. A prospective observational pilot study was performed in which five EPP patients wore two light dosimeters for 3 weeks, one as a watch, and one as a shirt clip. RESULTS Standard deviation (SD) increases from the mean in the daily blue light dose increased the odds ratio (OR) for symptom risk more than the self-reported outdoor time (OR 2.76 vs. 2.38) or other wavelengths, and a one SD increase from the mean in the daily blue light wristband device dose increased the OR for symptom risk more than the daily blue light shirt clip (OR 2.45 vs. 1.62). The area under the receiver operator curve for the blue light wristband dose was 0.78, suggesting 78% predictive accuracy. CONCLUSION These data demonstrate that wearable blue light dosimetry worn as a wristband is a promising method for measuring light exposure and predicting and preventing symptoms in EPP.
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Affiliation(s)
- Amy K Dickey
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Jaime Berkovich
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
- Northwestern University Department of Materials Science and Engineering, Evanston, IL, USA
| | - Rebecca K Leaf
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul Y Jiang
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Lina Rebeiz
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Irene Kochevar
- Harvard Medical School, Boston, MA, USA
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | - Seung Y Heo
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
| | - Jacob Trueb
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
| | | | - John Rogers
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
- Northwestern University Department of Materials Science and Engineering, Evanston, IL, USA
| | - Anthony Banks
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
| | - Jan-Kai Chang
- Wearifi, Inc., Evanston, IL, USA
- Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL, USA
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2
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Mathias SD, Burke L, Colwell HH, Mensing G, Savage W, Naik H. Development and Content Validation of Novel Patient-Reported Outcome Measures to Assess Disease Severity and Change in Patients with Erythropoietic Protoporphyria: The EPP Impact Questionnaire (EPIQ). Patient Relat Outcome Meas 2024; 15:17-30. [PMID: 38375415 PMCID: PMC10875163 DOI: 10.2147/prom.s438892] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose Erythropoietic protoporphyria (EPP), a rare inherited disorder, presents in early childhood with severe, painful phototoxicity, with significant impacts on health-related quality of life (HRQoL). Previous studies have not captured all concepts important to patients. Therefore, this study sought to develop a novel, comprehensive, and content valid patient-reported outcome (PRO) measure to assess the efficacy of new therapies. Patients and Methods Qualitative interviews were conducted with EPP participants and clinical experts to obtain views on concepts relevant to patients. Results informed the development of novel PROs, which were debriefed during subsequent combined concept elicitation and cognitive debriefing interviews. Results Twenty-three interviews were conducted with 17 adults and 6 adolescents with EPP. Concept elicitation revealed that participants experienced many symptoms with significant variability. The most common were burning, pain, swelling, and tingling. Tingling was the most common prodromal symptom, while burning was the most bothersome, and pain was the worst full reaction symptom. Participants reported being negatively impacted in their ability to do daily activities, and social and emotional functioning. Many reported impacted ability to work and be productive at their job. Participants reviewed and completed the newly developed PRO measures assessing full reactions and ability to do activities, as well as items to assess severity and change in severity of prodromal symptoms, full reactions, and EPP overall. All measures were found to be comprehensive, clear, and relevant. Conclusion PRO measures are needed to assess important aspects of HRQoL and evaluate therapeutic response. These PRO measures are unique in assessing overall severity and change in EPP.
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Affiliation(s)
| | | | | | | | | | - Hetanshi Naik
- Department of Genetics, Stanford University School of Medicine, Palo Alto, CA, USA
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3
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Abstract
The porphyrias are a group of rare diseases, each resulting from a defect in a different enzymatic step of the heme biosynthetic pathway. They can be broadly divided into two categories, hepatic and erythropoietic porphyrias, depending on the primary site of accumulation of heme intermediates. These disorders are multisystemic with variable symptoms that can be encountered by physicians in any specialty. Here, we review the porphyrias and describe their clinical presentation, diagnosis, and management. We discuss novel therapies that are approved or in development. Early diagnosis is key for the appropriate management and prevention of long-term complications in these rare disorders.
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Affiliation(s)
- Amy K Dickey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA;
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca Karp Leaf
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA;
| | - Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA;
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4
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Madigan KE, Rudnick SR, Agnew MA, Urooj N, Bonkovsky HL. Illuminating Dersimelagon: A Novel Agent in the Treatment of Erythropoietic Protoporphyria and X-Linked Protoporphyria. Pharmaceuticals (Basel) 2023; 17:31. [PMID: 38256864 PMCID: PMC10819203 DOI: 10.3390/ph17010031] [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: 09/28/2023] [Revised: 11/05/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Erythropoietic protoporphyria (EPP) is a genetic disorder stemming from reduced ferrochelatase expression, the final enzyme in the pathway of heme biosynthesis. A closely related condition, X-linked protoporphyria (XLP), bears similar clinical features although it arises from the heightened activity of δ-aminolevulinic acid synthase 2 (ALAS2), the first and normally rate-controlling enzyme in heme biosynthesis in developing red blood cells. Both of these abnormalities result in the buildup of protoporphyrin IX, leading to excruciating light sensitivity and, in a minority of cases, potentially fatal liver complications. Traditionally, managing EPP and XLP involved sun avoidance. However, the emergence of innovative therapies, such as dersimelagon, is reshaping the therapeutic landscape for these conditions. In this review, we summarize salient features of the properties of dersimelagon, shedding light on its potential role in advancing our understanding of treatment options for EPP and XLP.
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Affiliation(s)
- Katelyn E. Madigan
- Section on Gastroenterology & Hepatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (S.R.R.); (H.L.B.)
| | - Sean R. Rudnick
- Section on Gastroenterology & Hepatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (S.R.R.); (H.L.B.)
| | - Matthew A. Agnew
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA;
| | - Numra Urooj
- Department of Medicine, Parkview Health, Fort Wayne, IN 46845, USA;
| | - Herbert L. Bonkovsky
- Section on Gastroenterology & Hepatology, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; (S.R.R.); (H.L.B.)
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5
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Yasuda M, Lee S, Gan L, Bergonia HA, Desnick RJ, Phillips JD. Cimetidine Does Not Inhibit 5-Aminolevulinic Acid Synthase or Heme Oxygenase Activity: Implications for Treatment of Acute Intermittent Porphyria and Erythropoietic Protoporphyria. Biomolecules 2023; 14:27. [PMID: 38254627 PMCID: PMC10813085 DOI: 10.3390/biom14010027] [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: 11/20/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Acute intermittent porphyria (AIP) is characterized by acute neurovisceral attacks that are precipitated by the induction of hepatic 5-aminolevulinic acid synthase 1 (ALAS1). In erythropoietic protoporphyria (EPP), sun exposure leads to skin photosensitivity due to the overproduction of photoreactive porphyrins in bone marrow erythroid cells, where heme synthesis is primarily driven by the ALAS2 isozyme. Cimetidine has been suggested to be effective for the treatment of both AIP and EPP based on limited case reports. It has been proposed that cimetidine acts by inhibiting ALAS activity in liver and bone marrow for AIP and EPP, respectively, while it may also inhibit the hepatic activity of the heme catabolism enzyme, heme oxygenase (HO). Here, we show that cimetidine did not significantly modulate the activity or expression of endogenous ALAS or HO in wildtype mouse livers or bone marrow. Further, cimetidine did not effectively decrease hepatic ALAS activity or expression or plasma concentrations of the putative neurotoxic porphyrin precursors 5-aminolevulinic acid (ALA) and porphobilinogen (PBG), which were all markedly elevated during an induced acute attack in an AIP mouse model. These results show that cimetidine is not an efficacious treatment for acute attacks and suggest that its potential clinical benefit for EPP is not via ALAS inhibition.
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Affiliation(s)
- Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1425 Madison Ave Box 1498, New York, NY 10029, USA; (S.L.); (L.G.); (R.J.D.)
| | - Sangmi Lee
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1425 Madison Ave Box 1498, New York, NY 10029, USA; (S.L.); (L.G.); (R.J.D.)
| | - Lin Gan
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1425 Madison Ave Box 1498, New York, NY 10029, USA; (S.L.); (L.G.); (R.J.D.)
| | - Hector A. Bergonia
- Department of Medicine, Hematology Division, University of Utah School of Medicine, Salt Lake City, UT 84132, USA; (H.A.B.); (J.D.P.)
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1425 Madison Ave Box 1498, New York, NY 10029, USA; (S.L.); (L.G.); (R.J.D.)
| | - John D. Phillips
- Department of Medicine, Hematology Division, University of Utah School of Medicine, Salt Lake City, UT 84132, USA; (H.A.B.); (J.D.P.)
