1
|
Sivadasan A, Cortel-LeBlanc MA, Cortel-LeBlanc A, Katzberg H. Peripheral nervous system and neuromuscular disorders in the emergency department: A review. Acad Emerg Med 2024; 31:386-397. [PMID: 38419365 DOI: 10.1111/acem.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies. METHODS An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations. SUMMARY The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders. CONCLUSIONS Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.
Collapse
Affiliation(s)
- Ajith Sivadasan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Dissaux N, Neyme P, Kim-Dufor DH, Lavenne-Collot N, Marsh JJ, Berrouiguet S, Walter M, Lemey C. Psychosis Caused by a Somatic Condition: How to Make the Diagnosis? A Systematic Literature Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1439. [PMID: 37761400 PMCID: PMC10529854 DOI: 10.3390/children10091439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND First episode of psychosis (FEP) is a clinical condition that usually occurs during adolescence or early adulthood and is often a sign of a future psychiatric disease. However, these symptoms are not specific, and psychosis can be caused by a physical disease in at least 5% of cases. Timely detection of these diseases, the first signs of which may appear in childhood, is of particular importance, as a curable treatment exists in most cases. However, there is no consensus in academic societies to offer recommendations for a comprehensive medical assessment to eliminate somatic causes. METHODS We conducted a systematic literature search using a two-fold research strategy to: (1) identify physical diseases that can be differentially diagnosed for psychosis; and (2) determine the paraclinical exams allowing us to exclude these pathologies. RESULTS We identified 85 articles describing the autoimmune, metabolic, neurologic, infectious, and genetic differential diagnoses of psychosis. Clinical presentations are described, and a complete list of laboratory and imaging features required to identify and confirm these diseases is provided. CONCLUSION This systematic review shows that most differential diagnoses of psychosis should be considered in the case of a FEP and could be identified by providing a systematic checkup with a laboratory test that includes ammonemia, antinuclear and anti-NMDA antibodies, and HIV testing; brain magnetic resonance imaging and lumbar puncture should be considered according to the clinical presentation. Genetic research could be of interest to patients presenting with physical or developmental symptoms associated with psychiatric manifestations.
Collapse
Affiliation(s)
- Nolwenn Dissaux
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| | - Pierre Neyme
- Fondation du Bon Sauveur d’Alby, 30 Avenue du Colonel Teyssier, 81000 Albi, France
| | - Deok-Hee Kim-Dufor
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
| | - Nathalie Lavenne-Collot
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Laboratoire du Traitement de l’Information Médicale, Inserm U1101, 29200 Brest, France
| | - Jonathan J. Marsh
- Graduate School of Social Service, Fordham University, 113 West 60th Street, New York, NY 10023, USA
| | - Sofian Berrouiguet
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| | - Michel Walter
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| | - Christophe Lemey
- Centre Hospitalier Régional et Universitaire de Brest, 2 Avenue Foch, 29200 Brest, France
- Unité de Recherche EA 7479 SPURBO, Université de Bretagne Occidentale, 29200 Brest, France
| |
Collapse
|
3
|
Valbuena Valecillos A, Yatham P, Alderman M, Shapiro L, Tiozzo E, Gober J. Acute Intermittent Porphyria: A Review and Rehabilitation Perspective. Cureus 2023; 15:e44260. [PMID: 37772218 PMCID: PMC10526832 DOI: 10.7759/cureus.44260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
Acute intermittent porphyria (AIP) is an uncommon metabolic disease that impacts multiple organs and can manifest in many ways. It is often misdiagnosed due to its nonspecific symptoms. Neurovisceral signs and symptoms should alert physicians to consider AIP in the differential after excluding more common causes. Identifying the underlying cause is critical in preventing acute attacks, and trigger avoidance is the optimal approach to managing AIP. Medications that are contraindicated should be reviewed thoroughly. Prompt intravenous hematin administration is the primary treatment for acute attacks, and additional pharmacological therapies may be necessary to treat concurrent symptoms. A severe neurological manifestation of AIP is flaccid paralysis or severe motor weakness, which can develop into total quadriplegia and respiratory insufficiency. A comprehensive rehabilitation program is an integral aspect of the treatment plan. Since the incidence of this disease is low, functional prognosis is not well-known. As a result, it is challenging to determine the most appropriate structure, intensity, and duration of rehabilitation therapy. By extending the treatment plan, individuals with tetraplegia due to AIP can continue to make functional gains years after the onset of weakness. Understanding the disease's functional prognosis will aid in coordinating resources and improving healthcare expenditures.
Collapse
Affiliation(s)
- Adriana Valbuena Valecillos
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Puja Yatham
- Department of Medicine, Herbert Wertheim College of Medicine, Miami, USA
| | - Matison Alderman
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Lauren Shapiro
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Eduard Tiozzo
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Joslyn Gober
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| |
Collapse
|
4
|
Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
Collapse
Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
| |
Collapse
|
5
|
[Rapidly progressive neuropathy, diffuse pain and pseudohallucinations in a young female patient]. DER NERVENARZT 2022; 93:1243-1246. [PMID: 35522308 DOI: 10.1007/s00115-022-01293-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
|
6
|
Motley W, Chaudry V, Lloyd TE. Treatment and Management of Hereditary Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
7
|
Gerischer LM, Scheibe F, Nümann A, Köhnlein M, Stölzel U, Meisel A. Acute porphyrias - A neurological perspective. Brain Behav 2021; 11:e2389. [PMID: 34661997 PMCID: PMC8613433 DOI: 10.1002/brb3.2389] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/21/2021] [Accepted: 09/14/2021] [Indexed: 01/23/2023] Open
Abstract
Acute hepatic porphyrias (AHP) can cause severe neurological symptoms involving the central, autonomic, and peripheral nervous system. Due to their relative rarity and their chameleon-like presentation, delayed diagnosis and misdiagnosis are common. AHPs are genetically inherited disorders that result from heme biosynthesis enzyme deficiencies and comprise four forms: acute intermittent porphyria (AIP), variegate porphyria (VP), hereditary coproporphyria (HCP), and ALA-dehydratase porphyria (ALADP). Depending on the clinical presentation, the main differential diagnoses are Guillain-Barré syndrome and autoimmune encephalitis. Red flags that could raise the suspicion of acute porphyria are neurological symptoms starting after severe (abdominal) pain, in association with reddish urine, hyponatremia or photodermatitis, and the presence of encephalopathy and/or axonal neuropathy. We highlight the diagnostic difficulties by presenting three cases from our neurological intensive care unit and give a comprehensive overview about the diagnostic findings in imaging, electrophysiology, and neuropathology.
Collapse
Affiliation(s)
- Lea M. Gerischer
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| | - Franziska Scheibe
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| | - Astrid Nümann
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
| | - Martin Köhnlein
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
| | - Ulrich Stölzel
- Department of Internal Medicine II, Porphyria Center SaxoniaKlinikum Chemnitz gGmbHChemnitzGermany
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, Department of NeurologyBerlinGermany
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu Berlin, NeuroCure Clinical Research CenterBerlinGermany
| |
Collapse
|
8
|
de Souza PVS, Badia BDML, Farias IB, Pinto WBVDR, Oliveira ASB. Acute Hepatic Porphyria: Pathophysiological Basis of Neuromuscular Manifestations. Front Neurosci 2021; 15:715523. [PMID: 34646118 PMCID: PMC8502968 DOI: 10.3389/fnins.2021.715523] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/31/2021] [Indexed: 12/12/2022] Open
Abstract
Acute hepatic porphyria represents a rare, underdiagnosed group of inherited metabolic disorders due to hereditary defects of heme group biosynthesis pathway. Most patients have their definite diagnosis after several years of complex and disabling clinical manifestations and commonly after life-threatening acute neurovisceral episodes or severe motor handicap. Many key studies in the last two decades have been performed and led to the discovery of novel possible diagnostic and prognostic biomarkers and to the development of new therapeutic purposes, including small interfering RNA-based therapy, specifically driven to inhibit selectively delta-aminolevulinic acid synthase production and decrease the recurrence number of severe acute presentation for most patients. Several distinct mechanisms have been identified to contribute to the several neuromuscular signs and symptoms. This review article aims to present the current knowledge regarding the main pathophysiological mechanisms involved with the acute and chronic presentation of acute hepatic porphyria and to highlight the relevance of such content for clinical practice and in decision making about therapeutic options.
