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Abstract
PURPOSE OF REVIEW The aim of this paper is to review psychiatric manifestations, comorbidities, and psychopharmacological management in individuals with acute porphyria (AP). RECENT FINDINGS Recent literature begins to clarify associations between AP, schizophrenia, bipolar disorder, and other psychopathology. Broad psychiatric symptoms have been associated to acute porphyria (AP) and correspond to a spectrum of heterogeneous manifestations such as anxiety, affective alterations, behavioral changes, personality, and psychotic symptoms. These symptoms may be difficult to identify as being related to porphyria since symptoms may arise at any time during the disease process. In addition, these patients may present psychiatric conditions secondary to the disease, such as adjustment disorder and substance use disorders. Timely diagnosis and appropriate treatment of psychiatric manifestations positively impact the course of the disease.
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102
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Komac A, Gram E, Gulec F, Akar H. Secret Underlying Unexplained Abdominal Pain, Neurological Symptoms and Intermittent Hypertension: Acute Intermittent Porphyria. BANTAO JOURNAL 2017. [DOI: 10.1515/bj-2017-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
A 21-year-old female patient with abdominal pain, vomiting and constipation was admitted to the hospital with the possible diagnosis of diabetic ketoacidosis. Due to increased abdominal pain and constipation the patient underwent a surgery with the diagnosis of ileus. However, no pathological findings were found in the abdominal organs apart from serous fluid in the abdominal cavity. The patient became hypertensive, tachycardic and had an episode of seizures postoperatively. Neurological manifestations with unexplained abdominal pain indicated a diagnosis of acute intermittent porphyria (AIP). Acute intermittent porphyria diagnosis is based on elevated urinary δ-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels as well as hydroxymethylbilane synthase (HMBS) IVS13-2 A>G heterozygous mutation. Familial Mediterranean Fever (FMF) gene mutations were not confirmed. Porphyria should be considered in the differential diagnosis of patients with recurrent abdominal pain, neurological symptoms and lack of FMF gene polymorphism.
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Affiliation(s)
- Andac Komac
- University of Health Sciences, Izmir Tepecik Health Research and Application Center, Department of Internal Medicine, Izmir , Turkey
| | - Elif Gram
- University of Health Sciences, Izmir Tepecik Health Research and Application Center, Department of Internal Medicine, Izmir , Turkey
| | - Feray Gulec
- University of Health Sciences, Izmir Tepecik Health Research and Application Center, Department of Neurology, Izmir , Turkey
| | - Harun Akar
- University of Health Sciences, Izmir Tepecik Health Research and Application Center, Department of Internal Medicine, Izmir , Turkey
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103
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Abstract
This is an overview of the cutaneous porphyrias. It is a narrative review based on the published literature and my personal experience; it is not based on a formal systematic search of the literature. The cutaneous porphyrias are a diverse group of conditions due to inherited or acquired enzyme defects in the porphyrin-haem biosynthetic pathway. All the cutaneous porphyrias can have (either as a consequence of the porphyria or as part of the cause of the porphyria) involvement of other organs as well as the skin. The single commonest cutaneous porphyria in most parts of the world is acquired porphyria cutanea tarda, which is usually due to chronic liver disease and liver iron overload. The next most common cutaneous porphyria, erythropoietic protoporphyria, is an inherited disorder in which the accumulation of bile-excreted protoporphyrin can cause gallstones and, rarely, liver disease. Some of the porphyrias that cause blistering (usually bullae) and fragility (clinically and histologically identical to porphyria cutanea tarda) can also be associated with acute neurovisceral porphyria attacks, particularly variegate porphyria and hereditary coproporphyria. Management of porphyria cutanea tarda mainly consists of visible-light photoprotection measures while awaiting the effects of treating the underlying liver disease (if possible) and treatments to reduce serum iron and porphyrin levels. In erythropoietic protoporphyria, the underlying cause can be resolved only with a bone marrow transplant (which is rarely justifiable in this condition), so management consists particularly of visible-light photoprotection and, in some countries, narrowband ultraviolet B phototherapy. Afamelanotide is a promising and newly available treatment for erythropoietic protoporphyria and has been approved in Europe since 2014.
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Affiliation(s)
- Robert Dawe
- Scottish Cutaneous Porphyria Service, Scottish Photodiagnostic Unit, Department of Dermatology, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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104
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Kumar S, Bhalla A, Sharma N, Dhibar DP, Kumari S, Varma S. Clinical, Biochemical Characteristics and Hospital Outcome of Acute Intermittent Porphyria Patients: A Descriptive Study from North India. Ann Indian Acad Neurol 2017; 20:263-269. [PMID: 28904459 PMCID: PMC5586122 DOI: 10.4103/aian.aian_91_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Acute intermittent porphyria (AIP) is an inherited metabolic disease characterized by disordered heme biosynthesis. There is no recent study reported from India. MATERIALS AND METHODS It was a retrospective, observational study. Clinical records of patients of AIP with acute porphyric attacks admitted from April 2008 to December 2016 were analyzed. RESULTS Fifteen AIP patients constituted of eight females and seven males were analyzed. Mean age at presentation was 34.33 ± 15.86 years. Thirteen patients (86.67%) had acute flaccid paralysis (AFP). All of them had peripheral neuropathy. These patients concomitantly had abdominal pain, seizure, encephalopathy, autonomic hyperactivity, history of passage of dark urine, and electrolyte abnormality (hyponatremia) in various combinations. Abdominal pain was the presenting symptom in 11 (73.33%) patients. Seven (46.67%) patients had seizure episodes. Five patients (33.33%) had hyponatremia at presentation. Significantly higher percentage of them had seizure at presentation or during hospital stay (P = 0.007). These patients also had evidence of autonomic hyperactivity in the form of higher pulse rate, systolic and diastolic blood pressure at presentation. They had prolonged duration of hospital stay as well (P = 0.016). Eleven patients had partial recovery and rest four patients (26.67%) had in-hospital mortality. CONCLUSION Patients had severe neurological involvement manifesting mainly as AFP and seizure episodes. We recommend screening for AIP in patients presenting with features of AFP along with any combination of clinical/laboratory manifestations such as abdominal pain, seizure, encephalopathy, autonomic hyperactivity, passage of dark urine, and hyponatremia. Electrolyte abnormality in the form of hyponatremia was an important severity marker.
