1
|
Balogun O, Nejak-Bowen K. Understanding Hepatic Porphyrias: Symptoms, Treatments, and Unmet Needs. Semin Liver Dis 2024; 44:209-225. [PMID: 38772406 PMCID: PMC11268267 DOI: 10.1055/s-0044-1787076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
Hepatic porphyrias are a group of metabolic disorders that are characterized by overproduction and accumulation of porphyrin precursors in the liver. These porphyrins cause neurologic symptoms as well as cutaneous photosensitivity, and in some cases patients can experience life-threatening acute neurovisceral attacks. This review describes the acute hepatic porphyrias in detail, including acute intermittent porphyria, hereditary coproporphyria, and variegate porphyria, as well as the hepatic porphyrias with cutaneous manifestations such as porphyria cutanea tarda and hepatoerythropoietic porphyria. Each section will cover disease prevalence, clinical manifestations, and current therapies, including strategies to manage symptoms. Finally, we review new and emerging treatment modalities, including gene therapy through use of adeno-associated vectors and chaperone therapies such as lipid nanoparticle and small interfering RNA-based therapeutics.
Collapse
Affiliation(s)
- Oluwashanu Balogun
- Department of Experimental Pathology, University of Pittsburgh, Pittsburgh, PA
| | - Kari Nejak-Bowen
- Department of Experimental Pathology, University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Liver Institute, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
2
|
Erwin AL, Balwani M. Porphyrias in the Age of Targeted Therapies. Diagnostics (Basel) 2021; 11:diagnostics11101795. [PMID: 34679493 PMCID: PMC8534485 DOI: 10.3390/diagnostics11101795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 01/04/2023] Open
Abstract
The porphyrias are a group of eight rare genetic disorders, each caused by the deficiency of one of the enzymes in the heme biosynthetic pathway, resulting in the excess accumulation of heme precursors and porphyrins. Depending on the tissue site as well as the chemical characteristics of the accumulating substances, the clinical features of different porphyrias vary substantially. Heme precursors are neurotoxic, and their accumulation results in acute hepatic porphyria, while porphyrins are photoactive, and excess amounts cause cutaneous porphyrias, which present with photosensitivity. These disorders are clinically heterogeneous but can result in severe clinical manifestations, long-term complications and a significantly diminished quality of life. Medical management consists mostly of the avoidance of triggering factors and symptomatic treatment. With an improved understanding of the underlying pathophysiology and disease mechanisms, new treatment approaches have become available, which address the underlying defects at a molecular or cellular level, and promise significant improvement, symptom prevention and more effective treatment of acute and chronic disease manifestations.
Collapse
Affiliation(s)
- Angelika L. Erwin
- Center for Personalized Genetic Healthcare, Cleveland Clinic & Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH 44195, USA
- Correspondence: ; Tel.: +1-216-444-9249
| | - Manisha Balwani
- Department of Genetics and Genomics, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| |
Collapse
|
3
|
Sarró-Fuente C, Martín-Alcalde J, Pampín-Franco A, Palencia-Pérez SI, López-Estebaranz JL. Hypertrichosis and blisters in an infant. Pediatr Dermatol 2021; 38:688-690. [PMID: 34224613 DOI: 10.1111/pde.14574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Claudia Sarró-Fuente
- Department of Dermatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Ana Pampín-Franco
- Department of Dermatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | | |
Collapse
|
4
|
Noorian S, Khonsari NM, Savad S, Hakak-Zargar B, Voth T, Kabir K. Whole-Exome Sequencing in Idiopathic Short Stature: Rare Mutations Affecting Growth. J Pediatr Genet 2020; 10:284-291. [PMID: 34849273 DOI: 10.1055/s-0040-1716400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/26/2020] [Indexed: 12/24/2022]
Abstract
Idiopathic short stature (ISS) is a common diagnosis of exclusion in patients with short stature (SS). In this article, we aimed to identify the genetic causes of SS in patients with ISS and investigate treatment options. Fourteen children with diagnosis of ISS were identified, and whole-exome sequencing (WES) was subsequently conducted on blood-derived DNA. Five patients were correctly diagnosed with ISS and four had rare mutations that have not been previously reported. Four patients had mutations known to cause SS and one had a mutation that was known not to affect height. WES can help identify rare mutations implicated in ISS.