Collapse
Affiliation(s)
- Paulo Victor Sgobbi de Souza
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Bruno de Mattos Lombardi Badia
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Igor Braga Farias
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | | | - Acary Souza Bulle Oliveira
- Division of Neuromuscular Diseases, Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| |
Collapse
|
9
|
McCray BA, Scherer SS. Axonal Charcot-Marie-Tooth Disease: from Common Pathogenic Mechanisms to Emerging Treatment Opportunities. Neurotherapeutics 2021; 18:2269-2285. [PMID: 34606075 PMCID: PMC8804038 DOI: 10.1007/s13311-021-01099-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 01/12/2023] Open
Abstract
Inherited peripheral neuropathies are a genetically and phenotypically diverse group of disorders that lead to degeneration of peripheral neurons with resulting sensory and motor dysfunction. Genetic neuropathies that primarily cause axonal degeneration, as opposed to demyelination, are most often classified as Charcot-Marie-Tooth disease type 2 (CMT2) and are the focus of this review. Gene identification efforts over the past three decades have dramatically expanded the genetic landscape of CMT and revealed several common pathological mechanisms among various forms of the disease. In some cases, identification of the precise genetic defect and/or the downstream pathological consequences of disease mutations have yielded promising therapeutic opportunities. In this review, we discuss evidence for pathogenic overlap among multiple forms of inherited neuropathy, highlighting genetic defects in axonal transport, mitochondrial dynamics, organelle-organelle contacts, and local axonal protein translation as recurrent pathological processes in inherited axonal neuropathies. We also discuss how these insights have informed emerging treatment strategies, including specific approaches for single forms of neuropathy, as well as more general approaches that have the potential to treat multiple types of neuropathy. Such therapeutic opportunities, made possible by improved understanding of molecular and cellular pathogenesis and advances in gene therapy technologies, herald a new and exciting phase in inherited peripheral neuropathy.
Collapse
Affiliation(s)
- Brett A. McCray
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205 USA
| | - Steven S. Scherer
- Department of Neurology, The University of Pennsylvania, Philadelphia, PA 19104 USA
| |
Collapse
|
10
|
Oliveira Santos M, Leal Rato M. Neurology of the acute hepatic porphyrias. J Neurol Sci 2021; 428:117605. [PMID: 34375916 DOI: 10.1016/j.jns.2021.117605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 07/01/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Abstract
Porphyrias are a set of rare inherited metabolic disorders, each of them representing a defect in one of the eight enzymes in the haem biosynthetic pathway resulting in the accumulation of organic compounds called porphyrins. Acute hepatic porphyrias (AHP) are those in which the enzyme deficiency occurs in the liver, of which acute intermittent porphyria is by far the most common subtype. Neurology of the AHP is still challenging in practice, and patients rarely receive the correct diagnosis early in the disease course. For AHP, which primarily affects the central and peripheral nervous system, the cause of symptoms seems to be the increased production of neurotoxic precursors, in particular delta-aminolaevulinic acid and porphobilinogen. Neurological complications usually result from severe episodes of acute attacks. The neurologic hallmark of porphyrias is an acute predominantly motor axonal neuropathy resembling a Guillain-Barré syndrome that generally occurs after the onset of other clinical features such as abdominal pain and central nervous system manifestations. Neuropsychiatric syndromes, seizures, encephalopathy, and cerebrovascular disorders are among the possible central nervous system presentations. Therapeutic approach to AHP is divided into management and prophylaxis of an acute attack, including long standing options such as intravenous hematin and new therapeutic agents such as givosiran.
Collapse
Affiliation(s)
- Miguel Oliveira Santos
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Institute of Physiology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
| | - Miguel Leal Rato
- Neurology, Department of Neurosciences and Mental Health, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal; Institute of Pharmacology and Neurosciences, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| |
Collapse
|
11
|
Huang S, Li R, Yuan Y. Severe neuropathic attack in a woman with acute intermittent porphyria: a case report. J Int Med Res 2021; 49:300060520983143. [PMID: 33430675 PMCID: PMC7809922 DOI: 10.1177/0300060520983143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Acute intermittent porphyria (AIP) is a rare autosomal dominant metabolic disease with a broad spectrum of clinical manifestations, and can be easily confused with other diseases. Many patients with porphyria may have symptoms of peripheral nerve damage during an AIP attack, but most such patients are usually only mildly affected. Herein, we describe the case of an undiagnosed woman who developed overall weakness and respiratory failure within 48 hours, leading to her referral to the intensive care unit. Her neuropathy rapidly deteriorated, leading to quadriplegia and bulbar palsy within 14 days. Finally, the reddish color of her urine and further genetic analysis led to a diagnosis of AIP. The patient was treated with intravenous glucose infusion and her condition gradually improved; however, severe neurological sequelae remained. To the best of our knowledge, the AIP reported in this case, involving rapid and severe neuropathy, is extremely rare worldwide. A diagnosis of AIP should therefore be considered when patients present with severe progressive neuropathy. Moreover, early diagnosis may considerably improve patient prognosis.
Collapse
Affiliation(s)
- Shiqian Huang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yin Yuan
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
12
|
Abstract
The acute hepatic porphyrias (AHP) are a group of four inherited diseases of heme biosynthesis. They present with similar severe, episodic, acute neurovisceral symptoms due to abnormally elevated levels of porphyrin precursors delta-aminolevulinic acid (ALA). Recently genetic screening indicates that the prevalence of mutation carrier state is more common than previously thought, occurring in 1 in 1,500, though the clinical penetrance of symptomatic AHP is low at ~1%. Symptomatic attacks occur primarily in females during their reproductive years. In an acute porphyria attack, the primary symptom is abdominal pain, due to intestinal dysmotility from autonomic nerve injury. Other manifestations include seizures, weakness and mood changes, point to injury involving peripheral and central nervous system. Due to the non-specific nature of the symptoms and signs in AHP, the diagnosis is often delayed by many years. The diagnosis of AHP depends on biochemical evidence of elevated ALA and PBG levels in urine during symptomatic attacks. Genetic testing is used for confirmation of the gene involved and the exact mutation. Treatment involves administration of heme, which downregulates production of ALA. Long-term management centers on educating genetic carriers on avoiding triggers that increase the risk of acute attacks and screening family members.
