[A case report of rapid inhalation induction with sevoflurane in a patient with porphyria]

We experienced anesthetic management for a patient with acute intermittent porphyria. A 52-year-old woman underwent a partial right mastectomy. She was anesthetized with continuous thoracic epidural blockade combined with general anesthesia using nitrous oxide, oxygen and sevoflurane. To avoid porphyric attack, we chose vital capacity breath technique for rapid induction. We could successfully manage the patient during the perioperative period without appearance of porphyric symptoms. We conclude that vital capacity breath technique for rapid induction may be suitable for use in patients with porphyria.

Levetiracetam in Porphyric Status Epilepticus

Status epilepticus in patients with acute intermittent porphyria (AIP) are difficult to treat. In this report the author describes a patient with AIP and status epilepticus who was successfully treated with a combination of intravenous magnesium and levetiracetam. This case and the limited experience reported in the literature show that it is probably safe to administer levetiracetam in patients with AIP; however, its role in the treatment of status epilepticus deserves further evaluation.

Kortikale Amaurosis und Status epilepticus bei akuter Porphyrie

The most common neurologic manifestations of acute intermittent porphyria (AIP) are autonomic visceral neuropathy, peripheral motor neuropathy, and CNS dysfunctions including seizures and neuropsychiatric disturbances. In rare instances, however, AIP patients have presented with acute cortical blindness. We present a 20-year-old woman who suffered her first attack of AIP. Following 1 week of abdominal pain, she was transferred from a surgical department because of sudden visual loss and deterioration of consciousness. On admission, she developed several generalized seizures. Magnetic resonance imaging showed bilateral DWI lesions occipitally and in the left anterior circulation. Cerebrospinal fluid, MR angiography, and duplex ultrasound were normal. On the following day, sedation and intubation became necessary because of a generalized status epilepticus. Analysis of porphyrinogens in blood, urine and stool showed significantly elevated values. Intravenous therapy with häm-arginate was initiated and antiepileptic therapy was changed to gagabentine. Under this therapeutical regime she remained stable and extubation was possible 48 h later.

Anesthesia in a child with homozygous porphobilinogen deaminase deficiency: a severe form of acute intermittent porphyria

We report a case history of the anesthetic management of a child with a severe form of acute intermittent porphyria (AIP). AIP is an autosomal dominant condition with incomplete penetrance, caused by deficiency of porphobilinogen deaminase, an enzyme found in the synthetic pathway for heme. Anesthesia and surgery may present many precipitants for a potentially fatal acute porphyric attack. These include fasting, dehydration, stress, infection and drugs. Here, we describe the safe use of sevoflurane in the maintenance of anesthesia. Its relative insolubility and low metabolism suggest that sevoflurane may be a reasonable agent for anesthesia in the porphyric patient.

Familial occurrence of myoclonic epilepsy syndrome and acute intermittent porphyria

OBJECTIVES

Myoclonic epilepsy (ME) syndrome is not rare in north-eastern Europe; it is also seen in various forms. Familial occurrence of ME syndrome and acute intermittent porphyria (AIP) was observed in three siblings. The following report was aimed the differentiation between co-morbidity of two different disorders or presence the epileptic seizures within the clinical picture of latent AIP.

MATERIAL AND METHODS

A case report of three siblings who suffered from seizures, myoclonias, ataxia and minor psychological changes since the age of 8 and 9 years is described in the following report.

RESULTS

The clinical picture most resembled that of "Baltic myoclonus" (dentate-rubral degeneration or dyssynergia cerebellaris myoclonica -- Ramsay-Hunt syndrome) with epilepsy and/or a benign form of progressive myoclonic epilepsy (PME). The possibility of juvenile myoclonic epilepsy (JME) and other aetiological factors, as less probable causes of ME syndrome, were considered. After 15 years of the treatment by anti-epileptic drugs in all three siblings, AIP was discovered.

CONCLUSION

Our interest lies in the differentiation of co-morbidity of two different disorders or presence of epileptic seizures as the clinical picture of latent AIP. We propose that the AIP attacks were caused by long-term administration of anti-epileptic drugs. At the same time we suggest it is a coincidence that the two independent genetic abnormalities coexist in the subjects (benign form of degenerative cerebral disease and AIP).