Collapse
Affiliation(s)
- Shahab Noorian
- Department of Pediatrics, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | | | | | - Benyamin Hakak-Zargar
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Tessa Voth
- Department of Biomedical Physiology and Kinesiology, Faculty of Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Koroush Kabir
- Department of Community Medicine and Epidemiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| |
Collapse
|
5
|
Weiss Y, Chen B, Yasuda M, Nazarenko I, Anderson KE, Desnick RJ. Porphyria cutanea tarda and hepatoerythropoietic porphyria: Identification of 19 novel uroporphyrinogen III decarboxylase mutations. Mol Genet Metab 2019; 128:363-366. [PMID: 30514647 PMCID: PMC8132452 DOI: 10.1016/j.ymgme.2018.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 11/19/2022]
Abstract
Porphyria Cutanea Tarda (PCT) is a cutaneous porphyria that results from the hepatic inhibition of the heme biosynthetic enzyme uroporphyrinogen decarboxylase (UROD), and can occur either in the absence or presence of an inherited heterozygous UROD mutation (PCT subtypes 1 and 2, respectively). A heterozygous UROD mutation causes half-normal levels of UROD activity systemically, which is a susceptibility factor but is not sufficient alone to cause type 2 PCT. In both Types 1 and 2 PCT, the cutaneous manifestations are precipitated by additional factors that lead to generation of an inhibitor that more profoundly reduces hepatic UROD activity. PCT is an iron-related disorder, and many of its known susceptibility factors, which include infections (e.g. hepatitis C virus, HIV), high alcohol consumption, smoking, estrogens, and genetic traits (e.g. hemochromatosis mutations) can increase hepatic iron accumulation. Hepatoerythropoietic Porphyria (HEP) is a rare autosomal recessive disease that results from homozygosity or compound heterozygosity for UROD mutations and often causes infantile or childhood onset of both erythropoietic and cutaneous manifestations. During the 11-year period from 01/01/2007 through 12/31/2017, the Mount Sinai Porphyrias Diagnostic Laboratory provided molecular diagnostic testing for 387 unrelated patients with PCT and four unrelated patients with HEP. Of the 387 unrelated individuals tested for Type 2 PCT, 79 (20%) were heterozygous for UROD mutations. Among 26 family members of mutation-positive PCT patients, eight (31%) had the respective family mutation. Additionally, of the four unrelated HEP patients referred for UROD mutation analyses, all had homozygosity or compound heterozygosity for UROD mutations, and all eight asymptomatic family members were heterozygotes for UROD mutations. Of the UROD mutations identified, 19 were novel, including nine missense, two nonsense, one consensus splice-site, and seven insertions and deletions. These results expand the molecular heterogeneity of PCT and HEP by adding a total of 19 novel UROD mutations. Moreover, the results document the usefulness of molecular testing to confirm a genetic susceptibility trait in Type 2 PCT, confirm a diagnosis in HEP, and identify heterozygous family members.
Collapse
Affiliation(s)
- Yedidyah Weiss
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Brenden Chen
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.
| | - Makiko Yasuda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.
| | - Irina Nazarenko
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.
| | - Karl E Anderson
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA.
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
6
|
Kakoullis L, Louppides S, Papachristodoulou E, Panos G. Porphyrias and photosensitivity: pathophysiology for the clinician. Postgrad Med 2018; 130:673-686. [PMID: 30296862 DOI: 10.1080/00325481.2018.1533380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Porphyrias are disorders caused by defects in the biosynthetic pathway of heme. Their manifestations can be divided into three distinct syndromes, each attributable to the accumulation of three distinct classes of molecules. The acute neurovisceral syndrome is caused by the accumulation of the neurotoxic porphyrin precursors, delta aminolevulinic acid, and porphobilinogen; the syndrome of immediate painful photosensitivity is caused by the lipid-soluble protoporphyrin IX and, the syndrome of delayed blistering photosensitivity, caused by the water-soluble porphyrins, uroporphyrin, and coproporphyrin. Porphyrias can manifest with one, or with a combination, of these syndromes, depending on whether one or more types of molecules are being accumulated. Iron plays a significant role in some of these conditions, as evidenced by improvements in both clinical manifestations and laboratory parameters, following iron depletion in porphyria cutanea tarda, or iron administration in some cases of X-linked erythropoietic protoporphyria. While the pathophysiology of a specific type of porphyrias, the protoporphyrias, appears to favor the administration of zinc, results so far have been conflicting, necessitating further studies in order to assess its potential benefit. The pathways involved in each disease, as well as insights into their pathobiological processes are presented, with an emphasis on the development of photosensitivity reactions.