Collapse
Affiliation(s)
- Bruce Wang
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
13
|
Martinez MDC, Cerbino GN, Granata BX, Batlle A, Parera VE, Rossetti MV. Clinical, biochemical, and genetic characterization of acute hepatic porphyrias in a cohort of Argentine patients. Mol Genet Genomic Med 2021; 9:e1059. [PMID: 33764674 PMCID: PMC8172188 DOI: 10.1002/mgg3.1059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/04/2019] [Accepted: 02/10/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute Hepatic Porphyrias (AHPs) are characterized by an acute neuroabdominal syndrome including both neuropsychiatric symptoms and neurodegenerative changes. Two main hypotheses explain the pathogenesis of nervous system dysfunction: (a) the ROS generation by autooxidation of 5-aminolevulinic acid accumulated in liver and brain; (b) liver heme deficiency and in neural tissues that generate an oxidative status, a component of the neurodegenerative process. METHODS We review results obtained from Acute Intermittent Porphyria (AIP) and Variegate Porphyria (VP) families studied at clinical, biochemical, and molecular level at the CIPYP in Argentina. The relationship between the porphyric attack and oxidative stress was also evaluated in AHP patients and controls, to identify a marker of neurological dysfunction. RESULTS We studied 116 AIP families and 30 VP families, 609 and 132 individuals, respectively. Genotype/phenotype relation was studied. Oxidative stress parameters and plasma homocysteine levels were measured in 20 healthy volunteers, 22 AIP and 12 VP individuals. CONCLUSION No significant difference in oxidative stress parameters and homocysteine levels between the analyzed groups were found.
Collapse
Affiliation(s)
- María Del Carmen Martinez
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), Hospital de Clínicas José de San Martín, CONICET-UBA, Buenos Aires, Argentina.,Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales - Universidad de Buenos Aires (UBA), Buenos Aires, Argentina
| | - Gabriela Nora Cerbino
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), Hospital de Clínicas José de San Martín, CONICET-UBA, Buenos Aires, Argentina
| | - Bárbara Xoana Granata
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), Hospital de Clínicas José de San Martín, CONICET-UBA, Buenos Aires, Argentina
| | - Alcira Batlle
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), Hospital de Clínicas José de San Martín, CONICET-UBA, Buenos Aires, Argentina
| | - Victoria Estela Parera
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), Hospital de Clínicas José de San Martín, CONICET-UBA, Buenos Aires, Argentina
| | - María Victoria Rossetti
- Centro de Investigaciones sobre Porfirinas y Porfirias (CIPYP), Hospital de Clínicas José de San Martín, CONICET-UBA, Buenos Aires, Argentina
| |
Collapse
|
14
|
Inherited Neuromuscular Disorders: Which Role for Serum Biomarkers? Brain Sci 2021; 11:brainsci11030398. [PMID: 33801069 PMCID: PMC8004068 DOI: 10.3390/brainsci11030398] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/08/2021] [Accepted: 03/18/2021] [Indexed: 12/12/2022] Open
Abstract
Inherited neuromuscular disorders (INMD) are a heterogeneous group of rare diseases that involve muscles, motor neurons, peripheral nerves or the neuromuscular junction. Several different lab abnormalities have been linked to INMD: sometimes they are typical of the disorder, but they usually appear to be less specific. Sometimes serum biomarkers can point out abnormalities in presymtomatic or otherwise asymptomatic patients (e.g., carriers). More often a biomarker of INMD is evaluated by multiple clinicians other than expert in NMD before the diagnosis, because of the multisystemic involvement in INMD. The authors performed a literature search on biomarkers in inherited neuromuscular disorders to provide a practical approach to the diagnosis and the correct management of INMD. A considerable number of biomarkers have been reported that support the diagnosis of INMD, but the role of an expert clinician is crucial. Hence, the complete knowledge of such abnormalities can accelerate the diagnostic workup supporting the referral to specialists in neuromuscular disorders.
Collapse
|
15
|
Kesserwani H. The "Dangles" - Wrist, Finger and Thumb Drop: A Case Report of Saturday Night Palsy and a Historical and Molecular Detour. Cureus 2021; 13:e13195. [PMID: 33717737 PMCID: PMC7942519 DOI: 10.7759/cureus.13195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 11/11/2022] Open
Abstract
Saturday night palsy refers to neuropraxia of the radial nerve following prolonged compression against the spiral groove of the humerus. The pattern of weakness is unique with wrist, thumb, and finger drop, and recovery is universal by six months. What makes this clinical entity fascinating are the toxic and metabolic diseases that can manifest similarly, namely, plumbism (Saturnism) and acute porphyrias. The acute porphyrias (heme biosynthetic inborn errors of metabolism) are well known to cause motor neuropathy, with upper more than lower limb weakness, with wrist, thumb and finger drop a frequent manifestation. Intriguingly, lead neurotoxicity (plumbism), which has historically been tightly associated with wrist, thumb, and finger drop, is associated with the inhibition of at least three enzymes of heme biosynthesis. Mechanistically, interference with heme ring synthesis interferes with electron transport chain protein synthesis, which leads to oxidative phosphorylation defects, energy failure, axonal transport impairment, and, subsequently, an axonopathy. The lead atom has a valence of two (giving up two electrons) similar to that of the calcium atom, allowing lead to bind to spongy and cortical bone and interfering with the presynaptic voltage-gated calcium channel (VGCC) neurons. We list the salient features and similarities of these two very rare entities, hence, the term plumboporphyric neuropathy for one of the genetic variants of heme biosynthesis. Lastly, we briefly outline the spectacular history of plumbism and adumbrate on the similarity of the bacchanalian ecstasy of Roman festivals (Saturnism), over-indulgence in lead-sweetened and lead-laden barrels of wine, and the syncretism between the Saturnine palsy and Saturday night palsy. We present a case of wrist, thumb, and finger drop due to compressive neuropraxia as a platform to segue into the historical simulacra.
Collapse
|
16
|
Chiabrando D, Fiorito V, Petrillo S, Bertino F, Tolosano E. HEME: a neglected player in nociception? Neurosci Biobehav Rev 2021; 124:124-136. [PMID: 33545213 DOI: 10.1016/j.neubiorev.2021.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
Despite increasing progress in the understanding of the pathophysiology of pain, current management of pain syndromes is still unsatisfactory. The recent discovery of novel pathways associated with pain insensitivity in humans represents a unique opportunity to improve our knowledge on the pathophysiology of pain. Heme metabolism recently emerged as a crucial regulator of nociception. Of note, alteration of heme metabolism has been associated with pain insensitivity as well as with acute and chronic pain in porphyric neuropathy and hemolytic diseases. However, the molecular mechanisms linking heme to the pain pathways still remain unclear. The review focuses on the major heme-regulated processes relevant for sensory neurons' maintenance, peripheral and central sensitization as well as for pain comorbidities, like anxiety and depression. By discussing the body of knowledge on the topic, we provide a novel perspective on the molecular mechanisms linking heme to nociception.
Collapse
Affiliation(s)
- Deborah Chiabrando
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy.
| | - Veronica Fiorito
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| | - Sara Petrillo
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| | - Francesca Bertino
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| | - Emanuela Tolosano
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Turin, Italy
| |
Collapse
|
17
|
Steinberg T, Kilic M, Fuchs K, Hanyk K, Linker RA, Schlachetzki F, Neumann B. Case report of a complicated neurologically manifesting acute porphyria treated successfully with Givosiran. J Neurol Sci 2021; 422:117334. [PMID: 33581419 DOI: 10.1016/j.jns.2021.117334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Tim Steinberg
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| | - Mustafa Kilic
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| | - Kornelius Fuchs
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| | - Karel Hanyk
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| | - Ralf A Linker
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| | - Felix Schlachetzki
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| | - Bernhard Neumann
- Department of Neurology, University of Regensburg, Bezirksklinikum Regensburg, Germany.
