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

[Hormone therapy in menopause: when not to use]

Menopause is defined as the permanent cessation of menses, as a result of the loss of ovarian follicular function or of surgical removal of ovaries. The mean age for occurrence of natural menopause is around 50 years. Estrogen deficiency has been associated with vasomotor symptoms, urogenital atrophy, and cognitive impairment, as well as increased risk of chronic degenerative diseases such as osteoporosis and Alzheimer's disease. Estrogen therapy remains the most effective treatment for the management of vasomotor symptoms and urogenital atrophy. Progesterone or progestins should be added to estrogen treatment in women with uterus, in order to antagonize the estrogen-induced endometrial proliferation. In turn, in specific clinical conditions hormone therapy is not recommended. In the present article, the authors critically focus these clinical conditions in which hormone therapy should not be used.

Abdominal pain due to acute intermittent porphyria: when is the sound of hoof-beats not horses, but zebras? A case report

Acute intermittent porphyria is a rare autosomal dominant hereditary inborn error of metabolism of the heme biosynthetic pathway that can be exacerbated through a multitude of environmental factors. This article is a case study describing the pathophysiology, clinical presentation management, and exacerbation prevention of acute intermittent porphyria. The disease is clinically manifested with severe abdominal pain, confusion, and seizures which may be life threatening. Specific treatment with heme preparations should be instituted as soon as increased excretion of porphobilinogen through urine sampling is confirmed. Supportive treatment includes opiate analgesia, monitoring for and treating complications such as hypertension and hyponatremia. Follow-up should include family counseling regarding genetic defects and individual counseling regarding lifestyle changes including avoidance of environmental factors that have been implicated in the exacerbation of the disease.

Initial presentation of undiagnosed acute intermittent porphyria as a rare complication of ovulation induction

OBJECTIVE

To discuss the diagnosis and management of acute intermittent porphyria following ovulation induction.

DESIGN

Case report.

SETTING

Academic IVF center.

PATIENT(S)

A patient with polycystic ovary syndrome and primary infertility undergoing ovulation induction with clomiphene citrate.

INTERVENTION(S)

Serial phlebotomy, IV fluid, inpatient observation.

MAIN OUTCOME MEASURE(S)

Condition at discharge.

RESULT(S)

The patient was diagnosed with severe hyponatremia caused by acute volume depletion and possible syndrome of inappropriate antidiuretic hormone secretion, secondary to acute intermittent prophyria, and was successfully managed with supportive measures. Neurovisceral symptoms resolved, and severe hyponatremia was corrected with IV saline solution without complications.

CONCLUSION(S)

Acute intermittent porphyrias are rare complications of ovulation induction, but should be considered in patients who develop unexplained hyponatremia or neurovisceral symptoms.

Life-threatening dermatoses due to metabolic and endocrine disorders

Cardiovascular heart disease due to atherosclerosis is the commonest cause of mortality and morbidity in the Western world. Atherosclerosis is directly related to disorders of lipid metabolism, diabetes mellitus (DM), and insulin resistance. Disorders of thyroid function and porphyrin metabolism occur less frequently but may cause life-threatening situations if unrecognized. All these disorders are associated with characteristic dermatoses, which should permit early diagnosis and meaningful intervention.

The porphyrias

The porphyrias are a group of disorders involving enzymatic defects in heme synthesis. The porphyrias classically manifest neuro-visceral or photocutaneous symptoms based on which enzyme in the heme metabolic pathway is deficient. Although rare, the porphyrias would most likely be encountered in the emergency department in patients presenting with chronic unspecified abdominal or musculoskeletal pain and those with new onset of psychiatric complaints.

Acute intermittent porphyria

Acute intermittent porphyria (AIP) is characterised by neurovisceral crises the most common clinical presentation of which is abdominal pain. It is an autosomal dominant condition with incomplete penetrance and is potentially life-threatening. The key point in management is to suspect and confirm the diagnosis as early as possible in order to treat the attack and to avoid inappropriate treatments which may exacerbate the crisis. In this chapter we briefly outline the haem biosynthetic pathway and how deficiencies in individual enzymes give rise to the different porphyrias. We then describe the clinical features and diagnosis of AIP, followed by a discussion of pathogenesis, highlighting advances in the molecular biology of AIP and introducing the debate as to whether neurovisceral crises might result from porphyrin precursor neurotoxicity or from haem deficiency. Finally we discuss management, including family screening, avoidance of triggering factors, analgesia, maintenance of a high calorie intake, and administration of haem derivatives.