Clinical and biochemical characteristics and genotype-phenotype correlation in 143 Finnish and Russian patients with acute intermittent porphyria

Acute intermittent porphyria (AIP), resulting from a deficiency of porphobilinogen deaminase (PBGD) in heme biosynthesis, is genetically heterogeneous and manifests with variable penetrance. The clinical outcome, prognosis, and correlation between PBGD genotype and phenotype were investigated in 143 Finnish and Russian AIP patients with 10 mutations (33G-->T, 97delA, InsAlu333, R149X, R167W, R173W, R173Q, R225G, R225X, 1073delA). Thirty-eight percent of the patients had experienced 1 or more acute attacks during their lives. The proportion of symptomatic patients has decreased dramatically from 49% to 17% among patients diagnosed before and after 1980, respectively. Patients with the R167W and R225G mutations showed lower penetrance (19% and 11%, respectively) and recurrence rate (33% and 0%, respectively) than patients with other mutations (range, 36%-67% and 0%-66%, respectively). Moreover, urinary excretions of porphyrins and their precursors were significantly lower in these patients (porphobilinogen [PBG], 47 +/- 10 vs. 163 +/- 21 micromol/L, p < 0.001; uroporphyrin, 130 +/- 40 vs. 942 +/- 183 nmol/d, p < 0.001). Erythrocyte PBGD activity did not correlate with PBG excretion in remission or with the clinical severity of the disease. Mutations R167W and R225G resulted in milder biochemical abnormalities and clinical symptoms indicating a milder form of AIP in these patients. In all AIP patients, normal PBG excretion predicted freedom from acute attacks. The risk of symptoms was highest for female patients with markedly increased PBG excretion (>100 micromol/L). Proper counseling contributed to the prevention of subsequent attacks in 60% of previously symptomatic and in 95% of previously symptom-free patients.

An analysis of 112 acute porphyric attacks in Cape Town, South Africa: Evidence that acute intermittent porphyria and variegate porphyria differ in susceptibility and severity

Four forms of porphyria may present clinically with the acute attack, an episodic, severe, and potentially life-threatening manifestation characterized by abdominal and neurologic symptoms. We describe our experience with 112 consecutive attacks observed and treated in 25 patients with the 2 most common forms of acute porphyria in Cape Town, South Africa; 25 attacks in 10 patients with variegate porphyria and 87 attacks in 14 patients with acute intermittent porphyria. The remaining patient experienced more than 100 sequential, severe, and poorly remitting attacks, which are not included in our analysis. In our population, the relative risk of an acute attack in acute intermittent porphyria compared with that in variegate porphyria was 14.3 (confidence intervals, 6.3-32.7). Patients with variegate porphyria were significantly older (median age at first attack, 30 yr) than those with acute intermittent porphyria (median age at first attack, 23.5 yr; p < 0.0001), and demonstrated an equal sex ratio, whereas the male:female ratio in acute intermittent porphyria was 2:12 (p < 0.0001). There was a significant difference in the incidence of factors precipitating the acute attack. Drug exposure was a frequent precipitant of the acute attack in variegate porphyria, whereas hormonal factors were more important in acute intermittent porphyria (p < 0.00001). Patients with acute intermittent porphyria also showed a trend to earlier and more frequent recurrent acute attacks following the initial admission. Mean urine precursor levels, blood pressure, pulse rate, and heme arginate requirement were all significantly higher in patients with acute intermittent porphyria. No significant difference in the frequency of serious complications or in outcome could be shown. We describe our experience with treatment with heme arginate, and provide evidence that heme arginate results in a prompt and statistically significant improvement in symptoms. The incidence of serious complications and mortality in this series was low, confirming a trend to an increasingly good prognosis for patients with acute porphyria who receive expert treatment.

[Late diagnosis of a severe attack of acute intermittent porphyria (AIP)--diagnostic dilemmas]

The article presents diagnostic problems concerning the case of 54-year old woman with a delayed diagnosis of a severe attack of acute intermittent porphyria (AIP), which on admission manifested mainly as flaccid quadriplegia. The signs of neurological deficit were accompanied by changes in electrocardiographic recording that suggested acute myocardial ischaemia without apparent chest pain. Based upon a detailed history and identification of potential factors that might have triggered the attack the suspicion of acute hepatic porphyria was raised. The suspicion was confirmed by biochemical testing in the Institute of Hematology and Transfusiology in Warsaw. The treatment with glucose was administered, drugs contraindicated in porphyria were excluded, and early rehabilitation programme was instituted, which led to a marked improvement of general status and resolution of quadriplegia after 16 weeks. Parallel to the improvement of neurological status and a decrease in urinary excretion of heme precursors the normalisation of ECG changes was observed. The authors point out that differential diagnosis of abdominal pain with concomitant hyponatraemia should include an attack of acute porphyria since early administration of proper management prevents the development of life-threatening neurological signs accompanying the severe attack. The diagnosis of an attack of acute porphyria in the phase of predominant neurological signs, in the absence of abdominal pain, may be difficult and always warrants, apart from anamnestic data, the confirmation with appropriate biochemical testing.