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6
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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: 8] [Impact Index Per Article: 8.0] [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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7
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Li Q, Chen X, Wang H, Tuo B, Zhou Z, Yang L. A case of erythrogenic protoporphyria with thyrotoxicosis and liver dysfunction in an adult female. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2023; 48:1769-1774. [PMID: 38432869 PMCID: PMC10929955 DOI: 10.11817/j.issn.1672-7347.2023.230242] [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] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Indexed: 03/05/2024]
Abstract
Erythropoietic protoporphyria (EPP) is an inherited metabolic disease caused by the deficiency in ferrochelatase (FECH) encoded by the FECH gene, and it is inherited in an autosomal recessive manner. EPP usually produces acute pain photosensitivity after exposure to sunlight in infancy or early childhood, and liver failure is the most serious associated complication. This article reported an adult female case of EPP complicated with thyrotoxicosis and liver dysfunction which is a rare condition. The patient's liver function improved after liver protection treatment, her thyroid function returned to normal, and her EPP symptoms improved significantly. Moreover, the c.286C>T gene mutation may be the pathogenic locus of EPP. For patients with abnormal liver function, the possibility of EPP should be considered after the common causes are excluded, and FECH gene detection should be done to confirm the diagnosis in time. When EPP is associated with thyrotoxicosis and liver dysfunction, priority may be given to hepatoprotective therapy.
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Affiliation(s)
- Qingqing Li
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000.
| | - Xiaoyan Chen
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000
| | - Hong Wang
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000.
| | - Biguang Tuo
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000
- Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi Guizhou 563000
| | - Zunlan Zhou
- Department of Gastroenterology, Guizhou Aerospace Hospital, Zunyi Guizhou 563000, China
| | - Lina Yang
- Department of Gastroenterology, Digestive Disease Hospital, Affiliated Hospital of Zunyi Medical University, Zunyi Guizhou 563000
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8
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Ogasawara H, Tokodai K, Nakanishi W, Fujio A, Kashiwadate T, Shono Y, Ohta M, Ishikawa Y, Miyagi S, Fujishima F, Unno M, Kamei T. Living-Donor Liver Transplantation for Erythropoietic Protoporphyria: A Case Report and Literature Review. TOHOKU J EXP MED 2023; 261:117-122. [PMID: 37495523 DOI: 10.1620/tjem.2023.j061] [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] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Erythropoietic protoporphyria (EPP) is a very rare disease with an estimated prevalence of 1 in 200,000 individuals. Decreased ferrochelatase activity causes the accumulation of protoporphyrin in the body, and light exposure results in the generation of active oxygen, causing photosensitivity. Liver damage has the greatest influence on the prognosis, and liver transplantation is the only treatment option for patients with decompensated liver cirrhosis. We report a case of living-donor liver transplantation for decompensated liver cirrhosis associated with EPP. The patient was a 52-year-old male who led a normal life except for mild photosensitivity. When the patient was 37-year-old, hepatic dysfunction was noticed. At 48-year-old, high erythrocyte protoporphyrin levels, skin biopsy, and genetic tests resulted in a diagnosis of EPP. The patient underwent living- donor liver transplantation because of decompensated liver cirrhosis. In the operating room and intensive care unit, a special light-shielding film was applied to all light sources to block light with harmful wavelengths during treatment. Due to the need for special measures, a lecture on patients with EPP was given before surgery to deepen understanding among all medical professionals involved in the treatment. As a result, no adverse events occurred during the perioperative period, and the patient was discharged on the 46th post-operative day. Currently, the transplanted liver is functioning extremely well, and the patient is alive 3 years post-transplant. Herein, we describe a case of living donor liver transplantation for EPP with a brief literature review.
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Affiliation(s)
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Wataru Nakanishi
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine
| | | | - Yoshihiro Shono
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Mineto Ohta
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Yuki Ishikawa
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine
| | | | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine
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Tsuda M, Ogawa K, Endou T, Goto T, Ogasawara Y, Ogasawara A. Absorption, metabolism, and excretion of [ 14 C]dersimelagon, an investigational oral selective melanocortin 1 receptor agonist, in preclinical species and healthy volunteers. Pharmacol Res Perspect 2023; 11:e01084. [PMID: 37078227 PMCID: PMC10116397 DOI: 10.1002/prp2.1084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/01/2023] [Accepted: 03/15/2023] [Indexed: 04/21/2023] Open
Abstract
Dersimelagon (formerly MT-7117) is a novel, orally administered nonpeptide small molecule selective agonist for melanocortin 1 receptor currently being investigated for the treatment of erythropoietic protoporphyria, X-linked protoporphyria, and diffuse cutaneous systemic sclerosis (dcSSc). Findings of studies evaluating the absorption, distribution, metabolism, and excretion (ADME) of dersimelagon following a single dose of [14 C]dersimelagon in healthy adult volunteers (N = 6) who participated in phase 1, single-center, open-label, mass balance study (NCT03503266), and in preclinical animal models are presented. Rapid absorption and elimination were observed following oral administration of [14 C]dersimelagon in clinical and nonclinical studies, with a mean Tmax of 30 min in rats and 1.5 h in monkeys, and a median Tmax of 2 h in humans. In rats, there was a widespread distribution of [14 C]dersimelagon-related material, but little or no radioactivity was detected in the brain or fetal tissues. In humans, elimination of radioactivity in urine was negligible (excretion of radioactivity into the urine: 0.31% of dose), and the primary route of excretion was feces, with more than 90% of the radioactivity recovered through 5 days postdose. Based on these findings, dersimelagon is not retained in the human body. Findings from humans and animals suggest dersimelagon is extensively metabolized to the glucuronide in the liver, which is eliminated in bile, and hydrolyzed to unchanged dersimelagon in the gut. The results to date for this orally administered agent elucidate the ADME of dersimelagon in human and animal species and support its continued development for the treatment of photosensitive porphyrias and dcSSc.
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Affiliation(s)
- Minoru Tsuda
- DMPK Research Laboratories, Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | - Kei Ogawa
- Data Science Department, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
| | - Tadashi Endou
- DMPK Research Laboratories, Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | - Takahiro Goto
- DMPK Research Laboratories, Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | - Yuko Ogasawara
- DMPK Research Laboratories, Mitsubishi Tanabe Pharma Corporation, Yokohama, Japan
| | - Akihito Ogasawara
- Data Science Department, Mitsubishi Tanabe Pharma Corporation, Tokyo, Japan
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10
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Dickey AK, Rebeiz L, Raef H, Leaf RK, Elmariah S, Naik H, Anderson K, Conley J, Iyasere C, Zhao S, Birkenfeld JS, Arroyo-Gallego T, Wheeden K, Ducamp S, Christiani DC, Fleming MD, Kochevar I. Prospective observational pilot study of quantitative light dosimetry in erythropoietic protoporphyria. J Am Acad Dermatol 2023; 88:1148-1151. [PMID: 36436693 PMCID: PMC10214829 DOI: 10.1016/j.jaad.2022.11.036] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/30/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Amy K Dickey
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Healthcare Transformation Lab, Massachusetts General Hospital, Boston, Massachusetts.
| | - Lina Rebeiz
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Haya Raef
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Rebecca K Leaf
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Sarina Elmariah
- Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karl Anderson
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, Texas
| | - Jared Conley
- Harvard Medical School, Boston, Massachusetts; Healthcare Transformation Lab, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christiana Iyasere
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Judith S Birkenfeld
- Instituto de Óptica "Daza de Valdés", Consejo Superior de Investigaciones Científicas, Madrid, Spain; MIT linQ, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Teresa Arroyo-Gallego
- MIT linQ, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts; nQ Medical, Cambridge, Massachusetts
| | | | - Sarah Ducamp
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - David C Christiani
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Mark D Fleming
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Irene Kochevar
- Harvard Medical School, Boston, Massachusetts; Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts
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11
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Phototesting in erythropoietic protoporphyria trials: A systematic review. Exp Dermatol 2023. [PMID: 37052136 DOI: 10.1111/exd.14809] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
Severe skin pain when exposed to long wave ultraviolet radiation or visible light is the main symptom of erythropoietic protoporphyria (EPP). Treatment options for EPP are inadequate and new treatments are needed but hampered by the lack of valid efficacy outcomes. Phototesting with well-defined illumination of the skin can be performed reliably. We aimed to provide an overview of phototest procedures used to evaluate EPP treatments. Systematic searches of Embase, MEDLINE and the Cochrane Library were performed. Searches identified 11 studies using photosensitivity as efficacy outcome. The studies used eight different phototest protocols. Illuminations were performed with a filtered high-pressure mercury arc, or a xenon arc lamp equipped with monochromator or filters. Some used broadband, others narrowband illumination. In all protocols phototests were performed on the hands or the back. Endpoints were minimal dose required to induce either first symptom of discomfort, erythema, urticaria or intolerable pain. Other endpoints were change in erythema intensity or diameter of any type of flare after exposure compared to before. In conclusion, protocols displayed extensive variability in illumination set-up and evaluation of phototest reactions. Implementation of a standardized phototest method will allow more consistent and reliable outcome evaluation in future therapeutic research of protoporphyric photosensitivity.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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12
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Miyakami Y, Minamikawa T, Ogawa H, Ichimura-Shimizu M, Tsuneyama K. Definitive Confirmation of Erythropoietic Protoporphyria via Re-biopsy Three Years After Initial Liver Biopsy at Age 15. Cureus 2023; 15:e38017. [PMID: 37228562 PMCID: PMC10204696 DOI: 10.7759/cureus.38017] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) is a rare inherited disorder of porphyrin metabolism that can cause liver damage and cholestatic hepatocellular failure. We report a case of EPP in a teenaged male who underwent liver biopsy for investigation of liver dysfunction of unknown cause. The diagnosis was not made until a re-biopsy approximately three years later, when the patient presented with recurrent skin lesions and elevated blood and urinary protoporphyrin levels. The liver biopsies contained brownish deposits that exhibited birefringence under polarized light and porphyrin fluorescence under fluorescence spectroscopy. EPP should be considered in young patients with unexplained liver dysfunction, skin symptoms, and seasonal changes in symptoms. Fluorescence spectroscopy of liver biopsy tissue can be a useful tool in the diagnosis of EPP.