| |
Collapse
|
18
|
Agarwal S, Habtemarium B, Xu Y, Simon AR, Kim JB, Robbie GJ. Normal reference ranges for urinary δ-aminolevulinic acid and porphobilinogen levels. JIMD Rep 2021; 57:85-93. [PMID: 33473344 PMCID: PMC7802627 DOI: 10.1002/jmd2.12173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/12/2020] [Accepted: 09/17/2020] [Indexed: 12/30/2022] Open
Abstract
Acute hepatic porphyria (AHP) is a family of rare, serious, and potentially life-threatening metabolic disorders caused by mutations in genes encoding enzymes involved in hepatic heme biosynthesis. AHP is characterized by accumulation of neurotoxic heme intermediates, δ-aminolevulinic acid (ALA), and porphobilinogen (PBG), which are thought to be causal for the disease manifestations. Novel therapeutic treatments such as givosiran, an RNA interference therapeutic that was recently approved for treatment of adults with AHP, are focused on reducing the levels of ALA and PBG in patients toward levels observed in a healthy population. While there are two published reports on the distribution of urinary ALA and PBG levels in healthy subjects, these lacked the required details to enable the calculation of reference limits for ALA and PBG. Therefore, urinary ALA and PBG levels were quantified in 150 healthy subjects using a validated liquid chromatography tandem mass spectrometry (LC-MS/MS) method that is highly sensitive, specific, accurate, and reproducible. These data were used to establish the upper limit of normal (ULN) values for ALA and PBG as 1.47 and 0.137 mmol/mol Cr, respectively. Relative to these ULN values, baseline urinary ALA and PBG levels in AHP patients were found to be 9.3- to 12-fold, and 238- to 336-fold higher, respectively. Results from this study can serve as a guide to assess the effectiveness of therapeutic interventions in lowering ALA and PBG.
Collapse
Affiliation(s)
| | | | - Yuanxin Xu
- Alnylam PharmaceuticalsCambridgeMassachusettsUSA
| | - Amy R. Simon
- Alnylam PharmaceuticalsCambridgeMassachusettsUSA
| | - Jae B. Kim
- Alnylam PharmaceuticalsCambridgeMassachusettsUSA
| | | |
Collapse
|
19
|
Nunnemann S, Uibel C, Budig P, Mäurer M. Acute intermittent porphyria (AIP) in a patient with celiac disease. Neurol Res Pract 2020; 2:2. [PMID: 33324908 PMCID: PMC7650118 DOI: 10.1186/s42466-020-0049-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/13/2020] [Indexed: 11/12/2022] Open
Abstract
We present the case of an 18 year old Caucasian with known celiac disease, who suffered a severe first attack of acute intermittent porphyria (AIP) with neuropsychiatric symptoms, severe tetraparesis and respiratory insufficiency. Treatment with heme arginate and high-dose intravenous glucose and rigorous rehabilitation resulted in a slow but almost complete recovery of her motor symptoms. To our knowledge this is the first case of acute intermittent porphyria triggered by malnutrition in the context of celiac disease. It is remarkable that the patient showed a favourable outcome despite the severity of her initial symptoms. This case shows the importance of early and systematic symptomatic treatment in patients with severe neurologic manifestation of AIP.
Collapse
Affiliation(s)
- Sebastian Nunnemann
- Department of Neurology, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, 97070 Würzburg, Germany
| | - Christoph Uibel
- Department of Neurology, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, 97070 Würzburg, Germany
| | - Petra Budig
- Department of Neurology, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, 97070 Würzburg, Germany
| | - Mathias Mäurer
- Department of Neurology, Klinikum Würzburg Mitte gGmbH, Standort Juliusspital, 97070 Würzburg, Germany
| |
Collapse
|
20
|
Mulroy E, Anderson NE. Altered mental status in "Guillain-Barré syndrome" -a noteworthy clinical clue. Ann Clin Transl Neurol 2020; 7:2489-2507. [PMID: 33136342 PMCID: PMC7732251 DOI: 10.1002/acn3.51226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/19/2020] [Accepted: 09/26/2020] [Indexed: 01/01/2023] Open
Abstract
Guillain‐Barré syndrome (GBS) is widely regarded as a “pure” peripheral nervous system disorder. However, this simplistic interpretation belies the fact that central nervous system involvement, often manifesting as derangements in mental status can occur as a complication of the “pure” form of the disorder, as part of GBS variants, as well as in a number of mimic disorders. Despite being common in clinical practice, there is no guidance in the literature as to how to approach such scenarios. Herein, we detail our approach to these cases.
Collapse
Affiliation(s)
- Eoin Mulroy
- UCL Queen Square Institute of Neurology, London, UK
| | | |
Collapse
|
21
|
Ma Y, Teng Q, Zhang Y, Zhang S. Acute intermittent porphyria: focus on possible mechanisms of acute and chronic manifestations. Intractable Rare Dis Res 2020; 9:187-195. [PMID: 33139977 PMCID: PMC7586881 DOI: 10.5582/irdr.2020.03054] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/28/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022] Open
Abstract
Porphyrias are a group of inherited metabolic diseases that include eight types, each of which is caused by a mutation that affects an enzyme of the heme biosynthetic pathway. When an enzyme defect has physiological significance, it leads to overproduction of pathway precursors prior to the defective step. The partial absence of the third enzyme in the heme biosynthetic pathway, porphobilinogen deaminase (PBGD) also known as hydroxymethylbilane synthase (HMBS), results in acute intermittent porphyria (AIP), which affects mainly women. Subjects who had AIP symptoms were deemed to have manifest AIP (MAIP). Clinical manifestations are usually diverse and non-specific. Acute AIP episodes may present with abdominal pain, nausea, and vomiting, and repeated episodes may result in a series of chronic injuries. Therefore, studying the mechanisms of acute and chronic manifestations of AIP is of great significance. This review aims to summarize the possible mechanisms of acute and chronic manifestations in patients with AIP.
Collapse
Affiliation(s)
- Yuelin Ma
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Qing Teng
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yiran Zhang
- School of First Clinical Medical College, Southern Medical University, Guangzhou, Guangdong, China
| | - Songyun Zhang
- Department of Endocrinology, The second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| |
Collapse
|
22
|
Porphyric Neuropathy: Pathophysiology, Diagnosis, and Updated Management. Curr Neurol Neurosci Rep 2020; 20:56. [PMID: 33026560 DOI: 10.1007/s11910-020-01078-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW To review the peripheral neurological complications of the acute hepatic porphyrias, as well as the latest advances in their pathophysiology and management. RECENT FINDINGS The diagnosis of porphyric neuropathy remains challenging as varying neuropathic patterns are encountered depending on disease stage, including a non-length-dependent distribution pattern. The major pathophysiologic mechanism is δ-aminolevulinic acid (ALA)-induced neurotoxicity. The less restrictive blood-nerve barrier in the autonomic ganglia and myenteric plexus may explain the frequency of dysautonomic manifestations. Recently, a prophylactic small interfering RNA (siRNA)-based therapy that reduces hepatic ALA Synthase-1 mRNA was approved for patients with recurrent neuro-visceral attacks. Neurologists should appreciate the varying patterns of porphyric neuropathy. As with most toxin-induced axonopathies, long-term outcomes depend on early diagnosis and treatment. While the short-term clinical and biochemical benefits of siRNA-based therapy are known, its long-term effects on motor recovery, chronic pain, and dysautonomic manifestations are yet to be determined.
