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Lin J, Liu J, Wang A, Si Z. A case report of acute intermittent porphyria leading to severe disability. Front Neurol 2024; 14:1334743. [PMID: 38274883 PMCID: PMC10808997 DOI: 10.3389/fneur.2023.1334743] [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] [Received: 11/07/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Acute intermittent porphyria (AIP) is a rare inherited metabolic disorder resulting from increased production of porphyrins and their precursors, δ-aminolevulinic acid (ALA) and porphobilinogen (PBG), due to deficiencies in the enzymatic activity of the heme synthesis pathway. The disease is typically characterized by a triad of abdominal pain, neurologic impairment symptoms, and psychiatric abnormalities. However, only a small percentage of patients present with this classic triad of symptoms. Our female patient, aged 23, was admitted to the hospital with a 4-year history of abnormal mood episodes and weakness in the limbs for over 1 week. She had a previous medical history of intestinal obstruction. After admission, a cranial MRI revealed reversible posterior leukoencephalopathy imaging manifestations, and the patient exhibited weakness of the extremities, respiratory failure, seizures, and severely reduced serum sodium concentration. The diagnosis of AIP was ultimately confirmed by a positive urine PBG-sunlight test and analysis of HMBS gene variants. The absence of typical triadic signs in acute attacks of AIP can make early recognition of the disease challenging. We present a case with multiple typical clinical manifestations of AIP in the hope of aiding clinicians in fully recognizing acute intermittent porphyria.
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Affiliation(s)
- Jie Lin
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, Shandong University, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong, China
| | - Jinzhi Liu
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong, China
| | - Aihua Wang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong, China
| | - Zhihua Si
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Institute of Neuroimmunology, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong, China
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Poli A, Manceau H, Nguyen AL, Moulouel B, Dessendier N, Talbi N, Puy H, Junot C, Gouya L, Schmitt C, Lefebvre T. Quantification of Urine and Plasma Porphyrin Precursors Using LC-MS in Acute Hepatic Porphyrias: Improvement in Routine Diagnosis and in the Monitoring of Kidney Failure Patients. Clin Chem 2023; 69:1186-1196. [PMID: 37608428 DOI: 10.1093/clinchem/hvad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/10/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND The quantification of delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) in urine are the first-line tests for diagnosis and monitoring of acute hepatic porphyrias (AHP). Ion-exchange chromatography (IEC), which is time- and staff-consuming and limited to urine, is still the preferred method in many specialized laboratories, despite the development of mass spectrometry-based methods. METHODS We describe a new LC-MS method that allows for rapid and simple quantification of ALA and PBG in urine and plasma with an affordable instrument that was used to analyze 2260 urine samples and 309 blood samples collected in 2 years of routine activity. The results were compared to those obtained with IEC, and urine reference ranges and concentrations in asymptomatic carriers were determined. Plasma concentrations were measured in healthy subjects and subgroups of symptomatic and asymptomatic AHP carriers. RESULTS In urine, the clinical decision limits were not impacted by the change of method despite discrepancies in low absolute concentrations, leading to lower normal values. Two-thirds of asymptomatic AHP carriers (with the exception of coproporphyria carriers) showed an increased urine PBG concentration. Urine and plasma levels showed a good correlation except in patients with kidney disease in whom the urine/plasma ratio was relatively low. CONCLUSION We described an LC-MS based method for the routine diagnosis and monitoring of AHP that allows for the detection of more asymptomatic carriers than the historical method. Blood analysis appears to be particularly relevant for patients with kidney disease, where urine measurement underestimates the increase in ALA and PBG levels.