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Affiliation(s)
- Yuko Miyakami
- Pathology and Laboratory Medicine, Graduate School of Biomedical Sciences, University of Tokushima, Tokushima, JPN
| | - Takeo Minamikawa
- Engineering, Laboratory for Advanced Photonic Science and Technology, University of Tokushima, Tokushima, JPN
| | - Hirohisa Ogawa
- Pathology and Laboratory Medicine, Graduate School of Biomedical Sciences, University of Tokushima, Tokushima, JPN
| | - Mayuko Ichimura-Shimizu
- Pathology and Laboratory Medicine, Graduate School of Biomedical Sciences, University of Tokushima, Tokushima, JPN
| | - Kohichi Tsuneyama
- Pathology and Laboratory Medicine, Graduate School of Biomedical Sciences, University of Tokushima, Tokushima, JPN
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13
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Barman-Aksözen J, Minder AE, Granata F, Pettersson M, Dechant C, Aksözen MH, Falchetto R. Quality-Adjusted Life Years in Erythropoietic Protoporphyria and Other Rare Diseases: A Patient-Initiated EQ-5D Feasibility Study. Int J Environ Res Public Health 2023; 20:5296. [PMID: 37047912 PMCID: PMC10094018 DOI: 10.3390/ijerph20075296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 06/19/2023]
Abstract
Erythropoietic protoporphyria (EPP) is an ultra-rare inborn error of metabolism characterised by painful phototoxic burn injuries after short exposure times to visible light. Patients with EPP are highly adapted to their condition which makes the quantification of their health-related quality of life (QoL) challenging. In the presented patient-initiated feasibility study, we describe a new approach to assess treatment benefits in EPP by measuring QoL with the generic EQ-5D instrument in five patients under long-term (≥two years) treatment with afamelanotide, the first approved therapy for EPP. For the study, we selected patients with EPP who in addition were affected by an involuntary treatment interruption (caused by a temporary reimbursement suspension) because we hypothesized that individuals who had previously unlearned their adaptation are better able to assess their life without treatment than treatment-naïve patients. QoL under treatment was comparable to the age-matched population norm, and retrospective results for a treatment interruption and phototoxic reaction time point were comparable to the QoL of patients with chronic neuropathic pain and acute burn injuries, respectively. The results were accepted by the National Institute for Health and Care Excellence in England for their evaluation of the cost-effectiveness of afamelanotide, i.e., the calculation of quality-adjusted life years.
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Affiliation(s)
- Jasmin Barman-Aksözen
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
- Institute of Laboratory Medicine, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Anna-Elisabeth Minder
- Swiss Reference Centre for Porphyrias, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
- Division for Endocrinology, Diabetology and Porphyria, Municipal Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Francesca Granata
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, S.C Medicine and Metabolic Disorders, 20122 Milano, Italy
| | - Mårten Pettersson
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
| | - Cornelia Dechant
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
| | | | - Rocco Falchetto
- International Porphyria Patient Network (IPPN), 8032 Zurich, Switzerland
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14
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Bhagat N, Singh P, De A, Mitra S, Kumar A, Dhanasekaran V, Parkhi MV, Ray D, Duseja A. An Enigmatic Case of Jaundice and Photosensitivity in an Adolescent. ACG Case Rep J 2023; 10:e00996. [PMID: 36891180 DOI: 10.14309/crj.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/30/2023] [Indexed: 03/06/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) presents with nonblistering photosensitivity. Hepatobiliary manifestations are seen in around 5% cases and include cholelithiasis, elevations in liver enzymes, progressive jaundice, and end-stage liver disease. The diagnosis is suspected based on clinical features and elevated erythrocyte metal-free protoporphyrin and confirmed by genetic analysis showing loss-of-function mutations in the ferrochelatase (FECH) gene. We present an adolescent boy who presented with jaundice and photosensitivity with the liver biopsy showing deposition of brown pigments within the canaliculi and hepatocytes. This pigment showed Maltese cross birefringence on polarizing microscopy and Medusa-head appearance on electron microscopy. Genetic analysis revealed loss-of-function mutations in FECH. Introduction of EPP is an inborn error of heme biosynthesis caused by mutations in FECH with a prevalence of 1:75,000 to 1:200,000. We present a case of a 16-year-old adolescent boy with photosensitivity, abdominal pain, and jaundice with protoporphyrin deposition in the liver who was ultimately diagnosed with EPP based on genetic analysis.
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15
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Takami T, Itatani Y, Shibuya R, Kiyasu Y, Kasahara K, Nishizaki D, Okamura R, Okada T, Nishigori T, Hoshino N, Hisamori S, Tsunoda S, Hida K, Kawada K, Obama K. Single-incision laparoscopic partial cecectomy for appendiceal mucocele in a patient with porphyria photosensitivity. Asian J Endosc Surg 2023; 16:86-89. [PMID: 35781071 DOI: 10.1111/ases.13102] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 01/05/2023]
Abstract
Erythropoietic protoporphyria (EPP) is a rare hereditary subtype of cutaneous porphyria characterized by photosensitivity. Increased exposure to light irradiation may precipitate acute liver failure, and surgical light-induced intestinal burns and perforations are known to occur. We report a case of EPP in a patient who underwent laparoscopic partial cecectomy for appendiceal mucocele. A 55-year-old man with EPP was presented for treatment of appendiceal mucocele. A light test using two types of laparoscopes (Companies O and S) was performed preoperatively. Light from the laparoscope manufactured by Company O caused photosensitivity; this effect was not observed with light from the laparoscope manufactured by Company S. Therefore, we performed laparoscopic partial cecectomy through a single umbilical incision using the laparoscope from Company S. Except for the incision site, the patient's skin was completely covered using surgical drapes. No intra- or postoperative complications were observed. Histopathological examination of the resected specimen revealed a low-grade appendiceal mucinous neoplasm.
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Affiliation(s)
- Takuya Takami
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiro Itatani
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Rintaro Shibuya
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiyuki Kiyasu
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Keiko Kasahara
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Daisuke Nishizaki
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Okamura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoaki Okada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuto Nishigori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobuaki Hoshino
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeo Hisamori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shigeru Tsunoda
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Kawada
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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16
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Endo Y, Hibi T, Shinoda M, Obara H, Kitago M, Yagi H, Abe Y, Hasegawa Y, Matsubara K, Hori S, Tanaka M, Makiuchi S, Nakano Y, Itano O, Kuroda T, Kitagawa Y. Reappraisal of liver transplantation for erythropoietic protoporphyria: A deadly combination of disease recurrence and biliary complication. Pediatr Transplant 2022; 26:e14261. [PMID: 35225415 DOI: 10.1111/petr.14261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 09/03/2021] [Revised: 01/23/2022] [Accepted: 02/17/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited disorder that causes the accumulation of protoporphyrin in the erythrocytes, skin, and liver. Severe protoporphyric hepatopathy results in liver failure, requiring both liver and bone marrow transplantation as a life-saving procedure and to correct the underlying enzymatic defect, respectively. CASE PRESENTATION We report a 20-year-old man who underwent split liver transplantation using a right trisegment and caudate lobe graft for EPP-induced liver failure, but succumbed to a deadly combination of early relapse of EPP and subsequent, intractable, late-onset bile leakage from the cut surface of segment 4. EPP recurrence most likely created a high-risk situation for bile leakage from the non-communicating bile ducts of segment 4; therefore, this case shed light on the potential relationship between EPP recurrence and biliary complications. CONCLUSION Physicians should recognize the potentially rapid and life-threatening progression of protoporphyric hepatopathy that leads to liver failure. For young patients with EPP, LT and sequential BMT should thoroughly be considered by a multidisciplinary team as soon as hepatic reserve deterioration becomes evident. Split liver transplantation should preferably be avoided and appropriate post-transplant management is critical before protoporphyrin depositions to the bile duct and hepatocyte causes irreversible damage to the liver graft.