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Affiliation(s)
- Susheel Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Navneet Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita Kumari
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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105
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Olivier P, Van Melkebeke D, Honoré PJ, Defreyne L, Hemelsoet D. Cerebral vasospasm in acute porphyria. Eur J Neurol 2017; 24:1183-1187. [DOI: 10.1111/ene.13347] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/22/2017] [Indexed: 01/22/2023]
Affiliation(s)
- P. Olivier
- Ghent University Hospital; Ghent Belgium
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106
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Dhital R, Basnet S, Poudel DR, Bhusal KR. Acute intermittent porphyria: a test of clinical acumen. J Community Hosp Intern Med Perspect 2017. [PMID: 28638573 PMCID: PMC5473191 DOI: 10.1080/20009666.2017.1317535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Acute intermittent porphyria (AIP) is a rare autosomal dominant hepatic porphyria due to deficiency of hydroxymethylbilane synthase (HMBS), also known as porphobilinogen deaminase leading to accumulation of porphyrin precursors. However, gene defect alone is usually not sufficient to cause an acute attack, and many extrinsic factors play a role. Diagnostic tests are defined, but clinical suspicion is often delayed as symptoms mimic other common conditions. We report a case of a 18-year-old male with severe, persistent, and generalized abdominal pain along with marked hyponatremia, with subsequent development of altered mentation needing intensive care. He improved after infusion of intravenous dextrose. AIP can mimic many common surgical and medical conditions such as appendicitis, cholecystitis, pancreatitis, etc., and may lead to extensive diagnostics or surgical intervention if missed. Diagnosis of AIP requires high clinical suspicion. It should be considered in a patient with recurrent abdominal symptoms, intractable hyponatremia, along with neurological manifestations. Early diagnosis and treatment can prevent recurrent episodes and can potentially be lifesaving. Abbreviations: AIP: Acute intermittent porphyria; ALA: Aminolevulinic acid; PBG: Porphobilinogen.
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Affiliation(s)
- Rashmi Dhital
- Department of Internal Medicine, Universal College Of Medical Sciences, Bhairahawa, Nepal
| | - Sijan Basnet
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Dilli Ram Poudel
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Khema Raj Bhusal
- Department of Internal Medicine, Manmohan Memorial Medical College, Kathmandu, Nepal
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107
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Ajayi T, Ward R, Summers B, Byrns J, Kappus M, Choi S, Wilder J. Pathophysiology, Pharmacology and Treatment of Acute Intermittent Porphyria: A Patient Case Description and Recommendations from the Current Literature. JOURNAL OF EXPLORATORY RESEARCH IN PHARMACOLOGY 2017; 2:49-53. [DOI: 10.14218/jerp.2016.00022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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108
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Júnior VRS, Lemos VMV, Feitosa IML, Florencio R, Correia CWB, Fontes LBC, Costa MFH, Correia MCB. Effect of Menstrual Cycle on Acute Intermittent Porphyria. Child Neurol Open 2017; 4:2329048X17736170. [PMID: 29094055 PMCID: PMC5652657 DOI: 10.1177/2329048x17736170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/21/2017] [Accepted: 09/13/2017] [Indexed: 01/10/2023] Open
Abstract
A 16-year-old female who was attended as an outpatient reported localized, acute abdominal pain with vomiting, symmetrical motor weakness, and burning sensation in both arms and legs. Her medical history showed irrational behavior, repeated admissions at the emergency units of many other reference hospitals, where she had been investigated for celiac disease and treated with analgesics for pain events. Her clinical condition remained unchanged despite the use of many oral analgesics. In those admissions, she showed dysautonomia, vomiting, and abdominal pain. Diagnosis investigation disclosed a notable serum hyponatremia (133.7 mEq/L). She was referred for endoscopy and the histopathological lesion of the antrum in the stomach did not show neoplastic lesions. Colonoscopy, pelvic magnetic resonance imaging (MRI), total abdominal computed tomography, and video laparoscopy were without significant abnormalities. Suspicion of acute intermittent porphyria was confirmed by quantitative urine porphobilinogen-level tests and genetic analysis. Patient was successfully treated with intravenous infusion of glucose and hemin therapy.
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Affiliation(s)
- V. R. Souza Júnior
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
- The College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
- Federal University of Pernambuco Society for Haematology, Recife, Brazil
| | - V. M. V. Lemos
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
| | - I. M. L. Feitosa
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
| | - R. Florencio
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
| | - C. W. B. Correia
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
- Federal University of Pernambuco Society for Haematology, Recife, Brazil
| | - L. B. Correia Fontes
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
| | - M. F. Hazin Costa
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
- Federal University of Pernambuco Society for Haematology, Recife, Brazil
| | - M. C. B. Correia
- Department of Clinical Medicine-Hematology, Universidade Federal de Pernambuco, Recife, Brazil
- Federal University of Pernambuco Society for Haematology, Recife, Brazil
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