Collapse
|
23
|
Ponciano A, Carvalho JN, Gala D, Leite J, Fernandes C. Pearls & Oy-sters: Guillain-Barré syndrome. Neurology 2020; 95:e1437-e1440. [DOI: 10.1212/wnl.0000000000009838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
24
|
Abstract
El término 'porfiria' proviene del griego 'porphyra' y alude a un grupo heterogéneo de trastornos metabólicos causados por una deficiencia enzimática en la biosíntesis del grupo hemo. La causa de la porfiria intermitente aguda es la deficiencia de la enzima deaminasa del porfobilinógeno. Se presenta el caso de una mujer de 40 años que presentó dolor abdominal de 10 días de evolución, trastorno hidroelectrolítico grave debido a hiponatremia e hipopotasemia, taquicardia e hipertensión arterial sistémica persistentes, por lo cual fue sometida a una laparotomía en la que no se encontró ninguna afección de origen quirúrgico, A los siete días del examen inicial, la paciente desarrolló cuadriparesia flácida aguda y presentó una crisis convulsiva tónico-clónica generalizada. Los estudios neurofisiológicos evidenciaron una polineuropatía axonal mixta, y los valores de porfobilinógeno y porfirinas en orina eran elevados. Tras diagnosticarse porfiria intermitente aguda, esta se trató con hemina, lo que estabilizó los signos clínicos y normalizó el porfobilinógeno. La prevalencia de esta enfermedad es de 1 en 2.000 personas. Tiene un patrón de herencia autosómico dominante y se manifiesta principalmente en mujeres con edades entre los 20 y los 40 años. La enfermedad cursa con síntomas neurológicos y viscerales, y se trata con la administración de hemina y dextrosa, evitando las soluciones hipotónicas por el riesgo de exacerbar la hiponatremia.
Collapse
|
25
|
Fatima SA, Jurair H, Abbas Q, Rehman AJ. Paediatric porphyria and human hemin: a treatment challenge in a lower middle income country. BMJ Case Rep 2020; 13:e232236. [PMID: 31919062 PMCID: PMC6954746 DOI: 10.1136/bcr-2019-232236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2019] [Indexed: 11/04/2022] Open
Abstract
Here, we report a case of a 15-year-old girl who presented to the emergency department with symptoms of abdominal pain, nausea, vomiting and seizures. She was diagnosed with acute intermittent porphyria. Treatment was started by removing all porphogenic drugs, providing high glucose intake (oral and intravenous), which initially resulted in good clinical outcomes. However, she deteriorated again and also developed neurological manifestation (paraplegia) for which she required mechanical ventilation because of acute respiratory failure. This time she was initiated on human hemin for four consecutive days. After 2 days of therapy, her porphobilinogen levels decreased to 50% of the initial raised value. Increased lactic acid and blood urea nitrogen were the two side effects observed after the treatment, with no apparent signs of acute kidney injury. To the best of our knowledge, in paediatric population, this is the first reported case of treatment of acute intermittent porphyria with human hemin in Pakistan.
Collapse
Affiliation(s)
- Syeda Anum Fatima
- Department of Pharmacy Services, Aga Khan University Hospital, Karachi, Pakistan
| | - Humaira Jurair
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Qalab Abbas
- Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | | |
Collapse
|
26
|
Mutluay B, Köksal A, Çelık RGG, Bülbül HH. A Case of Acute Intermittent Porphyria Mimicking Guillain-Barré Syndrome. ACTA ACUST UNITED AC 2020; 56:311-312. [PMID: 31903042 DOI: 10.5152/npa.2017.19474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/30/2016] [Indexed: 11/22/2022]
Abstract
Patients with acute intermittent porphyria attacks present with severe abdominal pain, neuropathy and psychiatric disturbances. Porphyric neuropathy mostly causes confusion in clinical practice, and patients with porphyria are rarely correctly diagnosed early in the course of the illness. We report a patient with acute intermittent porphyria mimicking Guillain-Barré syndrome with acute onset weakness that rapidly progressed to severe quadriplegia.
Collapse
Affiliation(s)
- Belgin Mutluay
- Department of Neurology, Bakırköy Research and Training Hospital for Neurologic and Psychiatric Diseases, İstanbul, Turkey
| | - Ayhan Köksal
- Department of Neurology, Bakırköy Research and Training Hospital for Neurologic and Psychiatric Diseases, İstanbul, Turkey
| | - Rabia Gökçen Gözübatik Çelık
- Department of Neurology, Bakırköy Research and Training Hospital for Neurologic and Psychiatric Diseases, İstanbul, Turkey
| | - Hafsa Hicret Bülbül
- Department of Neurology, Bakırköy Research and Training Hospital for Neurologic and Psychiatric Diseases, İstanbul, Turkey
| |
Collapse
|
27
|
Shiratori T, Hotta K, Satoh M, Kiuchi C, Ogawa N, Kamigaito T. Preanesthetic severe postural hypotension following 5-aminolevulinic acid pretreatment in patients for photodynamic diagnosis-assisted urological surgery. JA Clin Rep 2019; 5:74. [PMID: 32025937 PMCID: PMC6967019 DOI: 10.1186/s40981-019-0295-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 5-Aminolevulinic acid (5-ALA) is utilized for photodynamic diagnosis-assisted (PDD) surgery. However, it has been associated with vasodilation, hence, occasional hypotension. CASE PRESENTATION We encountered two patients who had severe postural hypotension following 5-ALA pretreatment prior to an operation. They were scheduled for urological PDD surgery, but upon standing to walk to the operation room, they felt sick because of severe hypotension. One of them underwent the surgery after recovery, but the other surgery was canceled due to a prolonged hypotension that lasted for more than a day. CONCLUSIONS Severe postural hypotension may develop as a result of the high concentration of porphyrin precursors, which may affect the nervous system. Severe postural hypotension may be due to 5-ALA-induced autonomic dysfunction as well as vasodilative action of 5-ALA. These observations suggest that in addition to the careful monitoring of patients' vital signs, standing should be avoided following 5-ALA pretreatment.
Collapse
Affiliation(s)
- Tohru Shiratori
- Department of Anesthesiology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Kunihisa Hotta
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498 Japan
| | - Masaaki Satoh
- Department of Urology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Chiaki Kiuchi
- Department of Anesthesiology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Noriyuki Ogawa
- Department of Urology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| | - Takayuki Kamigaito
- Department of Urology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555 Japan
| |
Collapse
|
28
|
Erazo-Narváez AF, Erazo-Rosero MS, Zamora-Bastidas TO. Porfiria intermitente aguda como desencadenante de síndrome de Guillain-Barre. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n2.68373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introducción. La porfiria es un conjunto de enfermedades metabólicas que tienen como base fisiopatológica la acumulación de precursores tóxicos. Su similitud clínica con enfermedades como el síndrome de Guillain-Barre puede retrasar el diagnostico, aumentando la posibilidad de complicaciones.Presentación del caso. Paciente femenino quien presentó síntomas inespecíficos de porfiria y síndrome de Guillain-Barre. La mujer fue evaluada de manera integral y recibió tratamiento para ambas patologías, respondiendo de manera inusual.Conclusión. La respuesta farmacológica atípica encontrada y la relación causa-efecto entre ambas entidades se justifica a la luz de sus procesos fisiopatológicos y la respuesta inmune desencadenada por los mismos.
Collapse
|
29
|
Abstract
Peripheral neuropathy is a commonly encountered disorder in clinical practice. In light of an aging population and the diabetes and obesity pandemic, the prevalence of peripheral neuropathy is increasing, posing a significant public health concern. This article provides a diagnostic framework for neuropathies and summarizes treatment options.
Collapse
Affiliation(s)
- Kelsey Barrell
- Department of Neurology, University of Utah School of Medicine, 175 North Medical Drive, Salt Lake City, UT 84132, USA.
| | - A Gordon Smith
- Department of Neurology, Virginia Commonwealth University, 417 North 11th Street, Richmond, VA 23298, USA
| |
Collapse
|
30
|
Alqwaifly M, Bril V, Dodig D. Acute Intermittent Porphyria: A Report of 3 Cases with Neuropathy. Case Rep Neurol 2019; 11:32-36. [PMID: 31205461 PMCID: PMC6558341 DOI: 10.1159/000496420] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 11/25/2022] Open
Abstract
The porphyrias are metabolic disorders due to a defect in the heme biosynthetic pathway. Patients have diverse clinical presentations with neuropathy being frequent in acute intermittent porphyria (AIP). Associated symptoms are abdominal pain and seizures. Three patients presenting with neuropathy were later diagnosed with AIP on the basis of clinical features, erythrocyte porphobilinogen deaminase activity, neuropathic patterns, and nerve conduction studies. Testing for the HMBS genetic mutation confirmed the diagnosis of AIP in 1 patient. The findings from this case series confirm that porphyric neuropathy in AIP is a predominantly motor neuropathy with differing neuropathic presentations ranging from focal motor neuropathy to quadriplegia and respiratory failure.