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Affiliation(s)
- Yutaka Endo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Masahiro Shinoda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.,Department of Digestive Center, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Matsubara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masayuki Tanaka
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satomi Makiuchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Itano
- Department of Gastrointestinal Surgery, International University of Health and Welfare, Chiba, Japan
| | - Tatsuo Kuroda
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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17
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Di Pierro E, Granata F, De Canio M, Rossi M, Ricci A, Marcacci M, De Luca G, Sarno L, Barbieri L, Ventura P, Graziadei G. Recognized and Emerging Features of Erythropoietic and X-Linked Protoporphyria. Diagnostics (Basel) 2022; 12:diagnostics12010151. [PMID: 35054318 PMCID: PMC8775248 DOI: 10.3390/diagnostics12010151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are inherited disorders resulting from defects in two different enzymes of the heme biosynthetic pathway, i.e., ferrochelatase (FECH) and delta-aminolevulinic acid synthase-2 (ALAS2), respectively. The ubiquitous FECH catalyzes the insertion of iron into the protoporphyrin ring to generate the final product, heme. After hemoglobinization, FECH can utilize other metals like zinc to bind the remainder of the protoporphyrin molecules, leading to the formation of zinc protoporphyrin. Therefore, FECH deficiency in EPP limits the formation of both heme and zinc protoporphyrin molecules. The erythroid-specific ALAS2 catalyses the synthesis of delta-aminolevulinic acid (ALA), from the union of glycine and succinyl-coenzyme A, in the first step of the pathway in the erythron. In XLP, ALAS2 activity increases, resulting in the amplified formation of ALA, and iron becomes the rate-limiting factor for heme synthesis in the erythroid tissue. Both EPP and XLP lead to the systemic accumulation of protoporphyrin IX (PPIX) in blood, erythrocytes, and tissues causing the major symptom of cutaneous photosensitivity and several other less recognized signs that need to be considered. Although significant advances have been made in our understanding of EPP and XLP in recent years, a complete understanding of the factors governing the variability in clinical expression and the severity (progression) of the disease remains elusive. The present review provides an overview of both well-established facts and the latest findings regarding these rare diseases.
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Affiliation(s)
- Elena Di Pierro
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
- Correspondence: or ; Tel.: +39-0255036155
| | - Francesca Granata
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Michele De Canio
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Mariateresa Rossi
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Andrea Ricci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Matteo Marcacci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giacomo De Luca
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Luisa Sarno
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Luca Barbieri
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Paolo Ventura
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giovanna Graziadei
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
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18
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Sernicola A, Cama E, Pelizzo MG, Tessarolo E, Nicolli A, Viero G, Alaibac M. In vitro Assessment of Solar Filters for Erythropoietic Protoporphyria in the Action Spectrum of Protoporphyrin IX. Front Med (Lausanne) 2021; 8:796884. [PMID: 34988101 PMCID: PMC8720878 DOI: 10.3389/fmed.2021.796884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: Subjects with erythropoietic protoporphyria rely on broad-spectrum sunscreens with high sun protection factor, which is not informative on efficacy in the absorption spectrum of protoporphyrin IX, spanning visible radiation and peaking around 408 nm. Photoactivation of protoporphyrin IX is responsible for painful skin photosensitivity in erythropoietic protoporphyria. The authors assessed the protective efficacy of six sunscreens in vitro in the absorption spectrum of protoporphyrin IX. Method: Transmittance measurements were performed in the 300-850 nm wavelengths on samples of six photoprotective products applied to polymethyl methacrylate plates. Porphyrin protection factor was calculated in the 300-700 nm region to provide a measurement for the efficacy of each product based on the action spectrum of protoporphyrin IX. Results: Product A showed the highest porphyrin protection factor among tested products with a median value of 4.22. Product A is a sunscreen containing organic filters, titanium dioxide and synthetic iron oxides, pigmentary grade active ingredients that absorb visible radiation. Other products showed inefficient protection in the visible, with transmittance between 75 and 95% at 500 nm. The low porphyrin protection factor of inorganic filter product B was attributed to particle micronization, as declared by the manufacturer. Conclusion: Adding porphyrin protection factor to sunscreen labeling could help patients with erythropoietic protoporphyria and other photosensitivity disorders identify products tailored on their specific needs. The development of sunscreens providing protection from visible radiation and excellent cosmetical tolerability could improve the lifestyle of patients with erythropoietic protoporphyria.
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Affiliation(s)
- Alvise Sernicola
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Elena Cama
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Maria Guglielmina Pelizzo
- Department of Information Engineering, University of Padova, Padua, Italy
- Institute for Photonics and Nanotechnologies, National Research Council of Italy, Padua, Italy
| | - Enrico Tessarolo
- Institute for Photonics and Nanotechnologies, National Research Council of Italy, Padua, Italy
| | - Annamaria Nicolli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health (DCTV), University of Padova, Padua, Italy
| | - Giulia Viero
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Mauro Alaibac
- Dermatology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
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19
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Pathman L, Bennett M, d'Udekem Y, Phillips R. Cardiopulmonary bypass in a child with erythropoietic protoporphyria. Australas J Dermatol 2021; 63:e60-e62. [PMID: 34817070 DOI: 10.1111/ajd.13751] [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: 08/30/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
Children with erythropoietic porphyria are generally under the care of paediatric dermatologists. When these children undergo major surgery, they are at risk of unusual complications due to their photosensitivity. Dermatologists may be consulted prior to surgery for advice. We describe a case of a child with erythropoietic porphyria undergoing open heart surgery, utilising an exchange transfusion alongside other strategies to minimise the risk of photosensitivity-induced haemolysis.
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Affiliation(s)
| | | | - Yves d'Udekem
- The Royal Children's Hospital, Melbourne, Australia.,Children's National Hospital, Washington, DC, USA
| | - Roderic Phillips
- The Royal Children's Hospital, Melbourne, Australia.,Monash Medical Centre, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
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20
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Poli A, Schmitt C, Moulouel B, Mirmiran A, Puy H, Lefèbvre T, Gouya L. Iron, Heme Synthesis and Erythropoietic Porphyrias: A Complex Interplay. Metabolites 2021; 11:798. [PMID: 34940556 DOI: 10.3390/metabo11120798] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/13/2022] Open
Abstract
Erythropoietic porphyrias are caused by enzymatic dysfunctions in the heme biosynthetic pathway, resulting in porphyrins accumulation in red blood cells. The porphyrins deposition in tissues, including the skin, leads to photosensitivity that is present in all erythropoietic porphyrias. In the bone marrow, heme synthesis is mainly controlled by intracellular labile iron by post-transcriptional regulation: translation of ALAS2 mRNA, the first and rate-limiting enzyme of the pathway, is inhibited when iron availability is low. Moreover, it has been shown that the expression of ferrochelatase (FECH, an iron-sulfur cluster enzyme that inserts iron into protoporphyrin IX to form heme), is regulated by intracellular iron level. Accordingly, there is accumulating evidence that iron status can mitigate disease expression in patients with erythropoietic porphyrias. This article will review the available clinical data on how iron status can modify the symptoms of erythropoietic porphyrias. We will then review the modulation of heme biosynthesis pathway by iron availability in the erythron and its role in erythropoietic porphyrias physiopathology. Finally, we will summarize what is known of FECH interactions with other proteins involved in iron metabolism in the mitochondria.
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21
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Wang YM, Gloude NJ, Davies SM, Lucky AW, Nelson AS. Hematopoietic stem cell transplant for erythropoietic porphyrias in pediatric patients. Pediatr Blood Cancer 2021; 68:e29231. [PMID: 34245225 DOI: 10.1002/pbc.29231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/02/2020] [Revised: 06/06/2021] [Accepted: 06/25/2021] [Indexed: 11/08/2022]
Abstract
Cutaneous, hematopoietic, and hepatic manifestations of congenital erythropoietic porphyria (CEP) and erythropoietic protoporphyria (EPP) can be debilitating. We present our institution's experience with five patients with porphyria who underwent hematopoietic stem cell transplant (HSCT). Four patients with CEP, including three under age 2, received myeloablation. One patient with EPP, with prior liver transplant, received reduced intensity conditioning (RIC). Four patients are alive without porphyria symptomology and with full donor chimerism. HSCT corrects the defective heme pathway and should be considered early in patients with severe erythropoietic porphyrias to minimize end-organ damage. RIC regimens can minimize toxicity in patients with comorbidities.