[Acute intermittent porphyria coexisting with chronic postinfectious renal failure]

In this paper a case of 46-year-old woman suffering from the acute intermittent porphyria (AIP) was presented. She developed the chronic renal failure due to the hypertension, reccurent urinary tract infections and neurogenic urinary bladder following the autonomic neuropathy. The patient eventually died in spite of haemodialysis. Skin lesions observed in the last stage of the disease could be an evidence of the possible conversion of AIP in variegate porphyria (VP). However, this suspicion is only the hypothesis due to the lack of the adequate enzymatic lab tests.

Desfluran bei akute intermittierender Porphyrie

Despite the low incidence of the acute porphyrias, a profound knowledge of the disease is essential for anaesthesiologists, as a variety of perioperatively administered drugs are potential triggers of an acute attack. There is an ongoing discussion about the use of volatile anaesthetics in porphyrias, but halothane and isoflurane seem to be safe. There is no clinical data or case report about the use of desflurane in this specific patient group, but its fast and relatively unchanged elimination and the minimal induction of the cytochrome P 450 system seem to be favorable in this setting. We report the use of desflurane in a patient with acute intermittent porphyria, scheduled for hemihepatectomy. To minimize perioperative distress by pain or the need for postoperative mechanical ventilation, we chose a balanced anaesthesia technique with desflurane, sufentanil and atracurium in combination with a continuous epidural analgesia (bupivacain and fentanyl) for the postoperative period. Preoperatively the porphyrin precursors were analyzed in serum and urine and postoperatively the 24 h-urine was screened every 2 days until postoperative day 6 to monitor the porphyria activity. The preoperative data showed high concentrations of porphyrin precursor excretion, confirming the diagnosis of AIP. The postoperative data in the 24 h-urine were significantly lower than preoperative levels and reached normal levels at postoperative day 5. There were no clinical symptoms of a porphyric attack during the postoperative hospitalization. The patient was discharged on postoperative day 21 in excellent condition. We conclude that our perioperative management prevented an acute porphyric attack in this case. Desflurane might be a valuable alternative to other hypnotics in patients with AIP.

Renal transplantation in a case of acute intermittent porphyria

Acute intermittent porphyria (AIP) results from a deficiency of the porphobilinogen deaminase enzyme of heme biosynthesis. The disease is exacerbated by a wide variety of drugs. Only steroids and azathioprine (Aza) have so far been considered safe in patients with AIP, and cyclosporine is listed as contraindicated. From the transplantation point of view, it is well known that cyclosporine (CsA) is a superior immunosuppressive agent compared to azathioprine. This case report presents a female patient evaluated for renal transplantation. A test dose of CsA was given, and no symptoms of AIP occurred. Renal transplantation with a cadaveric donor was performed, and the patient was immunosuppressed with CsA, Aza, and prednisolone. Following three acute rejections, Aza was replaced by mycophenolate mofetil. Nevertheless, graft function deteriorated slowly, necessitating return to dialysis 3 years after transplantation. No symptoms of AIP were observed while the patient was on cyclosporine and/or mycophenolate mofetil therapy, and the authors conclude that these drugs can be safely administered to at least some patients with AIP.

Acute intermittent porphyria in women: clinical expression, use and experience of exogenous sex hormones. A population-based study in northern Sweden

OBJECTIVE

To describe the clinical expression of acute intermittent porphyria (AIP) in women, their use of exogenous sex hormones, and the effects on AIP.

DESIGN

A retrospective population-based study.

SUBJECTS

All women aged > or =18 years (n = 190) with DNA-diagnosed AIP in northern Sweden.

RESULTS

A total of 166 women (87%) participated; 91 (55%) had manifest AIP. Severe attacks were reported by 82%; 39% reported recurrent premenstrual AIP attacks and 22% reported chronic AIP symptoms. Oral hormonal contraceptives had been used by 58% of all these women and by 50 with manifest AIP (57%). Twelve women (24%) associated oral contraceptives as precipitating AIP attacks; in nine cases their first attack. One woman experienced relief from AIP symptoms. On commencing their treatment, 72% of the women with manifest AIP had not yet suffered their first attack. Twenty-two women (25%) aged > or =45 years had used hormonal replacement therapy (HRT) at menopause to remedy climacteric symptoms (the percutaneous route was most frequently used); no AIP attack was precipitated. HRT to remedy vaginal dryness was used by 26 women (28%) aged > or =45 years without triggering an AIP attack. Miscarriages were more frequent in women with manifest AIP (50%) than in the latent group (30%, P = 0.014).

CONCLUSIONS

About half of the women with AIP had used oral hormonal contraceptives. As 25% of women with manifest AIP reported attacks associated with such drugs, caution must still be recommended. Menopausal HRT only rarely affected the disorder. Miscarriage was more common amongst women with manifest AIP.

