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Lindemann H, Diehl-Wiesenecker E, Gerischer L, Frank J. [An overview of porphyrias]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2024; 75:539-547. [PMID: 38902527 DOI: 10.1007/s00105-024-05370-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/22/2024]
Abstract
Porphyrias are predominantly genetic metabolic disorders caused by dysregulation of specific enzymes in porphyrin-heme biosynthesis. The enzymatic dysfunction leads to formation and excretion of intermediate metabolic products in the form of porphyrins and/or their precursors δ‑aminolevulinic acid and porphobilinogen, which have cyto- and tissue-toxic properties. Clinically, porphyrias are extremely diverse, with symptoms ranging from skin changes on light-exposed areas of the body to potentially life-threatening neurovisceral attacks. Biochemical tests in urine, blood and stool are used for diagnosis, which can be supplemented by molecular genetic analyses. Treatment of the various forms of porphyria is complex and often requires close interdisciplinary cooperation between different medical specialties.
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Affiliation(s)
- Hanna Lindemann
- Klinik für Dermatologie und Allergologie, Universitätsspital Basel, Basel, Schweiz
| | - Eva Diehl-Wiesenecker
- Innere Medizin mit Gastroenterologie und Nephrologie, Zentrale Notaufnahme, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Lea Gerischer
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jorge Frank
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Robert Koch Str. 40, 37075, Göttingen, Deutschland.
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2
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Brenner DM, Brandt LJ, Fenster M, Hamilton MJ, Kamboj AK, Oxentenko AS, Wang B, Chey WD. Rare, Overlooked, or Underappreciated Causes of Recurrent Abdominal Pain: A Primer for Gastroenterologists. Clin Gastroenterol Hepatol 2023; 21:264-279. [PMID: 36180010 DOI: 10.1016/j.cgh.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 01/28/2023]
Abstract
Recurrent abdominal pain is a common reason for repeated visits to outpatient clinics and emergency departments, reflecting a substantial unmet need for timely and accurate diagnosis. A lack of awareness of some of the rarer causes of recurrent abdominal pain may impede diagnosis and delay effective management. This article identifies some of the key rare but diagnosable causes that are frequently missed by gastroenterologists and provides expert recommendations to support recognition, diagnosis, and management with the ultimate aim of improving patient outcomes.
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Affiliation(s)
- Darren M Brenner
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Lawrence J Brandt
- Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Marc Fenster
- Division of Gastroenterology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Matthew J Hamilton
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amrit K Kamboj
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Amy S Oxentenko
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Bruce Wang
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - William D Chey
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
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3
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Muschalek W, Hermasch MA, Poblete-Gutiérrez P, Frank J. The Porphyrias. J Dtsch Dermatol Ges 2022; 20:316-331. [PMID: 35304965 DOI: 10.1111/ddg.14743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/16/2022] [Indexed: 12/01/2022]
Abstract
The porphyrias are clinically variable and genetically heterogeneous, predominantly hereditary metabolic diseases, which are caused by a dysfunction of specific enzymes in heme biosynthesis. Here, we provide an overview of the etiopathogenesis, clinic, differential diagnosis, laboratory diagnostics and therapy of these complex metabolic disorders and cover in detail the most common form of porphyria worldwide (porphyria cutanea tarda), the most frequent childhood porphyria (erythropoietic protoporphyria), and the most common neurocutaneous porphyria (variegate porphyria).