Collapse
Affiliation(s)
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Institute for Research and Medical Consultations, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Dubravka Dodig
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
31
|
McCorquodale D, Smith AG. Clinical electrophysiology of axonal polyneuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:217-240. [PMID: 31307603 DOI: 10.1016/b978-0-444-64142-7.00051-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Axonal neuropathies encompass a wide range of acquired and inherited disorders with electrophysiologic characteristics that arise from the unique neurophysiology of the axon. Accurate interpretation of nerve conduction studies and electromyography requires an in-depth understanding of the pathophysiology of the axon. Here we review the unique neurophysiologic properties of the axon and how they relate to clinical electrodiagnostic features. We review the length-dependent Wallerian or "dying-back" processes as well as the emerging body of literature from acquired axonal neuropathies that highlights the importance of axonal disease at the nodes of Ranvier. Neurophysiologic features of individual inherited and acquired axonal diseases, including primary nerve disease as well as systemic immune mediated, metabolic, and toxic diseases involving the peripheral nerve, are reviewed. This comprehensive review of electrodiagnostic findings coupled with the current understanding of pathophysiology will aid the clinician in the evaluation of axonal polyneuropathies.
Collapse
Affiliation(s)
- Donald McCorquodale
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| | - A Gordon Smith
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States.
| |
Collapse
|
32
|
Chiabrando D, Fiorito V, Petrillo S, Tolosano E. Unraveling the Role of Heme in Neurodegeneration. Front Neurosci 2018; 12:712. [PMID: 30356807 PMCID: PMC6189481 DOI: 10.3389/fnins.2018.00712] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/19/2018] [Indexed: 12/24/2022] Open
Abstract
Heme (iron-protoporphyrin IX) is an essential co-factor involved in several biological processes, including neuronal survival and differentiation. Nevertheless, an excess of free-heme promotes oxidative stress and lipid peroxidation, thus leading to cell death. The toxic properties of heme in the brain have been extensively studied during intracerebral or subarachnoid hemorrhages. Recently, a growing number of neurodegenerative disorders have been associated to alterations of heme metabolism. Hence, the etiology of such diseases remains undefined. The aim of this review is to highlight the neuropathological role of heme and to discuss the major heme-regulated pathways that might be crucial for the survival of neuronal cells. The understanding of the molecular mechanisms linking heme to neurodegeneration will be important for therapeutic purposes.
Collapse
Affiliation(s)
- Deborah Chiabrando
- Molecular Biotechnology Center, Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy
| | - Veronica Fiorito
- Molecular Biotechnology Center, Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy
| | - Sara Petrillo
- Molecular Biotechnology Center, Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy
| | - Emanuela Tolosano
- Molecular Biotechnology Center, Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy
| |
Collapse
|
33
|
Mitochondrial Targeting in Neurodegeneration: A Heme Perspective. Pharmaceuticals (Basel) 2018; 11:ph11030087. [PMID: 30231533 PMCID: PMC6161291 DOI: 10.3390/ph11030087] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/07/2018] [Accepted: 09/14/2018] [Indexed: 02/06/2023] Open
Abstract
Mitochondrial dysfunction has achieved an increasing interest in the field of neurodegeneration as a pathological hallmark for different disorders. The impact of mitochondria is related to a variety of mechanisms and several of them can co-exist in the same disease. The central role of mitochondria in neurodegenerative disorders has stimulated studies intended to implement therapeutic protocols based on the targeting of the distinct mitochondrial processes. The review summarizes the most relevant mechanisms by which mitochondria contribute to neurodegeneration, encompassing therapeutic approaches. Moreover, a new perspective is proposed based on the heme impact on neurodegeneration. The heme metabolism plays a central role in mitochondrial functions, and several evidences indicate that alterations of the heme metabolism are associated with neurodegenerative disorders. By reporting the body of knowledge on this topic, the review intends to stimulate future studies on the role of heme metabolism in neurodegeneration, envisioning innovative strategies in the struggle against neurodegenerative diseases.
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW This article describes clinical features of axonal sensorimotor polyneuropathies based on selected etiologies. RECENT FINDINGS Axonal sensorimotor polyneuropathies have been well described for some time. Recent advances include the assessment of the incidence of peripheral neuropathy in the elderly, the recognition of the limited influence of electrodiagnostic testing on the clinical management of uncomplicated axonal sensorimotor polyneuropathy, the development of guidelines for treatment of painful neuropathy, the identification of risk factors predisposing patients for chemotherapy-induced neuropathy, a report on the association of metabolic syndrome and idiopathic axonal sensorimotor neuropathy, and the availability of more cost-effective genetic testing for identifying inherited polyneuropathies. SUMMARY Axonal sensorimotor polyneuropathies carry an extensive list of differential diagnoses. Diagnosis is based on detailed history, physical examination, recognition of associated neurologic and non-neurologic features, and appropriate testing. Disease-modifying treatments are lacking in many cases. Management focuses on modification of predisposing lifestyle and medical factors, rehabilitation, and pain relief.
Collapse
|
35
|
Abstract
Despite medical advances, the diagnosis and management of acute intermittent porphyria continues to be challenging. Acute pain is one of the most important clinical manifestations in acute intermittent porphyria, but management and pain assessment have been poorly studied in these patients. The lack of information and evidence based recommendations regarding these topics in the medical literature is certainly surprising. Furthermore, pain management is discussed based on extrapolating concepts adopted for other pain syndromes. An important arsenal of medications, including reportedly safe opioid and non-opioid analgesics, is available for use in this type of patient. In addition to conducting an extensive review of the current literature, the present article aims to show the general aspects of a disease that generates a challenge for the clinician, emphasizing what is related to pain as a cardinal symptom and to create awareness about the need for studies supporting the development of guidelines, based on evidence obtained from analgesic management in patients presenting with this disorder. A systematic assessment directed at understanding the physiopathological processes underlying acute pain combined with a stepwise approach to pain management with safe opioid and non-opioid drugs constitutes the fundamental basis for a successful pain management program in patients with acute intermittent porphyria.
Collapse
|
36
|
Abstract
The diagnosis of acute intermittent porphyria (AIP) is often overlooked. We describe a patient with this condition who had all the 'bells and whistles', in whom the diagnosis was only made after considerable delay. Far from an esoteric condition haunting examination candidates, AIP is an important cause of a broad spectrum of neurological symptoms. Its early recognition allows the astute clinician to prevent potentially devastating sequelae. We provide practical guidance on the investigation and management of this complex disorder. With a 'back to basics' approach to the underlying genetics and biochemistry, we hope to dispel some of the confusion that may obstruct a timely diagnosis.