Acute intermittent porphyria: an unusual cause of malignant hypertension

Hypertension is a rare complication of acute intermittent porphyria (AIP) and is related to the sympathetic over-activity seen in this condition. We report a patient with AIP with malignant hypertension that recurred with a subsequent episode. Mechanisms of hypertension and renal damage are discussed.

Atypical attack of acute intermittent porphyria--paresis but no abdominal pain

We report a case of acute intermittent porphyria (AIP) in a 45-year-old woman. Her first attack occurred at the age of 38. Because of escalating cyclical premenstrual attacks, the following 2 years, depletion of the endogenous sex hormone was considered as haeme arginate treatment proved insufficient. Gonadotropin releasing hormone agonist treatment with low-dose oestradiol add back was quite successful initially but was abandoned after 18 months when progesterone add back precipitated a severe attack. Following hysterectomy and oophorectomy at age 42 and oestradiol add back, a remarkable monthly regularity of attacks ensured periodically but with milder symptoms. Two years after surgery, preceded by six attack-free months, a puzzling symptom-shift occurred, from abdominal pain, back and thigh pain during the attacks, to solely severe distal extensor paresis in the arms. Haeme arginate treatment interrupted the progress of the paresis almost immediately and motor function improved considerably up to the 9-month follow-up. Electrophysiological examination revealed only motor neuropathy, consistent with axonal degeneration. Subsequently the symptoms changed yet again, to sensory disturbances with numbness and dysesthesia as the primary expression followed by rather mild abdominal pain. However, cyclical attacks occurred, despite absence of endogenous ovarial hormone production, possibly attributable to impaired oestrogen metabolism in the liver, or adrenal oestrogen production. Treatment comprising oophorectomy, low-dose oestradiol add back and haeme arginate infusion for 2 days on the appearance of early AIP symptoms is now quite successful affording improvement in life quality.

[Fatal postoperative crisis in acute hereditary porphyria]

The acute porphyria is an autosomal dominant disorder of the héme biosynthesis enzyme. The aim of this work is to determin a diagnostic step in order to anticipate porphyric crises. We report the observation of a child which was hospitalized in the pédiatric service three years ago for peripheric arthralgies and myalgies where the diagnosis of an acute porphyria was not posed. He wase admitted in our service for appendicitis, he was operated, the anesthesie was carried out by the thiopenthal and the succinylcholine. At the first post-operative day, a respiratory insufficiency was the cause of death. The rate of coproporphyrines and of uroporphyrines in the urine had confirmed the diagnosis of acute porphyria. The positive diagnostic of acute porphyria is difficult, the association of abdominal, psychological and neurologic signs must suggest the diagnostic, all the more, if the urines have a dark colour. The presence of uroporphyrines and coproporphyrines and certain precursors in the urines or in the high-rated stools confirm the diagnostic. The family survey and dosage of porphyric compounds in the sickness-bearing patient's family members allow to reveal certain asymptomatic forms of the heriditary acute porphyria, it is caused by certain products used in neuropsychiatry, in aneasthesic or in certain circunstances, such as, the infection or the trauma. The treatment of the acute porphyria is an emergency wich requires the transfert of the patient to a unit of intensive care.

Diagnostic dilemmas in acute intermittent porphyria. A case report

OBJECTIVE

To present the importance of early diagnosis of acute intermittent porphyria (AIP) in patients with atypical presentation and discuss the diagnostic problems encountered in this case.

CLINICAL PRESENTATION

A 15-year-old girl presented with upper respiratory tract infection, fever, seizures and abdominal pain. An initial diagnosis of encephalitis was made. She received antiviral drugs and anticonvulsants. Two weeks later, she developed progressive flaccid quadriplegia and facial weakness. She also developed respiratory paralysis and was intubated. Cytoalbuminous dissociation was seen in the cerebrospinal fluid. A diagnosis of severe Guillain-Barré syndrome was made.

INTERVENTION

The patient received a course of intravenous immunoglobulins which did not result in any clinical improvement. Plasmapheresis, started after 12 weeks, led to partial improvement. The patient continued to have attacks of seizures, abdominal pain and vomiting with severe quadriparesis. A repeat screening test for urine porphyrins was positive, and AIP was confirmed by specific porphobilinogen deaminase in the blood. The patient was treated with large doses of intravenous glucose, followed by injections of hematin. The patient improved remarkably. She was extubated, discharged from Intensive Care Unit and started on a rehabilitation program.

CONCLUSION

This patient was initially diagnosed erroneously with a negative screening test for AIP and consequently treated inappropriately. The proper diagnosis was made after repeating the screening test followed by specific tests of porphobilinogen deaminase.