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Affiliation(s)
- Wiebke Muschalek
- Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, Göttingen, Germany
| | - Matthias A Hermasch
- Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, Göttingen, Germany
| | | | - Jorge Frank
- Department of Dermatology, Venereology and Allergology, University Hospital Göttingen, Göttingen, Germany
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4
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Muschalek W, Hermasch MA, Poblete-Gutiérrez P, Frank J. Die Porphyrien. J Dtsch Dermatol Ges 2022; 20:316-333. [PMID: 35304948 DOI: 10.1111/ddg.14743_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/16/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Wiebke Muschalek
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Matthias A Hermasch
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | | | - Jorge Frank
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsmedizin Göttingen, Göttingen, Deutschland
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Kuo HC, Lin CN, Tang YF. Prophylactic Heme Arginate Infusion for Acute Intermittent Porphyria. Front Pharmacol 2021; 12:712305. [PMID: 34690757 PMCID: PMC8526969 DOI: 10.3389/fphar.2021.712305] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/24/2021] [Indexed: 12/23/2022] Open
Abstract
Objectives: This study aimed to evaluate the efficacy of long-term weekly prophylactic heme arginate (HA) infusions in reducing attack frequency and severity in female AIP patients. Methods: We report the results of five female AIP patients with frequent recurrent attacks (>9/year) before and after institution of weekly prophylaxis with heme arginate (3 mg/kg body weight). All five cases had confirmed disease-associated mutations in the porphobilinogen deaminase gene, and all had received genetic and clinical counseling about AIP. Results: In the five included patients, average annual attack rate (AAR) in the year prior to HA prophylaxis was 11.82 (range 9.03–17.06), and average total HA usage was 32.60 doses (range: 13.71–53.13). After 2.58–14.64 years of HA prophylaxis, average AAR was reduced to 2.23 (range 0.00–5.58), and attack severity (i.e., doses required per attack) was reduced from 2.81 to 1.39 doses/attack. Liver and renal function remained stable during weekly administration of HA prophylaxis. The most common complications were port-A catheter-related events. No other complications or safety concerns occurred with long-term use of HA prophylaxis. Conclusion: Our study demonstrated women with AIP receiving weekly prophylactic HA infusions resulted in fewer episodes that required acute HA treatment while maintaining stable renal and liver function. Weekly prophylactic HA infusions effectively prevent frequent porphyric attacks and reduce attack severity.
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Affiliation(s)
- Hung-Chou Kuo
- Department of Neurology, Chang Gung Memorial Hospital-Linkou Medical Center, Chang Gung Memorial Hospital and College of Medicine, Taoyuan, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Fen Tang
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Gilles A, Vermeersch S, Vermeersch P, Wolff F, Cotton F, Tilleux S, Cassiman D. Expert consensus statement on acute hepatic porphyria in Belgium. Acta Clin Belg 2021; 77:735-741. [PMID: 34369323 DOI: 10.1080/17843286.2021.1961056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hepatic porphyrias (AHP) are a group of four different rare to ultra-rare, severely debilitating, and sometimes fatal diseases that significantly impact patients' lives: 5-aminolevulinic acid (ALA) dehydratase deficiency porphyria (ADP), acute intermittent porphyria (AIP), hereditary coproporphyria (HCP), and variegate porphyria (VP). Based on literature estimates, a conservative estimate of the number of AHP patients in Belgium requiring treatment, defined as patients experiencing recurrent attacks and/or chronic debilitating symptoms, is likely limited to 11-34 patients. These patients face a considerable unmet need, as there is currently no pharmaceutical treatment available that effectively prevents attacks and has an impact on other chronic symptoms of the disease.A panel consisting of the two European Porphyria Network1 (EPNet) centers in Belgium (Center for inborn errors of metabolism of UZ Leuven and the 'Centre Belge des Porphyries' of Erasme Hospital and LHUB-ULB) participated in an advisory board on 24 January 2020. Representatives of the sponsoring pharmaceutical company, Alnylam Pharmaceuticals, organized and attended the meeting. The objective of the meeting was to obtain expert input on the state-of-the-art clinical practice of AHP in Belgium. Following this meeting, this expert consensus statement was drafted, in collaboration with and coordinated by the EPNet centers in Belgium. This statement provides an overview of the state-of-the art in AHP, by means of a concise overview of AHP pathophysiology, clinical manifestations, and burden of disease, (Belgian) epidemiology, treatments, and proposed organization of care.