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Affiliation(s)
- Antoine Poli
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Hana Manceau
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Laboratory of Excellence, Gr-Ex, Paris, France
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie, Hôpital Beaujon, F-92110 Clichy la Garenne, France
| | - Anvi Laetitia Nguyen
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Boualem Moulouel
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
| | - Nathalie Dessendier
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
| | - Neila Talbi
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Hervé Puy
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Christophe Junot
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Laurent Gouya
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Caroline Schmitt
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
| | - Thibaud Lefebvre
- Université de Paris Cité, INSERM U1149, Centre de Recherche sur l'Inflammation, HIROS Team, F-75018 Paris, France
- Assistance Publique-Hôpitaux de Paris, Centre Français des Porphyries, Hôpital Louis Mourier, F-92700 Colombes, France
- Laboratory of Excellence, Gr-Ex, Paris, France
- Département Médicaments et Technologies pour La Santé (DMTS), Université Paris-Saclay, CEA, INRAE, MetaboHUB, F-91191 Gif-sur-Yvette, France
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Mortality in Pedigrees with Acute Intermittent Porphyria. Life (Basel) 2022; 12:life12122059. [PMID: 36556425 PMCID: PMC9785653 DOI: 10.3390/life12122059] [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] [Received: 10/20/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
High mortality rates have been reported in historical cohorts of acute intermittent porphyria (AIP) patients. The mortality associated with (hydroxymethylbilane synthase) HMBS variant heterozygosity is unknown. This study estimates all-cause mortality in pedigrees with HMBS gene variants that cause AIP. We collected data on the lifespan of individuals in Dutch AIP pedigrees and performed analyses using the family tree mortality ratio method. This gave us standardized mortality ratios for these pedigrees compared to the Dutch general population as a primary outcome. Between 1810 and 2017, the overall mortality in these pedigrees was identical to that of the general Dutch population: (SMR 1.01, p = 0.441). However, compared with the general population the SMR was significantly higher in women aged 45−64 years (SMR 1.99, p = 0.00003), which was based on excess mortality between 1915 and 1964 (SMR 1.94, p < 0.00002). In men aged 70−74 years, the SMR was 1.55 (p = 0.0021), based on excess mortality that occurred between 1925 and 1964 (SMR 1.92, p = 0000000003). Overall, mortality from HMBS variant heterozygosity was not increased compared with the general population. Severe excess mortality occurred in young women and old men between 1915 and 1964. Heterozygotes reached a normal lifespan during the past half-century, in parallel with disease awareness and the prevention of new attacks through family counselling.
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Cassiman D, Kauppinen R, Monroy S, Lee M, Bonkovsky HL, Thapar M, Guillén‐Navarro E, Minder A, Hale C, Sweetser MT, Ivanova A. EXPLORE B: A prospective, long-term natural history study of patients with acute hepatic porphyria with chronic symptoms. J Inherit Metab Dis 2022; 45:1163-1174. [PMID: 36069414 PMCID: PMC9825970 DOI: 10.1002/jimd.12551] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 01/11/2023]
Abstract
One-year data from EXPLORE Part A showed high disease burden and impaired quality of life (QOL) in patients with acute hepatic porphyria (AHP) with recurrent attacks. We report baseline data of patients who enrolled in EXPLORE Part B for up to an additional 3 years of follow-up. EXPLORE B is a long-term, prospective study evaluating disease activity, pain intensity, and QOL in patients with AHP with ≥1 attack in the 12 months before enrollment or receiving hemin or gonadotropin-releasing hormone prophylaxis. Data were evaluated in patients with more (≥3 attacks or on prophylaxis treatment) or fewer (<3 attacks and no prophylaxis treatment) attacks. Patients in the total population (N = 136), and more (n = 110) and fewer (n = 26) attack subgroups, reported a median (range) of 3 (0-52), 4 (0-52), and 1 (0-2) acute attacks, respectively, in the 12 months prior to the baseline visit. Pain, mood/sleep, digestive/bladder, and nervous system symptoms were each experienced by ≥80% of patients; most received hemin during attacks. Almost three-quarters of patients reported chronic symptoms between attacks, including 85% of patients with fewer attacks. Pain intensity was comparable among both attack subgroups; most patients required pain medication. All groups had diminished QOL on the EuroQol visual analog scale and the European Organisation for Research and Treatment of Cancer Quality-of-life Questionnaire Core 30 versus population norms. Patients with AHP with recurrent attacks, even those having fewer attacks, experience a high disease burden, as evidenced by chronic symptoms between attacks and impaired QOL.