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Affiliation(s)
- YunZu M Wang
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicholas J Gloude
- Division of Hematology Oncology, Rady Children's Hospital and Department of Pediatrics, University of California, San Diego, California, USA
| | - Stella M Davies
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Anne W Lucky
- Division of Dermatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam S Nelson
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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22
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Noyman Y, Edel Y, Snast I, Sherman S, Kaftory R, Lapidoth M, Mimouni D, Hodak E, Levi A. Inherited genetic late-onset erythropoietic protoporphyria: A systematic review of the literature. Photodermatol Photoimmunol Photomed 2021; 37:374-379. [PMID: 33556208 DOI: 10.1111/phpp.12667] [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] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/18/2021] [Accepted: 02/04/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Inherited genetic erythropoietic protoporphyria (EPP) is characterized by a photosensitive rash that emerges during infancy or early childhood. Acquired EPP can erupt at any age, even during adulthood, and is associated with hematological disorders. A third, less-studied type of EPP is also inherited but appears later in life (during adulthood). PURPOSE To evaluate the characteristics of inherited genetic late-onset (IGLO) EPP. METHODS A systematic comprehensive search of the literature was conducted using PubMed, Google Scholar, ScienceDirect, and clinicaltrials.gov databases. Studies describing patients with IGLO EPP were included. Additionally, we present an index case of a patient, treated at our clinic in whom inherited genetic EPP was diagnosed at age 21 years. RESULTS The search yielded 1514 citations. Five publications were eligible for review. Along with our case, 7 patients (4 males) were included in the analysis. Mean age at disease onset was 34.2 years (range 18-69, median 30). Most patients presented with mild pruritus and rash in a photosensitive distribution. Mean level of free erythrocyte protoporphyrin IX (FEP) was 8.6 μmol/L. A mutant ferrochelatase gene (FECH) in trans to a hypomorphic FECH allele was found in 3 of the 4 patients who underwent genetic testing. CONCLUSION We describe the distinct features of IGLO EPP. This work emphasizes that a diagnosis of inherited genetic EPP should not be ruled out in adults with new-onset photosensitive manifestations.
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Affiliation(s)
- Yehonatan Noyman
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Porphyria Center, Rabin Medical Center - Beilnson Hospital, Petah Tikva, Israel
- Rheumatology Unit, Rabin Medical Center - Beilnson Hospital, Petah Tikva, Israel
| | - Igor Snast
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shany Sherman
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kaftory
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Mimouni
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Emmilia Hodak
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assi Levi
- Photodermatosis Service, Division of Dermatology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Genovese G, Maronese CA, Moltrasio C, Piccinno R, Marletta DA, De Luca G, Graziadei G, Granata F, Di Pierro E, Cappellini MD, Marzano AV. Ultraviolet A phototest positivity is associated with higher free erythrocyte protoporphyrin IX concentration and lower transferrin saturation values in erythropoietic protoporphyria. Photodermatol Photoimmunol Photomed 2021; 38:141-149. [PMID: 34420239 PMCID: PMC9291137 DOI: 10.1111/phpp.12727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/15/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare disorder of heme biosynthesis hallmarked by early-onset photosensitivity and mainly due to defective ferrochelatase activity leading to increased erythrocyte protoporphyrin IX (PPIX) levels. Evidence regarding the relationship between erythrocyte PPIX concentration and photosensitivity is limited. METHODS To investigate the relationship between free erythrocyte PPIX (FEP) concentration; routine laboratory tests, particularly iron metabolism biomarkers; and ultraviolet (UV) A/visible light phototesting findings, 20 genetically confirmed EPP and one XLPP treatment-naive patients were included in our study. They underwent UVA and visible light phototesting. On the same day, blood samples were collected for measurement of FEP, serum iron, transferrin, transferrin saturation, and ferritin, 25-hydroxyvitamin D, and liver enzyme levels. RESULTS Median FEP concentration at the time of phototesting was 57.50 (IQR: 34.58-102.70) μg/g of Hb. UVA and visible light phototesting were positive in 9 (42.9%) and 8 (38.1%) patients, respectively. Median FEP concentration was significantly higher in UVA phototest-positive patients than in those negative (64.37 [IQR: 57.45-121.82] vs 45.35 [IQR: 24.53-74.61] μg/g of Hb, respectively; P = .04486). Similarly, UVA photosensitive individuals had significantly lower median serum iron levels (61.5 [IQR: 33.5-84] μg/dL vs 109 [IQR: 63.25-154] μg/dL, respectively; P = .01862) and transferrin saturation values (15.005 [IQR: 7.0775-18.41] % vs 29.645 [IQR: 17.8225-34.3575] %; P = .0109) than those negative. CONCLUSIONS Our study demonstrates that UVA phototest positivity is associated with higher FEP concentration and lower transferrin saturation and serum iron concentration in EPP.
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Affiliation(s)
- Giovanni Genovese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Carlo Alberto Maronese
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Roberta Piccinno
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Antonio Marletta
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Giacomo De Luca
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Graziadei
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Granata
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Di Pierro
- General Medicine Unit, Rare Disease Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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24
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Halloy F, Iyer PS, Ghidini A, Lysenko V, Barman-Aksözen J, Grubenmann CP, Jucker J, Wildner-Verhey van Wijk N, Ruepp MD, Minder EI, Minder AE, Schneider-Yin X, Theocharides APA, Schümperli D, Hall J. Repurposing of glycine transport inhibitors for the treatment of erythropoietic protoporphyria. Cell Chem Biol 2021; 28:1221-1234.e6. [PMID: 33756123 DOI: 10.1016/j.chembiol.2021.02.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/19/2021] [Accepted: 02/23/2021] [Indexed: 12/16/2022]
Abstract
Erythropoietic protoporphyria (EPP) is a rare disease in which patients experience severe light sensitivity. It is caused by a deficiency of ferrochelatase (FECH), the last enzyme in heme biosynthesis (HBS). The lack of FECH causes accumulation of its photoreactive substrate protoporphyrin IX (PPIX) in patients' erythrocytes. Here, we explored an approach for the treatment of EPP by decreasing PPIX synthesis using small-molecule inhibitors directed to factors in the HBS pathway. We generated a FECH-knockout clone from K562 erythroleukemia cells, which accumulates PPIX and undergoes oxidative stress upon light exposure. We used these matched cell lines to screen a set of publicly available inhibitors of factors in the HBS pathway. Inhibitors of the glycine transporters GlyT1 and GlyT2 lowered levels of PPIX and markers of oxidative stress selectively in K56211B4 cells, and in primary erythroid cultures from an EPP patient. Our findings open the door to investigation of glycine transport inhibitors for HBS disorders.
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Affiliation(s)
- François Halloy
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Pavithra S Iyer
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Alice Ghidini
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Veronika Lysenko
- Department of Medical Oncology and Hematology, University Hospital and University of Zurich, 8091 Zurich, Switzerland
| | - Jasmin Barman-Aksözen
- Institute of Laboratory Medicine, Municipal Hospital Waid and Triemli, 8063 Zurich, Switzerland
| | - Chia-Pei Grubenmann
- Institute of Laboratory Medicine, Municipal Hospital Waid and Triemli, 8063 Zurich, Switzerland
| | - Jessica Jucker
- Institute of Laboratory Medicine, Municipal Hospital Waid and Triemli, 8063 Zurich, Switzerland
| | | | - Marc-David Ruepp
- UK Dementia Research Institute at King's College London, SE5 9RT London, UK; Institute of Psychiatry, Psychology and Neuroscience, King's College London, SE5 8AF London, UK
| | - Elisabeth I Minder
- Department for Endocrinology, Diabetology, Porphyria, Municipal Hospital Waid and Triemli, 8063 Zurich, Switzerland
| | - Anna-Elisabeth Minder
- Department for Endocrinology, Diabetology, Porphyria, Municipal Hospital Waid and Triemli, 8063 Zurich, Switzerland
| | - Xiaoye Schneider-Yin
- Institute of Laboratory Medicine, Municipal Hospital Waid and Triemli, 8063 Zurich, Switzerland
| | - Alexandre P A Theocharides
- Department of Medical Oncology and Hematology, University Hospital and University of Zurich, 8091 Zurich, Switzerland
| | - Daniel Schümperli
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland.
| | - Jonathan Hall
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland.