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Affiliation(s)
- Axelle Gilles
- Dept of Clinical Hematology, Cliniques universitaires de Bruxelles, Erasme Hospital
| | | | | | - Fleur Wolff
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre Belge de Porphyries, Erasme Hospital, Université Libre de Bruxelles
| | - Frederic Cotton
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles (LHUB-ULB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre Belge de Porphyries, Erasme Hospital, Université Libre de Bruxelles
| | | | - David Cassiman
- Dienst Maag-Darm-Leverziekten en Metabool Centrum, UZ Leuven, Belgium
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Lazareth H, Talbi N, Kamar N, Levi C, Moulin B, Caillard S, Frimat L, Chemouny J, Chatelet V, Vachey C, Snanoudj R, Lefebvre T, Karras A, Gouya L, Schmitt C, Puy H, Pallet N. Kidney transplantation improves the clinical outcomes of Acute Intermittent Porphyria. Mol Genet Metab 2020; 131:259-266. [PMID: 32893121 DOI: 10.1016/j.ymgme.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute Intermittent Porphyria (AIP) is a rare inherited autosomal dominant disorder of heme biosynthesis. Porphyria-associated kidney disease occurs in more than 50% of the patients with AIP, and end stage renal disease (ESRD) can be a devastating complication for AIP patients. The outcomes of AIP patients after kidney transplantation are poorly known. METHODS We examined the outcomes of 11 individuals with AIP, identified as kidney transplant recipients in the French Porphyria Center Registry. RESULTS AIP had been diagnosed on average 19 years before the diagnosis of ESRD except for one patient in whom the diagnosis of AIP had been made 5 years after the initiation of dialysis. Median follow-up after transplantation was 9 years. A patient died 2 months after transplantation from a cardiac arrest and a patient who received a donation after cardiac death experienced a primary non-function. No rejection episode and no noticeable adverse event occurred after transplantation. Serum creatinine was on average 117 μmol/l, and proteinuria <0.5 g/l in all patients at last follow up. All usually prescribed drugs after transplantation are authorized except for trimethoprim/sulfamethoxazole. Critically, acute porphyria attacks almost disappeared after kidney transplantation, and skin lesions resolved in all patients. CONCLUSION Kidney transplantation is the treatment of choice for AIP patients with ESRD and dramatically reduces the disease activity.
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Affiliation(s)
- Helene Lazareth
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, France
| | - Neila Talbi
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Nassim Kamar
- Department of Nephrology, Dialysis and Organ Transplantation, CHU Rangueil, INSERM U1043, IFR-BMT, University Paul Sabatier, Toulouse, France
| | - Charlène Levi
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot University Hospital, Lyon, France
| | - Bruno Moulin
- Nephrology and Transplantation Department, University Hospital, Strasbourg, France
| | - Sophie Caillard
- Nephrology and Transplantation Department, University Hospital, Strasbourg, France
| | - Luc Frimat
- Nephrology, Dialysis and Transplantation Department, CHU Nancy, Nancy, France
| | - Jonathan Chemouny
- Nephrology, Dialysis and Transplantation Department, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, CIC-P 1414 (Centre d'investigation clinique), F-35000 Rennes, France
| | - Valérie Chatelet
- Nephrology, Dialysis, Transplantation Department, CHU Cote de Nacre, Caen University, Caen, France
| | - Clément Vachey
- Nephrology, Dialysis and Transplantation Department, CHU Besançon, Besançon, France
| | - Renaud Snanoudj
- Nephrology, Dialysis and Renal Transplantation Department, Hospital Foch, Suresnes, France
| | - Thibaud Lefebvre
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Alexandre Karras
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, France
| | - Laurent Gouya
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Caroline Schmitt
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Hervé Puy
- French Porphyria Center, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes and Research Center on Inflammation, INSERM U1149, Paris University, France
| | - Nicolas Pallet
- Nephrology Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, France; Clinical Chemistry Department, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France.
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Rigor J, Pinto SA, Martins-Mendes D. Porphyrias: A clinically based approach. Eur J Intern Med 2019; 67:24-29. [PMID: 31257150 DOI: 10.1016/j.ejim.2019.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Porphyrias are a group of metabolic diseases, individually rare but with an important combined prevalence. Because of their pathological complexity and clinical heterogeneity, they present a challenging diagnosis. The present review aims to provide a clinically based approach to the recognition and treatment of these disorders. METHODS We carried out a search in PubMed, with the keyword "porphyria", for reviews published in English from 2010 until 2017. RESULTS The research yielded 196 papers, of which 64 were included in the final narrative review. CONCLUSIONS Porphyrias can be divided based on clinical presentation in acute neurovisceral, chronic cutaneous bullous, chronic cutaneous non-bullous and acute neurovisceral/chronic cutaneous bullous. Each individual porphyria presents a characteristic pattern of porphyrins in plasma, urine, stool and red blood cells. As such, diagnosis is easily obtained by following a simple diagnostic algorithm. Early recognition is key in managing these diseases. Neurovisceral porphyrias require acute support therapy and chronic eviction of precipitating factors. Cutaneous prophyrias, as photosensitivity disorders, rely on sunlight avoidance and, in some cases, specific therapeutic interventions. Given the rarity of these conditions, physician awareness is crucial.