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Affiliation(s)
- David Cassiman
- Department of Gastroenterology‐Hepatology and Center for Metabolic DiseasesUniversity Hospital LeuvenLeuvenBelgium
| | - Raili Kauppinen
- Department of MedicineUniversity Hospital of HelsinkiHelsinkiFinland
| | - Susana Monroy
- Centro de Investigacion TraslacionalInstituto Nacional de Pediatría de MexicoMexico CityMexico
| | - Ming‐Jen Lee
- Department of NeurologyNational Taiwan University HospitalTaipeiTaiwan
| | - Herbert L. Bonkovsky
- Section on Gastroenterology and HepatologyWake Forest University/North Carolina Baptist Medical CenterWinston‐SalemNorth CarolinaUSA
| | - Manish Thapar
- Department of MedicineThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Encarna Guillén‐Navarro
- Medical Genetics Section, Virgen de la Arrixaca University Hospital, IMIB‐ArrixacaUniversidad de MurciaMurciaSpain
| | - Anna‐Elisabeth Minder
- Division of Endocrinology, Department of Internal MedicineStadtspital ZürichZürichSwitzerland
| | - Cecilia Hale
- Department of Biometrics and Department of Clinical DevelopmentAlnylam PharmaceuticalsCambridgeMassachusettsUSA
| | - Marianne T. Sweetser
- Department of Clinical DevelopmentAlnylam PharmaceuticalsCambridgeMassachusettsUSA
| | - Aneta Ivanova
- Porphyria Unit, Department of GastroenterologySt. Ivan Rilski University HospitalSofiaBulgaria
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Lissing M, Vassiliou D, Floderus Y, Harper P, Bottai M, Kotopouli M, Hagström H, Sardh E, Wahlin S. Risk of primary liver cancer in acute hepatic porphyria patients: A matched cohort study of 1244 individuals. J Intern Med 2022; 291:824-836. [PMID: 35112415 PMCID: PMC9311710 DOI: 10.1111/joim.13463] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The acute hepatic porphyrias (AHP) are associated with a risk of primary liver cancer (PLC), but risk estimates are unclear, and what AHP characteristics that predict PLC risk are unknown. In this register-based, matched cohort study, we assessed the PLC risk in relation to biochemical and clinical porphyria severity, genotype, age, and sex. METHODS All patients in the Swedish porphyria register with acute intermittent porphyria (AIP), variegate porphyria (VP), or hereditary coproporphyria (HCP) during 1987-2015 were included. This AHP cohort was compared with age-, sex-, and county-matched reference individuals from the general population. National register-based hospital admissions for AHP were used to indicate the clinical severity. For AIP, the most common AHP type, patients were stratified by genotype and urinary porphobilinogen (U-PBG). Incident PLC data were collected from national health registers. RESULTS We identified 1244 individuals with AHP (1063 [85%] AIP). During a median follow-up of 19.5 years, we identified 108 incident PLC cases, including 83 AHP patients (6.7%) and 25 of 12,333 reference individuals (0.2%). The adjusted hazard ratio for AHP-PLC was 38.0 (95% confidence interval: 24.3-59.3). Previously elevated U-PBG and hospitalizations for porphyria, but not AIP genotype or sex, were associated with increased PLC risk. Patients aged >50 years with previously elevated U-PBG (n = 157) had an annual PLC incidence of 1.8%. CONCLUSION This study confirmed a high PLC risk and identified a strong association with clinical and biochemical AIP activity. Regular PLC surveillance is motivated in patients older than 50 years with a history of active AIP.
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Affiliation(s)
- Mattias Lissing
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Daphne Vassiliou
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ylva Floderus
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Pauline Harper
- Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Kotopouli
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Unit for Clinical Epidemiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Eliane Sardh
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.,Centre for Inherited Metabolic Diseases (CMMS), Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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