Collapse
Affiliation(s)
- Ronan O'Malley
- Department of Neurology, Sheffield Teaching Hospitals (STH), Sheffield, UK.,Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Ganesh Rao
- Department of Neuroscience, University of Sheffield, Sheffield, UK.,Department of Neurophysiology, Sheffield Teaching Hospitals (STH), Sheffield, UK
| | - Penelope Stein
- Department of Haematological Medicine, Kings College Hospital NHS Foundation Trust, London, UK
| | - Oliver Bandmann
- Department of Neurology, Sheffield Teaching Hospitals (STH), Sheffield, UK.,Department of Neuroscience, University of Sheffield, Sheffield, UK
| |
Collapse
|
37
|
Oral rigidity and xerostomia in a 46-year-old man. J Am Dent Assoc 2018; 149:214-219. [DOI: 10.1016/j.adaj.2017.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 11/26/2017] [Accepted: 12/20/2017] [Indexed: 11/18/2022]
|
38
|
|
39
|
Balwani M, Wang B, Anderson KE, Bloomer JR, Bissell DM, Bonkovsky HL, Phillips JD, Desnick RJ. Acute hepatic porphyrias: Recommendations for evaluation and long-term management. Hepatology 2017; 66:1314-1322. [PMID: 28605040 PMCID: PMC5605422 DOI: 10.1002/hep.29313] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/10/2017] [Accepted: 06/08/2017] [Indexed: 12/12/2022]
Abstract
The acute hepatic porphyrias are a group of four inherited disorders, each resulting from a deficiency in the activity of a specific enzyme in the heme biosynthetic pathway. These disorders present clinically with acute neurovisceral symptoms which may be sporadic or recurrent and, when severe, can be life-threatening. The diagnosis is often missed or delayed as the clinical features resemble other more common medical conditions. There are four major subgroups: symptomatic patients with sporadic attacks (<4 attacks/year) or recurrent acute attacks (≥4 attacks/year), asymptomatic high porphyrin precursor excretors, and asymptomatic latent patients without symptoms or porphyrin precursor elevations. Given their clinical heterogeneity and potential for significant morbidity with suboptimal management, comprehensive clinical guidelines for initial evaluation, follow-up, and long-term management are needed, particularly because no guidelines exist for monitoring disease progression or response to treatment. The Porphyrias Consortium of the National Institutes of Health's Rare Diseases Clinical Research Network, which consists of expert centers in the clinical management of these disorders, has formulated these recommendations. These recommendations are based on the literature, ongoing natural history studies, and extensive clinical experience. Initial assessments should include diagnostic confirmation by biochemical testing, subsequent genetic testing to determine the specific acute hepatic porphyria, and a complete medical history and physical examination. Newly diagnosed patients should be counseled about avoiding known precipitating factors. The frequency of follow-up depends on the clinical subgroup, with close monitoring of patients with recurrent attacks who may require treatment modifications as well as those with clinical complications. Comprehensive care should include subspecialist referrals when needed. Annual assessments include biochemical testing and monitoring for long-term complications. These guidelines provide a framework for monitoring patients with acute hepatic porphyrias to ensure optimal outcomes. (Hepatology 2017;66:1314-1322).
Collapse
Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, CA
| | - Karl E. Anderson
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | | | | | - Herbert L. Bonkovsky
- Department of Medicine, Wake Forest NC Baptist Medical Center, Winston-Salem, NC
| | - John D. Phillips
- Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, NY, NY
| | | |
Collapse
|
40
|
Kuo HC, Ro LS, Jung SM, Huang CC, Chu CC. Porphyric neuropathies in an acute intermittent porphyria family. Neuropathology 2015; 36:290-294. [DOI: 10.1111/neup.12272] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Hung-Chou Kuo
- Department of Neurology; Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Long-Sun Ro
- Department of Neurology; Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Shih-Ming Jung
- Department of Pathology; Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Chin-Chang Huang
- Department of Neurology; Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - Chun-Che Chu
- Department of Neurology; Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine; Taoyuan Taiwan
| |
Collapse
|
41
|
Kuo HC. Reply. Muscle Nerve 2015; 52:917-8. [DOI: 10.1002/mus.24732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hung-Chou Kuo
- Department of Neurology; Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine; Taoyuan Taiwan
| |
Collapse
|
42
|
Wu X, Li C, Zhang B, Shen D, Li T, Liu K, Zhang HL. Predictors for mechanical ventilation and short-term prognosis in patients with Guillain-Barré syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:310. [PMID: 26330143 PMCID: PMC4557605 DOI: 10.1186/s13054-015-1037-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 08/16/2015] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Guillain-Barré syndrome (GBS) is an immune-mediated disorder of the peripheral nervous system. Respiratory failure requiring mechanical ventilation (MV) is a serious complication of GBS. Identification of modifiable risk factors for MV and poor short-term prognosis in mechanically ventilated patients with GBS may contribute to the individualized management and may help improve the outcome of the patients. METHODS We retrospectively analyzed the clinical data of 541 patients who were diagnosed with GBS from 2003 to 2014. Independent predictors for MV and short-term prognosis in mechanically ventilated patients were identified via multivariate logistic regression analysis. RESULTS The mean age was 41.6 years with a male predilection (61.2%). Eighty patients (14.8%) required MV. Multivariate analysis revealed that shorter interval from onset to admission (p < 0.05), facial nerve palsy (p < 0.01), glossopharyngeal and vagal nerve deficits (p < 0.01) and lower Medical Research Council (MRC) sum score at nadir (p < 0.01) were risk factors for MV; disease occurrence in summer (p < 0.01) was a protective factor. As to prognostic factors, absence of antecedent infections (p < 0.01) and lower MRC sum score at nadir (p < 0.01) were predictors of poor short-term prognosis in mechanically ventilated patients regardless of treatment modality. We further investigated the predictors of poor short-term prognosis in patients requiring MV with different nadir MRC sum scores. Combined use of intravenous corticosteroids with intravenous immunoglobulin (odds ratio 10.200, 95% confidence interval 1.068-97.407, p < 0.05) was an independent predictor of poor short-term prognosis in mechanically ventilated patients with a nadir MRC sum score from 0 to 12 points, regardless of existence of antecedent infection. CONCLUSIONS Clinical predictors of MV and poor short-term prognosis in mechanically ventilated GBS patients were distinct. Add-on use of intravenous corticosteroids was a risk factor for poor short-term prognosis in mechanically ventilated patients with a nadir MRC sum score from 0 to 12 points.
Collapse
Affiliation(s)
- Xiujuan Wu
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China.
| | - Chunrong Li
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China.
| | - Bing Zhang
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China.
| | - Donghui Shen
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China.
| | - Ting Li
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China.
| | - Kangding Liu
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China.
| | - Hong-Liang Zhang
- Neuroscience Center, Department of Neurology, the First Hospital of Jilin University, Jilin University, Xinmin Street 71#, 130021, Changchun, China. .,Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
| |
Collapse
|
43
|
Homedan C, Schmitt C, Laafi J, Gueguen N, Desquiret-Dumas V, Lenglet H, Karim Z, Gouya L, Deybach JC, Simard G, Puy H, Malthièry Y, Reynier P. Mitochondrial energetic defects in muscle and brain of a Hmbs-/- mouse model of acute intermittent porphyria. Hum Mol Genet 2015; 24:5015-23. [PMID: 26071363 DOI: 10.1093/hmg/ddv222] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 06/09/2015] [Indexed: 12/24/2022] Open
Abstract
Acute intermittent porphyria (AIP), an autosomal dominant metabolic disease (MIM #176000), is due to a deficiency of hydroxymethylbilane synthase (HMBS), which catalyzes the third step of the heme biosynthetic pathway. The clinical expression of the disease is mainly neurological, involving the autonomous, central and peripheral nervous systems. We explored mitochondrial oxidative phosphorylation (OXPHOS) in the brain and skeletal muscle of the Hmbs(-/-) mouse model first in the basal state (BS), and then after induction of the disease with phenobarbital and treatment with heme arginate (HA). The modification of the respiratory parameters, determined in mice in the BS, reflected a spontaneous metabolic energetic adaptation to HMBS deficiency. Phenobarbital induced a sharp alteration of the oxidative metabolism with a significant decrease of ATP production in skeletal muscle that was restored by treatment with HA. This OXPHOS defect was due to deficiencies in complexes I and II in the skeletal muscle whereas all four respiratory chain complexes were affected in the brain. To date, the pathogenesis of AIP has been mainly attributed to the neurotoxicity of aminolevulinic acid and heme deficiency. Our results show that mitochondrial energetic failure also plays an important role in the expression of the disease.