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Affiliation(s)
- Joana Rigor
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal.
| | - Sara Almeida Pinto
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal
| | - Daniela Martins-Mendes
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Rua Conceição Fernandes, s/n, 4434-502 Vila Nova de Gaia, Portugal; Biomedicine Department, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal, R. Alfredo Allen, 4200-135 Porto, Portugal
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Abstract
The porphyrias are a group of metabolic disorders resulting from an innate abnormality in haem biosynthesis, and the clinical settings of which vary according to the genetic enzyme abnormality in question. These are genetic disorders with autosomal dominant or recessive inheritance of varying penetrance, and whose clinical expression differs according to the preferential location of haem precursors. Different classifications have been proposed according to genetic inheritance, the enzyme anomaly at issue, and clinical expression. The clinical classification distinguishes between acute porphyria (acute intermittent porphyria, porphyria variegata, hereditary coproporphyria), bullous cutaneous porphyrias (porphyria cutanea tarda, porphyria variegata and hereditary coproporphyria), painful photosensitive acute cutaneous porphyrias (erythropoietic protoporphyria and X-linked dominant protoporphyria), and rare recessive porphyrias (congenital erythropoietic porphyria, Doss porphyria, hepatoerythropoietic porphyria and harderoporphyria). Treatment depends on the clinical expression of the disorder.
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Affiliation(s)
- J-F Cuny
- Service de dermatologie, CHR Metz-Thionville, 1, allée du Château, CS 45001, 57085 Metz cedex 03, France.
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10
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Yarra P, Faust D, Bennett M, Rudnick S, Bonkovsky HL. Benefits of prophylactic heme therapy in severe acute intermittent porphyria. Mol Genet Metab Rep 2019; 19:100450. [PMID: 30733921 PMCID: PMC6358544 DOI: 10.1016/j.ymgmr.2019.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/13/2019] [Indexed: 12/18/2022] Open
Abstract
Acute intermittent porphyria (AIP), an autosomal dominant inborn error of metabolism, is the most common and severe form of the acute porphyrias. Attacks of severe abdominal pain, often with hypertension, tachycardia, are cardinal features of AIP, often requiring hospital admissions. Frequent recurrent attacks of AIP, defined as >3 attacks in one year, during which at least one attack requires intravenous heme therapy, are associated with significant morbidity, lost productivity, and health care burden. We report two patients with such frequent attacks of AIP, who have been managed with prophylactic heme therapy on a weekly basis. We describe results particularly in relation to symptom control, biochemical findings, health care costs, quality of life, and utilization of resources. During 11-month duration of weekly prophylactic heme infusions, we observed a 100% decrease in acute attacks and inpatient admissions in one subject and a 75% decrease in the other. During this time, we also observed a significant decrease in the number of emergency room visits. The decrease in number of acute attacks requiring hospital admission was associated with significantly decreased health care costs and improved quality of life. Reduction of both emergency room visits and hospital admissions decreased the utilization of health care services. Outpatient weekly infusions were also noted to be associated with better reimbursements and reduced overall costs of health care for the subjects. Both our subjects also endorsed better symptom control, quality of life and better understanding of disease. Thus, prophylactic heme therapy, through a multi-disciplinary approach, decreases the incidence of acute attacks, decreases health care costs and leads to better patient satisfaction and quality of life.
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Affiliation(s)
- Pradeep Yarra
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Denise Faust
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Mary Bennett
- Department of Pharmacy, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Sean Rudnick
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
| | - Herbert L. Bonkovsky
- Department of Medicine, Wake Forest University/NC Baptist Medical Center, Winston-Salem, NC, United States
- Corresponding author at: E-112, NRC, Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, NC 27157, United States.