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25
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Minder AE, Barman-Aksoezen J, Schmid M, Minder EI, Zulewski H, Minder CE, Schneider-Yin X. Beyond pigmentation: signs of liver protection during afamelanotide treatment in Swiss patients with erythropoietic protoporphyria, an observational study. Ther Adv Rare Dis 2021; 2:26330040211065453. [PMID: 37181106 PMCID: PMC10032460 DOI: 10.1177/26330040211065453] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/18/2021] [Indexed: 05/16/2023]
Abstract
Erythropoietic protoporphyria (EPP) is an ultra-rare inherited disorder with overproduction of protoporphyrin in maturating erythroblasts. This excess protoporphyrin leads to incapacitating phototoxic burns in sunlight exposed skin. Its biliary elimination causes cholestatic liver injury in 20% and terminal liver failure in 4% of EPP patients. Thereby, the risk of liver injury increases with increasing erythrocyte protoporphyrin concentrations. Afamelanotide, an α-melanocyte-stimulating hormone (MSH) analog inducing skin pigmentation, was shown to improve sunlight tolerance in EPP. Beyond this well-known effect on pigmentation, the MSHs have liver-protective effects and improve survival of maturating erythroblasts, effects described in animal or in vitro models to date only. We investigated whether afamelanotide treatment in EPP has effects on erythropoiesis, protoporphyrin concentrations, and liver injury by analyzing retrospectively our long-term safety data. Methods From the 47 Swiss EPP-patients treated at our center since 2006, we included those 38 patients in the current analysis who received at least one afamelanotide dose between 2016 and 2018 and underwent regular laboratory testing before and during the treatment. We compared the means of pretreatment measurements with those during the treatment. Results Protoporphyrin concentrations dropped from 21.39 ± 11.12 (mean ± SD) before afamelanotide to 16.83 ± 8.24 µmol/L (p < .0001) during treatment. Aspartate aminotransferase decreased from 26.67 ± 13.16 to 22.9 ± 7.76 IU/L (p = .0146). For both entities, patients with higher values showed a more progressive decrease, indicating a risk reduction of EPP-related liver disease. The pre-existing hypochromia and broad mean red-cell distribution width were further augmented under afamelanotide. This was more likely due to an influence of afamelanotide on maturating erythroblasts than due to an exacerbated iron deficiency, as mean zinc-protoporphyrin decreased significantly and ferritin remained unchanged. No serious afamelanotide-related adverse events were observed for a total of 240 treatment years. Conclusion Our findings point to a protective effect of afamelanotide on erythroblast maturation and protoporphyrin-induced liver injury. Plain Language summary Afamelanotide, a skin tanning hormone, may protect patients with erythropoietic protoporphyria not only from skin burns, but also from liver injury associated with the disease. Patients with erythropoietic protoporphyria (EPP), an inherited metabolic disease, suffer from light-induced skin burns and liver injury elicited by the accumulated light sensitizer protoporphyrin. The excess protoporphyrin is produced in red cell precursors in the bone marrow, and it is eliminated from the body via the liver and bile. A high protoporphyrin excretion burden damages the liver cells, the risk for this increases with higher protoporphyrin concentrations. About 20% of EPP patients show some sign of liver injury and 4% develop life-threatening liver dysfunction.Afamelanotide, closely related to natural α-melanocyte stimulating hormone (MSH), induces skin tanning. This effect protects EPP patients from light-induced skin burns as shown in previous studies. We have treated Swiss EPP patients with afamelanotide since 2006, and we regularly perform safety tests of this treatment.Recent in vitro and animal studies demonstrated α-MSH effects other than skin tanning, including an improved synthesis of red blood cell precursors in the bone-marrow and protection of the liver from experimentally induced damage. Until now, it is unknown whether afamelanotide has similar effects in the human organism.To study this question, we analyzed retrospectively the safety laboratory data of 38 Swiss patients, who received at least one dose of afamelanotide from 2016 to 2019. We found that both, the average protoporphyrin concentrations and aspartate aminotransferase, a test for liver function, improved during afamelanotide treatment as compared to before.We concluded that afamelanotide applied to EPP patients to protect them from light-induced skin burns also may reduce their risk of liver injury.
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Affiliation(s)
- Anna-Elisabeth Minder
- Division of Endocrinology, Diabetology,
Porphyria, Stadtspital Zürich, Birmensdorferstrasse 497, 8063 Zurich,
Switzerland
| | | | - Mathias Schmid
- Department of Hematology and Oncology,
Stadtspital Zürich, Zurich, Switzerland
| | - Elisabeth I. Minder
- Division of Endocrinology, Diabetology,
Porphyria, Stadtspital Zürich, Zurich, Switzerland
| | - Henryk Zulewski
- Division of Endocrinology, Diabetology,
Porphyria, Stadtspital Zürich, Zurich, Switzerland
| | - Christoph E. Minder
- Department of Social and Preventive Medicine,
University of Bern, Bern, Switzerland
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26
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Liu Y, Trnka MJ, Guan S, Kwon D, Kim DH, Chen JJ, Greer PA, Burlingame AL, Correia MA. A Novel Mechanism for NF-κB-activation via IκB-aggregation: Implications for Hepatic Mallory-Denk-Body Induced Inflammation. Mol Cell Proteomics 2020; 19:1968-1986. [PMID: 32912968 PMCID: PMC7710137 DOI: 10.1074/mcp.ra120.002316] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 08/31/2020] [Indexed: 11/06/2022] Open
Abstract
Mallory-Denk-bodies (MDBs) are hepatic protein aggregates associated with inflammation both clinically and in MDB-inducing models. Similar protein aggregation in neurodegenerative diseases also triggers inflammation and NF-κB activation. However, the precise mechanism that links protein aggregation to NF-κB-activation and inflammatory response remains unclear. Herein we find that treating primary hepatocytes with MDB-inducing agents (N-methylprotoporphyrin (NMPP), protoporphyrin IX (PPIX), or Zinc-protoporphyrin IX (ZnPP)) elicited an IκBα-loss with consequent NF-κB activation. Four known mechanisms of IκBα-loss i.e. the canonical ubiquitin-dependent proteasomal degradation (UPD), autophagic-lysosomal degradation, calpain degradation and translational inhibition, were all probed and excluded. Immunofluorescence analyses of ZnPP-treated cells coupled with 8 M urea/CHAPS-extraction revealed that this IκBα-loss was due to its sequestration along with IκBβ into insoluble aggregates, thereby releasing NF-κB. Through affinity pulldown, proximity biotinylation by antibody recognition, and other proteomic analyses, we verified that NF-κB subunit p65, which stably interacts with IκBα under normal conditions, no longer binds to it upon ZnPP-treatment. Additionally, we identified 10 proteins that interact with IκBα under baseline conditions, aggregate upon ZnPP-treatment, and maintain the interaction with IκBα after ZnPP-treatment, either by cosequestering into insoluble aggregates or through a different mechanism. Of these 10 proteins, the nucleoporins Nup153 and Nup358/RanBP2 were identified through RNA-interference, as mediators of IκBα-nuclear import. The concurrent aggregation of IκBα, NUP153, and RanBP2 upon ZnPP-treatment, synergistically precluded the nuclear entry of IκBα and its consequent binding and termination of NF-κB activation. This novel mechanism may account for the protein aggregate-induced inflammation observed in liver diseases, thus identifying novel targets for therapeutic intervention. Because of inherent commonalities this MDB cell model is a bona fide protoporphyric model, making these findings equally relevant to the liver inflammation associated with clinical protoporphyria.
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Affiliation(s)
- Yi Liu
- Departments of Cellular & Molecular Pharmacology, University of California San Francisco, San Francisco, California, USA
| | - Michael J Trnka
- Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Shenheng Guan
- Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Doyoung Kwon
- Departments of Cellular & Molecular Pharmacology, University of California San Francisco, San Francisco, California, USA
| | - Do-Hyung Kim
- Departments of Biochemistry, Molecular Biology, and Biophysics, University of Minnesota, Minneapolis, USA
| | - J-J Chen
- Institute for Medical Engineering and Science, MIT, Cambridge, Massachusetts, USA
| | - Peter A Greer
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - A L Burlingame
- Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA
| | - Maria Almira Correia
- Departments of Cellular & Molecular Pharmacology, University of California San Francisco, San Francisco, California, USA; Pharmaceutical Chemistry, University of California San Francisco, San Francisco, California, USA; Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA; The Liver Center, University of California San Francisco, San Francisco, California, USA.
