Development of porphyria cutanea tarda after treatment with cyclophosphamide

Drug-associated porphyria: a pharmacovigilance study

BACKGROUND

The potentially fatal attacks experienced by porphyria carriers are triggered by various porphyrinogenic drugs. However, determining the safety of particular drugs is challenging.

METHODS

We retrospectively used the U.S. Food and Drug Administration's Adverse Event Reporting System (FAERS) to identify drugs associated with porphyria as an adverse event (AE) extracted from data from January 2004 to March 2022. The associated search terms included "Porphyria," "Porphyria screen," "Porphyria non-acute," "Porphyria acute," "Acquired porphyria," and "Pseudoporphyria." Signal mining analysis was performed to identify the association between drugs and AEs by four algorithms, namely the reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network, and multi-item gamma Poisson shrinker.

RESULTS

FAERS reported 1470 cases of porphyria-related AEs, and 406 drugs were screened after combining trade and generic names. All four algorithms identified 52 drugs with signals. The characteristics of all the reports and signaling drugs were analyzed.

CONCLUSIONS

This is the first report of drug-associated porphyria that provides critical information on drug porphyrogenicity, facilitating rational and evidence-based drug prescription and improving the accuracy of porphyrogenicity prediction based on model algorithms. Moreover, this study serves a reference for clinicians to ensure that porphyrinogenic drugs are not prescribed to carriers of porphyria genetic mutations.

Cutaneous reactions to chemotherapeutic drugs and targeted therapies for cancer: part I. Conventional chemotherapeutic drugs

Conventional chemotherapy continues to be an important part of cancer management, but may cause various cutaneous reactions because it disturbs specific cell cycle phases. The alkylating agents cyclophosphamide, ifosfamide, and thiotepa can produce hyperpigmentation, while hypersensitivity reactions can be seen with platinum alkylating agents. Antimetabolites vary in reactions from exanthematous to bullous skin lesions. 5-fluorouracil and its derivatives and liposomal doxorubicin and daunorubicin are characteristically known to cause hand-foot syndrome, while bleomycin can cause fibrosis and flagellate dermatitis. Several hypersensitivity reactions may also occur from mitotic inhibitors and topoisomerase inhibitors. These different characteristic presentations are important to dermatologists in identifying the correct diagnosis and management for the cancer patient.

Mucocutaneous side effects of antineoplastic chemotherapy

All structures of the skin may be affected by side effects of antineoplastic chemotherapy. The most commonly described effects concern skin adnexes, especially hair with alopecia. Nails are also frequently involved. Eccrine sweat or sebaceous gland involvement is more rarely reported. Mucous membranes, particularly in the mouth, are frequently altered by several mechanisms; direct cytotoxicity, infection, and a decrease in polymorphonuclear or platelet counts. Among cutaneous side effects, hyperpigmentation is very common and may have different clinical patterns; generalised, figurated, or localised. Acral erythema is another cutaneous side effect that is relatively specific to chemotherapy and is often dose-related. Some cutaneous side effects are related to an interaction between chemotherapy and radiation, particularly phototoxicity, recall phenomenon, and radiation enhancement. Miscellaneous, less frequent, side effects are described; sclerodermiform dermatitis, Raynaud's phenomenon, and hypersensitivity syndrome. In some cases, cutaneous side effects are relatively specific to one type of drug. Capillary leak syndrome is most often related to taxanes. Hydroxyurea is responsible for some peculiar cutaneous side effects (ulcerations, pseudo-dermatomyositis), perhaps due to long-term administration of the drug. Although mucocutaneous side effects of chemotherapy are frequent and sometimes severe, interruption of the culprit drug is rarely mandatory. However, adaptation of the dosage or prevention of some of these side effects remains necessary. Antineoplastic chemotherapies are widely used in many therapeutic protocols and may be responsible for numerous mucocutaneous side effects, either specific or more unusual. In rare cases, the severity of these side effects may require interruption of therapy. They may involve skin adnexes, mucous membranes or the skin itself. This review discusses cytotoxic antineoplastic drugs only, not cytokines, monoclonal antibodies or transduction factors used in the treatment of cancer.

Managing malignant disease in patients with porphyria

Certain types of porphyria have an increased incidence of malignant disease. In addition, patients with all forms of porphyria may develop malignant disease as a 'normal life event'. The investigation and treatment of porphyric patients with malignant disease requires specific precautions to minimize the risk of an acute porphyric attack, and to ensure optimum treatment of the malignancy. We briefly review the biochemical basis, clinical features and current management of porphyria in cancer patients.

Chlorambucil and acute intermittent porphyria

A 54-year-old women with quiescent acute intermittent porphyria (AIP) developed low-grade non-Hodgkin's lymphoma. She was successfully treated with chlorambucil without any significant rise in urinary proto-porphyrins. The case is described and a review of chemotherapy use in AIP is presented.

Mucocutaneous reactions to chemotherapy

Chemotherapeutic agents are a widely used treatment modality. Side effects range from common to unusual and may be confused with other cutaneous sequelae of oncologic treatment. The goal of this communication is to elaborate on previous descriptions of the cutaneous manifestations of chemotherapeutic treatment and to discuss more recent findings.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be able to generate a differential diagnosis of possible etiologies for varying patterns of cutaneous involvement in patients receiving chemotherapy and identify the various cutaneous side effects of chemotherapeutic treatment. In addition, they should be able to distinguish life-threatening side effects that require immediate management from more benign manifestations of chemotherapeutic treatment.

Porphyria cutanea tarda and hematologic malignancy--a report of 4 cases

Porphyria cutanea tarda has been reported in association with a variety of myeloproliferative and lymphoproliferative disorders, suggesting a possible association between these conditions. We describe four patients presenting within a 12 month period with sporadic porphyria cutanea tarda shortly following the diagnosis of hematologic malignancy. A review of the literature and evidence supportive of a causal association are presented.

Porphyria cutanea tarda and chronic lymphoid leukemia

A case of a familial porphyria cutanea tarda (PCT-II) is reported in which the clinically overt form of PCT was provoked by factors relating to chronic lymphoid leukemia (CLL). Typical lesions of PCT developed on a 55-year-old woman after several blood transfusions and chlorambucil treatment. Besides these provoking factors, cytomegalovirus (CMV) infection was diagnosed. Erythrocyte uroporphyrinogen decarboxylase activity was about 50% of normal in the patient and in her two children. This case supports the suggestion that development of PCT in patients with hematological disorders is more than coincidental but may in fact be provoked by exogenous factors relating to the treatment of leukemia.