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Corden MH, Frediani J, Xu F, Liu QY, Chen SYE, Bissell DM, Ostrom K. An 18-Year-Old With Acute-on-Chronic Abdominal Pain. Pediatrics 2018; 141:peds.2017-1332. [PMID: 29636397 DOI: 10.1542/peds.2017-1332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 11/24/2022] Open
Abstract
An 18-year-old woman with a complex past medical history presented with 2 days of vomiting and lower abdominal pain. She had been admitted for the majority of the previous 5 months for recurrent pancreatitis and had undergone a cholecystectomy. Additional symptoms included nausea, anorexia, constipation, and a 40-lb weight loss over 4 months. She appeared uncomfortable, and an examination was remarkable for tachycardia, hypertension, and diffuse abdominal tenderness to light palpation. Her initial laboratory test results revealed mildly elevated liver enzymes (aspartate aminotransferase 68 U/L, alanine aminotransferase 80 U/L) and a normal lipase. She was admitted for pain control and nutritional support. Over the next few days, the lipase increased to 1707 U/L. Despite optimizing her management for acute pancreatitis, the patient's symptoms persisted. Further history gathering and laboratory testing ultimately revealed her diagnosis. Our expert panel reviews her hospital course and elucidates the management of our eventual diagnosis.
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Affiliation(s)
- Mark H Corden
- Division of Hospital Medicine and .,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jamie Frediani
- Children's Center for Cancer and Blood Diseases, Department of Pediatrics, and
| | - Frank Xu
- The Pediatric Group of Southern California, Agoura Hills, California
| | - Quin Y Liu
- Division of Gastroenterology, Digestive Diseases Center, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Shiu-Yi Emily Chen
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - D Montgomery Bissell
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Kathleen Ostrom
- Division of Hospital Medicine and.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
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12
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Malinzak EB, Knudsen NW, Udani AD, Vikraman D, Sudan DL, Miller TE. Perioperative Challenges in Liver Transplantation for a Patient With Acute Intermittent Porphyria. J Cardiothorac Vasc Anesth 2017; 32:2716-2720. [PMID: 29306617 DOI: 10.1053/j.jvca.2017.11.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Indexed: 11/11/2022]
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13
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Sayiner M, Golabi P, Farhat F, Younossi ZM. Dermatologic Manifestations of Chronic Hepatitis C Infection. Clin Liver Dis 2017; 21:555-564. [PMID: 28689593 DOI: 10.1016/j.cld.2017.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Chronic hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, including dermatologic involvement mostly caused by immune complexes. Mixed cryoglobulinemia has a strong relationship with HCV with 95% of these patients being infected with HCV. Lichen planus is a disease of the squamous epithelium and may affect any part of the skin, with 4% to 24% of patients with lichen planus reported to have chronic HCV infection. Porphyria cutanea tarda is the most common form of porphyria, and it is thought that HCV interferes with iron stores, which can promote porphyria cutanea tarda. Finally, necrolytic acral erythema is a rare, psoriasis-like disease closely associated with HCV.
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Affiliation(s)
- Mehmet Sayiner
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA; Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Freba Farhat
- Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA; Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA.
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Conway AJ, Brown FC, Fullinfaw RO, Kile BT, Jane SM, Curtis DJ. A mouse model of hereditary coproporphyria identified in an ENU mutagenesis screen. Dis Model Mech 2017; 10:1005-1013. [PMID: 28600349 PMCID: PMC5560062 DOI: 10.1242/dmm.029116] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 06/02/2017] [Indexed: 12/14/2022] Open
Abstract
A genome-wide ethyl-N-nitrosourea (ENU) mutagenesis screen in mice was performed to identify novel regulators of erythropoiesis. Here, we describe a mouse line, RBC16, which harbours a dominantly inherited mutation in the Cpox gene, responsible for production of the haem biosynthesis enzyme, coproporphyrinogen III oxidase (CPOX). A premature stop codon in place of a tryptophan at amino acid 373 results in reduced mRNA expression and diminished protein levels, yielding a microcytic red blood cell phenotype in heterozygous mice. Urinary and faecal porphyrins in female RBC16 heterozygotes were significantly elevated compared with that of wild-type littermates, particularly coproporphyrinogen III, whereas males were biochemically normal. Attempts to induce acute porphyric crises were made using fasting and phenobarbital treatment on females. While fasting had no biochemical effect on RBC16 mice, phenobarbital caused significant elevation of faecal coproporphyrinogen III in heterozygous mice. This is the first known investigation of a mutagenesis mouse model with genetic and biochemical parallels to hereditary coproporphyria.