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27
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Ventura P, Brancaleoni V, Di Pierro E, Graziadei G, Macrì A, Carmine Guida C, Nicolli A, Rossi MT, Granata F, Fiorentino V, Fustinoni S, Sala R, Pinton PC, Trevisan A, Marchini S, Cuoghi C, Marcacci M, Corradini E, Sorge F, Aurizi C, Savino MG, Cappellini MD, Pietrangelo A. Clinical and molecular epidemiology of erythropoietic protoporphyria in Italy. Eur J Dermatol 2020; 30:532-40. [PMID: 33021473 DOI: 10.1684/ejd.2020.3880] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a rare inherited disease associated with heme metabolism, characterized by severe life-long photosensitivity and liver involvement. OBJECTIVE To provide epidemiological data of EPP in Italy. MATERIALS & METHODS Prospective/retrospective data of EPP patients were collected by an Italian network of porphyria specialist centres (Gruppo Italiano Porfiria, GrIP) over a 20-year period (1996-2017). RESULTS In total, 179 patients (79 females) with a clinical and biochemical diagnosis of EPP were assessed, revealing a prevalence of 3.15 cases per million persons and an incidence of 0.13 cases per million persons/year. Incidence significantly increased after 2009 (due to the availability of alfa-melanotide, which effectively limits skin photosensitivity). Mean age at diagnosis was 28 years, with only 22 patients (12.2%) diagnosed ≤10 years old. Gene mutations were assessed in 173 (96.6%) patients; most (164; 91.3%) were FECH mutations on one allele in association with the hypomorphic variant, c.315-48C, on the other (classic EPP), and nine (5.2%) were ALAS2 mutations (X-linked EPP). Only one case of autosomal recessive EPP was observed. Of the 42 different FECH mutations, 15 are novel, three mutations collectively accounted for 45.9% (75/164) of the mutations (c.215dupT [27.2%], c.901_902delTG [11.5%] and c.67 + 5G > A [7.2%]), and frameshift mutations were prevalent (33.3%). A form of light protection was used by 109/179 (60.8%) patients, and 100 (56%) had at least one α-melanotide implant. Three cases of severe acute liver involvement, requiring OLT, were observed. CONCLUSION These data define, for the first time, the clinical and molecular epidemiology of EPP in Italy.
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28
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Levoska MA, Griffith JL, Nagai S, Collins K, Lim HW. A multidisciplinary approach utilizing filters for surgical procedures in erythropoietic protoporphyria. J Am Acad Dermatol 2020; 83:e329-e330. [PMID: 32068036 DOI: 10.1016/j.jaad.2020.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/03/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Melissa A Levoska
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.
| | - James L Griffith
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
| | - Shunji Nagai
- Transplant Institute, Henry Ford Hospital, Detroit, Michigan
| | - Kelly Collins
- Transplant Institute, Henry Ford Hospital, Detroit, Michigan
| | - Henry W Lim
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan
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29
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Snast I, Kaftory R, Sherman S, Edel Y, Hodak E, Levi A, Lapidoth M. Acquired erythropoietic protoporphyria: A systematic review of the literature. Photodermatol Photoimmunol Photomed 2019; 36:29-33. [PMID: 31374130 DOI: 10.1111/phpp.12501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/16/2019] [Accepted: 07/24/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) is a semi-dominantly inherited porphyria presenting with photosensitivity during early childhood. Acquired EPP has been reported; however, data regarding this rare disorder are scarce. PURPOSE To evaluate the characteristics of acquired EPP. METHODS A comprehensive search of PubMed, Google Scholar, ScienceDirect, and clinicaltrials.gov databases was performed by three reviewers. Studies describing patients with acquired EPP were included. Additionally, we present an index case of a 26-year-old patient who acquired clinically and biochemically typical EPP in association with myelodysplastic syndrome (MDS). RESULTS We included 20 case reports describing 20 patients. Most (80%) patients were male of mean age 58 ± 13 years. In all patients, acquired EPP was associated with hematological disease, most commonly MDS (85%) followed by myeloproliferative disease (10%). In 86% of cases, hematological disease led to abnormality or somatic mutation in chromosome 18q (the locus of the ferrochelatase gene). The mean erythrocyte protoporphyrin IX concentration was very high (4286 μg/dL). Most (90%) patients presented with photosensitivity, 20% experienced blistering, and 25% presented with hepatic insufficiency, both uncommon in EPP. In 55% of patients, hematological disease was diagnosed after occurrence of cutaneous symptoms. Beta-carotene led to partial control of symptoms in 5 patients and resolution in another patient. Azacitidine treatment of MDS led to resolution of cutaneous symptoms in three patients. CONCLUSION We present the distinct features of acquired EPP and highlight that any patient presenting with new-onset photosensitivity, irrespective of age should be evaluated for porphyria.
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Affiliation(s)
- Igor Snast
- Photodermatosis Clinic, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kaftory
- Photodermatosis Clinic, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel
| | - Shani Sherman
- Photodermatosis Clinic, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Edel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Porphyria Center, Rabin Medical Center, Petach Tikva, Israel.,Rheumatology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Emmilia Hodak
- Photodermatosis Clinic, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assi Levi
- Photodermatosis Clinic, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Lapidoth
- Photodermatosis Clinic, Department of Dermatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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30
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Abstract
Erythropoietic protoporphyria is caused by a partial deficiency of ferrochelatase, which is the last enzyme in the heme biosynthesis pathway. In a typical erythropoietic protoporphyria, photosensitivity initially appears, following the first exposure to the sun in early infancy or childhood. Erythropoietic protoporphyria has been reported worldwide, but there is a regional variation in its epidemiology. Approximately 20% of the Japanese patients were recognized to have symptoms of erythropoietic protoporphyria after 10 years of age. Physicians occasionally encounter Japanese patients with erythropoietic protoporphyria, mild symptoms and no FECH gene mutations. The homozygous IVS3-48C polymorphism may cause a mild phenotype of the erythropoietic protoporphyria via a slight increase in protoporphyrin. The frequency of the homozygous IVS3-48C polymorphism in the Japanese population is higher than that observed in European countries. Japanese type of erythropoietic protopor-phyria shows a characteristic phenotype of the late onset and mild symptoms compared to the Caucasian erythropoietic protoporphyria. This review describes the characteristics of erythropoietic protoporphyria in Japanese patients.
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Affiliation(s)
- Megumi Mizawa
- Department of Dermatology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, 930-0194, Toyama, Japan.
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McNeil MM, Nahhas AF, Braunberger TL, Hamzavi IH. Afamelanotide in the Treatment of Dermatologic Disease. Skin Therapy Lett 2018; 23:6-10. [PMID: 30517779] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Afamelanotide, an α-melanocyte stimulating hormone analogue, has become an emerging therapeutic option for a variety of skin conditions previously refractory to other treatments. Its efficacy has been demonstrated in several dermatologic conditions, including erythropoietic protoporphyria (EPP), solar urticaria, polymorphic light eruption (PMLE), vitiligo, acne, and Hailey-Hailey disease. Its relatively low risk side effect profile makes it an attractive treatment option and also paves the way for innovative use in other disorders.
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Affiliation(s)
- Morgan M McNeil
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Amanda F Nahhas
- Department of Dermatology, Henry Ford Hospital, Detroit, MI, USA
- Department of Dermatology, Beaumont-Farmington Hills, Farmington Hills, MI, USA
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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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Suzuki H, Kikuchi K, Fukuhara N, Nakano H, Aiba S. Case of late-onset erythropoietic protoporphyria with myelodysplastic syndrome who has homozygous IVS3-48C polymorphism in the ferrochelatase gene. J Dermatol 2016; 44:651-655. [PMID: 28026050 DOI: 10.1111/1346-8138.13709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 09/09/2016] [Accepted: 10/24/2016] [Indexed: 11/30/2022]
Abstract
We report the case of a 42-year-old man with a 5-year history of myelodysplastic syndrome and photosensitivity who had developed painful erythema and blisters on sun-exposed sites. Histological examination of a mildly lichenified lesion on the dorsal finger revealed extensive deposits of a hyaline-like, periodic acid-Schiff-positive material around superficial dermal blood vessels. Laboratory tests showed elevated erythrocyte protoporphyrin and normal urinary porphyrins, suggesting a diagnosis of erythropoietic protoporphyria. Late-onset erythropoietic protoporphyria is rare and is usually associated with an acquired somatic mutation of the ferrochelatase gene secondary to a hematological malignancy such as myelodysplastic syndrome. DNA analysis revealed that our patient has the homozygous IVS3-48C polymorphism that is a low-expression variant of wild-type ferrochelatase allele.
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Affiliation(s)
- Hiromi Suzuki
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Katsuko Kikuchi
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriko Fukuhara
- Department of Hematology and Immunology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hajime Nakano
- Department of Dermatology, Hirosaki University School of Medicine, Hirosaki, Japan
| | - Setsuya Aiba
- Department of Dermatology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Abstract
BACKGROUND Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer. There is a clear association between BCC development and ultraviolet (UV) radiation. Erythropoietic protoporphyria (EPP) is an inherited porphyria disorder that is a result of protoporphyrin accumulation, typically manifesting with phototoxicity. CASE SUMMARY We report a case of a 24 year-old man with both EPP and BCC diagnoses. At the age of 4 years, the patient was diagnosed with EPP. The patient presented with a BCC on his nose at age 24 years, despite sun avoidance as the primary treatment for his EPP diagnosis. CONCLUSION Consider the diagnosis of BCC in a patient with EPP, despite sun avoidance.