Collapse
Affiliation(s)
- Chadi Homedan
- UMR INSERM 1063, Département de Biochimie et Génétique and
| | - Caroline Schmitt
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | | | - Naïg Gueguen
- Département de Biochimie et Génétique and UMR CNRS 6214 - INSERM 1083, Centre Hospitalier Universitaire, 4 rue Larrey, Angers 49933, France
| | - Valérie Desquiret-Dumas
- Département de Biochimie et Génétique and UMR CNRS 6214 - INSERM 1083, Centre Hospitalier Universitaire, 4 rue Larrey, Angers 49933, France
| | - Hugo Lenglet
- INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Zoubida Karim
- INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Laurent Gouya
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Jean-Charles Deybach
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Gilles Simard
- UMR INSERM 1063, Département de Biochimie et Génétique and
| | - Hervé Puy
- Assistance Publique Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier AP-HP, 178 rue des Renouillers, Colombes 92701, France, INSERM U1149, CNRS ERL 8252, Center for Research on Inflammation (CRI), Université Paris Diderot, site Bichat, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France and Laboratory of Excellence, GR-Ex, Sorbonne Paris Cité, 16 rue Henri Huchard, Paris 75018, France
| | - Yves Malthièry
- UMR INSERM 1063, Département de Biochimie et Génétique and
| | - Pascal Reynier
- Département de Biochimie et Génétique and UMR CNRS 6214 - INSERM 1083, Centre Hospitalier Universitaire, 4 rue Larrey, Angers 49933, France,
| |
Collapse
|
44
|
Wu CL, Ro LS, Jung SM, Tsai TC, Chu CC, Lyu RK, Huang CC, Kuo HC. Clinical presentation and electrophysiological findings of porphyric neuropathies: a follow-up study. Muscle Nerve 2015; 51:363-9. [PMID: 24985076 DOI: 10.1002/mus.24327] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 11/07/2022]
Abstract
INTRODUCTION A case series of acute intermittent porphyria (AIP) is described that focuses on the clinical course of the disease with regard to neurological manifestations of the peripheral nervous system. METHODS Eight patients were diagnosed with AIP on the basis of characteristic clinical findings, erythrocyte porphobilinogendeaminase activity, neuropathic patterns, serial changes in nerve conduction studies (NCS), and temporal relationship of central nervous system involvement. RESULTS Six patients diagnosed with AIP<2 months after symptom onset had neuropathy that was predominantly upper extremity, motor, and proximal. NCS recovery rates were slower in the lower than the upper limbs. Two patients diagnosed >2 months after symptom onset had distal sensorimotor polyneuropathy. CONCLUSIONS The findings from this case series suggest that the peripheral nerves may be differentially and selectively involved in different diagnostic stages of porphyric neuropathy.
Collapse
Affiliation(s)
- Chi-Lin Wu
- Department of Neurology, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, 199 Tung Hwa North Road, Taipei, Taiwan
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Shen J, O'Keefe K, Webb LB, DeGirolamo A. Acute porphyria in a patient with Arnold Chiari malformation. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:99-103. [PMID: 25697467 PMCID: PMC4343040 DOI: 10.12659/ajcr.891079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Patient: Female, 33 Final Diagnosis: Acute porphyria Symptoms: Abdominal pain • alternating bowel habits Medication: Metronidazole • bactrim • oxybutynin Clinical Procedure: EMG • porhyria workup Specialty: Neurology
Collapse
Affiliation(s)
- Jianbin Shen
- Department of Internal Medicine, Bridgeport Hospital, Yale University School of Medicine, Bridgeport, CT, USA
| | - Kevin O'Keefe
- Department of Internal Medicine, Bridgeport Hospital, Yale University School of Medicine, Bridgeport, CT, USA
| | - Lisa B Webb
- Department of Neurology, Bridgeport Hospital, Yale University School of Medicine, Bridgeport, CT, USA
| | - Angela DeGirolamo
- Department of Internal Medicine, Bridgeport Hospital, Yale University School of Medicine, Bridgeport, CT, USA
| |
Collapse
|
46
|
Abstract
Toxic neuropathy, although rare, is an important consideration in the setting of a known or suspected toxic exposure in the workplace or other environment. This chapter discusses the clinical and electrodiagnostic evaluation of peripheral neuropathies, highlighting findings that direct further workup and may point to specific toxins as etiology. The difficulty of establishing causality of a toxin in relation to peripheral neuropathy is discussed; guidelines for establishing causality are presented. Examples of common industrial toxins are listed, including their typical industrial uses and their mechanisms of action in producing neuropathy. Characteristic clinical presentations of specific toxic neuropathies are highlighted with selected case studies.
Collapse
Affiliation(s)
- Ann A Little
- Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA
| | - James W Albers
- Department of Neurology, University of Michigan Health System, Ann Arbor, MI, USA.
| |
Collapse
|
47
|
|
48
|
Schlessinger A, Khuri N, Giacomini KM, Sali A. Molecular modeling and ligand docking for solute carrier (SLC) transporters. Curr Top Med Chem 2014; 13:843-56. [PMID: 23578028 DOI: 10.2174/1568026611313070007] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/29/2013] [Accepted: 02/01/2013] [Indexed: 12/21/2022]
Abstract
Solute Carrier (SLC) transporters are membrane proteins that transport solutes, such as ions, metabolites, peptides, and drugs, across biological membranes, using diverse energy coupling mechanisms. In human, there are 386 SLC transporters, many of which contribute to the absorption, distribution, metabolism, and excretion of drugs and/or can be targeted directly by therapeutics. Recent atomic structures of SLC transporters determined by X-ray crystallography and NMR spectroscopy have significantly expanded the applicability of structure-based prediction of SLC transporter ligands, by enabling both comparative modeling of additional SLC transporters and virtual screening of small molecules libraries against experimental structures as well as comparative models. In this review, we begin by describing computational tools, including sequence analysis, comparative modeling, and virtual screening, that are used to predict the structures and functions of membrane proteins such as SLC transporters. We then illustrate the applications of these tools to predicting ligand specificities of select SLC transporters, followed by experimental validation using uptake kinetic measurements and other assays. We conclude by discussing future directions in the discovery of the SLC transporter ligands.
Collapse
Affiliation(s)
- Avner Schlessinger
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, 1700 4th Street, San Francisco, CA 94158, USA.
| | | | | | | |
Collapse
|
49
|
Tracy JA, Dyck PJB. Porphyria and its neurologic manifestations. HANDBOOK OF CLINICAL NEUROLOGY 2014; 120:839-49. [DOI: 10.1016/b978-0-7020-4087-0.00056-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
50
|
Abstract
Porphyric neuropathy often poses a diagnostic dilemma; it is typically associated with the hepatic porphyrias, characterized by acute life-threatening attacks of neurovisceral symptoms that mimic a range of acute medical and psychiatric conditions. The development of acute neurovisceral attacks is responsive to environmental factors, including drugs, hormones, and diet. This chapter reviews the clinical manifestations, genetics, pathophysiology, and mechanisms of neurotoxicity of the acute hepatic porphyrias. While the etiology of the neurological manifestations in the acute porphyrias remains undefined, the main hypotheses include toxicity of porphyrin precursors and deficiency of heme synthesis. These hypotheses will be discussed with reference to novel experimental models of porphyric neuropathy.
Collapse
Affiliation(s)
- Cindy Shin-Yi Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | | | | |
Collapse
|