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Affiliation(s)
- Ashlee J Conway
- Australian Centre for Blood Diseases, Monash University and Clinical Haematology, Alfred Health, Melbourne 3004, Australia
| | - Fiona C Brown
- Australian Centre for Blood Diseases, Monash University and Clinical Haematology, Alfred Health, Melbourne 3004, Australia
| | - Robert O Fullinfaw
- Porphyria Reference Laboratory, Biochemistry Department, Royal Melbourne Hospital, Parkville 3050, Australia
| | - Benjamin T Kile
- ACRF Chemical Biology Division, The Walter and Eliza Hall Institute of Medical Research, Parkville 3052, Australia
| | - Stephen M Jane
- Australian Centre for Blood Diseases, Monash University and Clinical Haematology, Alfred Health, Melbourne 3004, Australia.,Central Clinical School, Monash University, Melbourne 3004, Australia
| | - David J Curtis
- Australian Centre for Blood Diseases, Monash University and Clinical Haematology, Alfred Health, Melbourne 3004, Australia
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15
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Baumgartner A, Quesenberry PJ. A Unique Neuropsychiatric Syndrome in Variant Hereditary Coproporphyria: Case Report and Review of the Literature. J Hematol 2017; 6:21-24. [PMID: 32300387 PMCID: PMC7155817 DOI: 10.14740/jh315w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/11/2022] Open
Abstract
Hereditary coproporphyria (HCP) is the third most common of the acute porphyrias, after acute intermittent porphyria and variegate porphyria. It is caused by decreased activity of the sixth step in the heme biosynthetic pathway. Here we present a case of a woman with HCP who has experienced a wide variety of symptoms over several years. Most interesting among these is a unique neuropsychiatric syndrome marked by severe confusion, disorientation, and abnormal behavior. The literature is reviewed regarding the pathophysiology and management of neuropsychiatric manifestations of porphyria. As many other diagnoses are often considered before the diagnosis of porphyria is made, clinicians should keep in mind the highly variable neurological and psychiatric symptoms of porphyria.
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Affiliation(s)
- Alex Baumgartner
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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16
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Latorre S, Castro J, Mendoza F. Neuropatía periférica como forma de presentación inicial en ataque agudo de porfiria. Reporte de caso clínico. REPERTORIO DE MEDICINA Y CIRUGÍA 2017. [DOI: 10.1016/j.reper.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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17
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Tchernitchko D, Tavernier Q, Lamoril J, Schmitt C, Talbi N, Lyoumi S, Robreau AM, Karim Z, Gouya L, Thervet E, Karras A, Puy H, Pallet N. A Variant of Peptide Transporter 2 Predicts the Severity of Porphyria-Associated Kidney Disease. J Am Soc Nephrol 2016; 28:1924-1932. [PMID: 28031405 DOI: 10.1681/asn.2016080918] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/29/2016] [Indexed: 01/15/2023] Open
Abstract
CKD occurs in most patients with acute intermittent porphyria (AIP). During AIP, δ-aminolevulinic acid (ALA) accumulates and promotes tubular cell death and tubulointerstitial damage. The human peptide transporter 2 (PEPT2) expressed by proximal tubular cells mediates the reabsorption of ALA, and variants of PEPT2 have different affinities for ALA. We tested the hypothesis that PEPT2 genotypes affect the severity and prognosis of porphyria-associated kidney disease. We analyzed data from 122 individuals with AIP who were followed from 2003 to 2013 and genotyped for PEPT2 At last follow-up, carriers of the PEPT2*1*1 genotype (higher affinity variant) exhibited worse renal function than carriers of the lower affinity variants PEPT2*1/*2 and PEPT2*2/*2 (mean±SD eGFR: 54.4±19.1, 66.6±23.8, and 78.1±19.9 ml/min per 1.73 m2, respectively). Change in eGFR (mean±SD) over the 10-year period was -11.0±3.3, -2.4±1.9, and 3.4±2.6 ml/min per 1.73 m2 for PEPT2*1/*1, PEPT2*1*2, and PEPT*2*2*2 carriers, respectively. At the end of follow-up, 68% of PEPT2*1*1 carriers had an eGFR<60 ml/min per 1.73 m2, compared with 37% of PEPT2*1*2 carriers and 15% of PEPT2*2*2 carriers. Multiple regression models including all confounders indicated that the PEPT2*1*1 genotype independently associated with an eGFR<60 ml/min per 1.73 m2 (odds ratio, 6.85; 95% confidence interval, 1.34 to 46.20) and an annual decrease in eGFR of >1 ml/min per 1.73 m2 (odds ratio, 3.64; 95% confidence interval, 1.37 to 9.91). Thus, a gene variant is predictive of the severity of a chronic complication of AIP. The therapeutic value of PEPT2 inhibitors in preventing porphyria-associated kidney disease warrants investigation.