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Affiliation(s)
- Shayne D Reitmeier
- 1 College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brent Schacter
- 2 Department of Internal Medicine, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,3 Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Marni C Wiseman
- 2 Department of Internal Medicine, College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,3 Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
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Francis S, Williams N, Anker CJ, Shaaban A, Kim R, Shrieve D, Tward J. Stereotactic Body Radiotherapy for Hepatocellular Carcinoma Resulting in a Durable Relapse-Free Survival: A Case Report. Cureus 2016; 8:e841. [PMID: 27909629 PMCID: PMC5120964 DOI: 10.7759/cureus.841] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/23/2016] [Indexed: 11/24/2022] Open
Abstract
The standard of care for localized hepatocellular carcinoma (HCC) is surgical resection. For patients who decline or who are unfit for surgery, stereotactic body radiotherapy (SBRT) is emerging as a viable treatment approach. We present a case of a 77-year-old female in whom an early stage HCC was incidentally discovered. Given her religious edicts as a devout Jehovah's Witness and her subsequent desire to avoid a blood transfusion, she declined surgical resection or transplant due to the risk of hemorrhage. Ablative therapy was deemed inappropriate given the mass's size and location adjacent to the inferior vena cava and diaphragm. She was treated with definitive SBRT to a total dose of 60 Gy administered in three 20 Gy fractions every other day. She had a complete response to the treatment and remains without evidence of disease after 39 months of follow-up. Her only treatment-related side effect is a persistent CTCAE Grade 1 myositis on her back overlying the treatment area. We report this case to add to the growing body of literature suggesting SBRT as an effective and safe alternative treatment modality for HCC.
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Affiliation(s)
- Samual Francis
- Radiation Oncology, University of Utah Huntsman Cancer Hospital
| | - Ned Williams
- Radiation Oncology, University of Utah Huntsman Cancer Hospital
| | | | - Akram Shaaban
- Radiology, University of Utah Huntsman Cancer Hospital
| | - Robin Kim
- General Surgery, University of Utah School of Medicine
| | - Dennis Shrieve
- Radiation Oncology, University of Utah Huntsman Cancer Hospital
| | - Jonathan Tward
- Radiation Oncology, University of Utah Huntsman Cancer Hospital
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Abstract
BACKGROUND Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are genetic abnormalities of heme synthesis that result in excess production of protoporphyrin and that manifest as severe photosensitivity. These disorders are often associated with iron deficiency anaemia (IDA). Our aim was to determine whether hepcidin is increased in EPP/XLP patients, resulting in decreased enteral iron absorption and IDA. MATERIAL AND METHODS Eight subjects with EPP, one with XLP and nine controls had baseline blood and urine samples collected, and thereafter were given oral ferrous sulphate (660 mg). Post-iron blood and urine samples were collected at 2, 4, 6 and 8 h. Blood counts, serum cytokines, ferritin and iron studies were analysed at baseline. Serum iron studies, serum and urine hepcidin, and erythropoietin (Epo) were analysed at baseline and subsequent time points. RESULTS At baseline, EPP-XLP subjects had lower mean blood haemoglobin (13·9/15·3 g/dL) and serum ferritin (31·6/115 ng/mL) than controls. Serum iron levels increased markedly in both cohorts. Mean serum and urine hepcidin levels were significantly lower in the EPP-XLP group at 4 and 8 h post-iron (serum - 4 h, 3·79/26·6, 8 h, 5·79/34·6 nM; urine - 4 h, 0·85/2·50, 8 h, 1·44/6·63 nM/mM creatinine). Serum cytokines and Epo were normal and not different between groups. CONCLUSIONS We conclude that serum and urine hepcidin are not inappropriately increased in EPP/XLP subjects at baseline and do not increase over time as serum iron increases after oral ferrous sulphate. Levels of serum cytokines and Epo are normal in EPP/XLP. The molecular basis for the iron-deficient phenotype in EPP/XLP remains unknown.
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Affiliation(s)
- Krista Bossi
- The Liver-Biliary-Pancreatic Center, Carolinas HealthCare System, Charlotte, NC, USA
| | - Jingyun Lee
- Department of Research, Carolinas HealthCare System, Charlotte, NC, USA
| | - Paul Schmeltzer
- The Liver-Biliary-Pancreatic Center, Carolinas HealthCare System, Charlotte, NC, USA.,Department of Medicine, Carolinas HealthCare System, Charlotte, NC, USA
| | - Eric Holburton
- The Liver-Biliary-Pancreatic Center, Carolinas HealthCare System, Charlotte, NC, USA.,Department of Research, Carolinas HealthCare System, Charlotte, NC, USA
| | - Gale Groseclose
- The Liver-Biliary-Pancreatic Center, Carolinas HealthCare System, Charlotte, NC, USA
| | - Siddesh Besur
- The Liver-Biliary-Pancreatic Center, Carolinas HealthCare System, Charlotte, NC, USA.,Department of Medicine, Carolinas HealthCare System, Charlotte, NC, USA
| | - Sunil Hwang
- Department of Research, Carolinas HealthCare System, Charlotte, NC, USA
| | - Herbert L Bonkovsky
- The Liver-Biliary-Pancreatic Center, Carolinas HealthCare System, Charlotte, NC, USA.,Department of Research, Carolinas HealthCare System, Charlotte, NC, USA.,Department of Medicine, Carolinas HealthCare System, Charlotte, NC, USA
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Ninomiya Y, Kokunai Y, Tanizaki H, Akasaka E, Nakano H, Moriwaki S. X-linked dominant protoporphyria: The first reported Japanese case. J Dermatol 2015; 43:414-8. [PMID: 26387792 DOI: 10.1111/1346-8138.13101] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/05/2015] [Indexed: 01/19/2023]
Abstract
A 12-year-old boy with photosensitivity since 3 years of age presented with small concavities on both cheeks, the nasal root and the dorsal surface of both hands. According to the clinical features, erythropoietic protoporphyria (EPP) was suspected. Urine and blood samples were tested for porphyrin derivatives, which revealed a markedly elevated level of erythrocyte protoporphyrin (EP) and a diagnosis of EPP was made. The patient's mother had no photosensitivity, however, lesions appearing slightly as small scars were found on the dorsum of her right hand; his elder sister and father showed no rash. The EP levels were elevated in samples from his mother and mildly elevated in those from his elder sister and father. To obtain a definitive diagnosis, genetic analyses were performed using samples from all family members, which revealed no mutations in the ferrochelatase-encoding gene (FECH), which is responsible for EPP. Instead, a pathological mutation of the 5-aminolevulinic acid synthase-encoding gene (ALAS2) was identified in samples from the patient, his mother and his elder sister, confirming a definitive diagnosis of X-linked dominant protoporphyria (XLDPP). This is the first Japanese family reported to have XLDPP, demonstrating evidence of the condition in Japan. In addition, because XLDPP is very similar to EPP in its clinical aspects and laboratory findings, a genetic analysis is required for the differential diagnosis.
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Affiliation(s)
- Yukiko Ninomiya
- Department of Dermatology, Osaka Medical College, Osaka, Japan
| | | | | | - Eijiro Akasaka
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Hajime Nakano
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Aomori, Japan
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Butler DF, Ginn KF, Daniel JF, Bloomer JR, Kats A, Shreve N, Myers GD. Bone marrow transplant for X-linked protoporphyria with severe hepatic fibrosis. Pediatr Transplant 2015; 19:E106-10. [PMID: 25856424 DOI: 10.1111/petr.12472] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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] [Accepted: 03/13/2015] [Indexed: 11/27/2022]
Abstract
XLP is an erythroid porphyria that results in variable cutaneous photosensitivity due to accumulation of protoporphyrin. The genetic defect in XLP is mutation of the gene ALAS2, resulting in gain of function for the erythroid enzyme 5-aminolevulinate synthase 2. Previous reports have shown that protoporphyrin-induced liver disease may also occur in XLP, occasionally severe enough to warrant liver transplantation; however, transplantation may be followed by injury to the graft due to continued presence of the underlying metabolic disorder in the bone marrow. We present a case of XLP with severe liver disease successfully treated with HPCT to avoid liver transplantation. The case also demonstrates the feasibility of reduced intensity transplant to provide engraftment sufficient for correction of porphyria and tolerability of reduced intensity conditioning containing TLI in the face of severe liver injury.
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Affiliation(s)
- David F Butler
- Department of Pediatrics, Childrens Mercy Hospital, Kansas City, MO, USA
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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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