Collapse
Affiliation(s)
- Loukas Kakoullis
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus
| | - Stylianos Louppides
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus
| | - Eleni Papachristodoulou
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus
| | - George Panos
- a Department of Internal Medicine , Nicosia General Hospital, University of Cyprus Medical School , Nicosia , Cyprus.,b Department of Internal Medicine, Section of Infectious Diseases , Patras University General Hospital, University of Patras School of Medicine , Patras , Greece
| |
Collapse
|
7
|
Ramanujam VMS, Anderson KE. Porphyria Diagnostics-Part 1: A Brief Overview of the Porphyrias. CURRENT PROTOCOLS IN HUMAN GENETICS 2015; 86:17.20.1-17.20.26. [PMID: 26132003 PMCID: PMC4640448 DOI: 10.1002/0471142905.hg1720s86] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Porphyria diseases are a group of metabolic disorders caused by abnormal functioning of heme biosynthesis enzymes and characterized by excessive accumulation and excretion of porphyrins and their precursors. Precisely which of these chemicals builds up depends on the type of porphyria. Porphyria is not a single disease but a group of nine disorders: acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), variegate porphyria (VP), δ-aminolevulinic acid dehydratase deficiency porphyria (ADP), porphyria cutanea tarda (PCT), hepatoerythropoietic porphyria (HEP), congenital erythropoietic porphyria (CEP), erythropoietic protoporphyria (EPP), and X-linked protoporphyria (XLP). Each porphyria results from overproduction of heme precursors secondary to partial deficiency or, in XLP, increased activity of one of the enzymes of heme biosynthesis. Taken together, all forms of porphyria afflict fewer than 200,000 people in the United States. Based on European studies, the most common porphyria, PCT, has a prevalence of 1 in 10,000, the most common acute porphyria, AlP, has a prevalence of ∼1 in 20,000, and the most common erythropoietic porphyria, EPP, is estimated at 1 in 50,000 to 75,000. CEP is extremely rare, with prevalence estimates of 1 in 1,000,000 or less. Only six cases of ADP are documented. The current porphyria literature is very exhaustive and a brief overview of porphyria diseases is essential in order for the reader to better appreciate the relevance of this area of research prior to undertaking biochemical diagnostics procedures. This unit summarizes the current knowledge on the classification, clinical features, etiology, pathogenesis, and genetics of porphyria diseases.
Collapse
Affiliation(s)
| | - Karl Elmo Anderson
- Department of Preventive Medicine and Community Health, The University of Texas Medical Branch, Galveston, Texas 77555-1109
| |
Collapse
|
8
|
Gómez-Abecia S, Morán-Jiménez MJ, Ruiz-Casares E, Henriques-Gil N, García-Pastor I, Garrido-Astray MC, Enríquez de Salamanca R, Méndez M. Familial porphyria cutanea tarda in Spain: Characterization of eight novel mutations in the UROD gene and haplotype analysis of the common p.G281E mutation. Gene 2013; 522:89-95. [DOI: 10.1016/j.gene.2013.03.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/19/2013] [Accepted: 03/16/2013] [Indexed: 10/27/2022]
|
9
|
Asati DP, Singh S, Sharma VK, Tiwari S. Dermatoses misdiagnosed as deliberate injuries. MEDICINE, SCIENCE, AND THE LAW 2012; 52:198-204. [PMID: 22623714 DOI: 10.1258/msl.2012.011054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Examination of non-accidental injuries on a body should be done with caution, as often skin diseases can mimic deliberate injuries. Patients with active dermatoses or their residual/post-inflammatory spots seen during autopsy can generate false alarms or suspicion of burns, child abuse or battering, sexual assault or other medicolegal cases. The inability to distinguish between a mechanical injury and skin disease can cause unnecessary anxiety and can complicate medicolegal investigations. Many times, an elaborate history to find out the aetiology of the lesion is either unavailable or not reliable as in the cases of young children, insane or mentally subnormal patients or in medicolegal deaths. The greatest chance of misinterpretation may be in cases of extensive denudation of the skin seen in severe drug reactions like toxic epidermal necrolysis, which can be mistaken for scald burns. Other important cases include bruises diagnosed on seeing discoloured spots on the skin or genital lesions raising the suspicion of sexual abuse in children. This diagnostic dilemma can also lead to undue forensic investigations, imprecise expert opinions and distress to patients or their family members. This review aims to generate awareness about proper interpretation of findings with an open mind, the clues to differentiate between true and false injuries and the management thereof.
Collapse
Affiliation(s)
- Dinesh P Asati
- Department of Dermatology, LN Medical College, Bhopal, India.
| | | | | | | |
Collapse
|