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Affiliation(s)
- Dimitri Tchernitchko
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France
| | - Quentin Tavernier
- Institut National pour la Santé et la Recherche Médicale (INSERM) U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France
| | - Jérôme Lamoril
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France
| | - Caroline Schmitt
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France.,Université Paris Diderot, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Neila Talbi
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France
| | - Said Lyoumi
- Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France.,Université Versailles Saint Quentin, Versailles, France; and
| | - Anne-Marie Robreau
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France
| | - Zoubida Karim
- Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France
| | - Laurent Gouya
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France.,Université Paris Diderot, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Eric Thervet
- Institut National pour la Santé et la Recherche Médicale (INSERM) U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Diderot, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Alexandre Karras
- Institut National pour la Santé et la Recherche Médicale (INSERM) U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Diderot, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Hervé Puy
- Centre Français des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, Paris, France.,Institut National pour la Santé et la Recherche Médicale (INSERM) U1149, Center for Research on Inflammation (CRI), Site Bichat, Paris, France.,Université Paris Diderot, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Nicolas Pallet
- Institut National pour la Santé et la Recherche Médicale (INSERM) U1147, Centre Universitaire des Saints Pères, Paris, France; .,Université Paris Descartes, Paris, France.,Service de Néphrologie and.,Service de Biochimie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
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18
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Kürten V, Neumann NJ, Frank J. [Diagnosis of the porphyrias : From A (as in aminolevulinic acid) to Z (as in zinc protoporphyrin)]. Hautarzt 2016; 67:201-6. [PMID: 26743052 DOI: 10.1007/s00105-015-3741-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The porphyrias comprise a clinically, biochemically, and genetically heterogeneous group of predominantly hereditary metabolic disorders resulting from a dysfunction along the heme biosynthetic pathway. Whereas most variants can manifest with different cutaneous symptoms, some types only reveal life-threatening acute neurovisceral attacks. Therefore, interdisciplinary care of these patients is advisable. In this article, we provide an overview of characteristic clinical and laboratory findings in the various forms of porphyria and a diagnostic algorithm.
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Affiliation(s)
- V Kürten
- Hautklinik und Europäisches Porphyriezentrum, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - N J Neumann
- Hautklinik und Europäisches Porphyriezentrum, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - J Frank
- Hautklinik und Europäisches Porphyriezentrum, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Universitätsklinikum Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
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19
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Abstract
Porphyrias comprise a heterogeneous group of predominantly genetically determined metabolic diseases which are due to a dysfunction in heme biosynthesis. Variegate porphyria and hereditary coproporphyria are referred to as neurocutaneous porphyrias because affected patients can develop both cutaneous symptoms on light-exposed body sites and potentially life-threatening acute neurovisceral symptoms, thereby mimicking several other diseases. In this overview, we provide an update on pathogenesis, clinical manifestation, diagnosis, and therapy of these two types of porphyria.
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Affiliation(s)
- J Frank
- Hautklinik und Europäisches Porphyriezentrum, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
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20
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Norton J, Hymers C, Stein P, Jenkins JM, Bew D. Acute Porphyria Presenting as Major Trauma: Case Report and Literature Review. J Emerg Med 2016; 51:e115-e122. [PMID: 27624508 DOI: 10.1016/j.jemermed.2016.06.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/24/2016] [Accepted: 06/29/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Acute porphyria is historically known as "the little imitator" in reference to its reputation as a notoriously difficult diagnosis. Variegate porphyria is one of the four acute porphyrias, and can present with both blistering cutaneous lesions and acute neurovisceral attacks involving abdominal pain, neuropsychiatric features, neuropathy, hyponatremia, and a vast array of other nonspecific clinical features. CASE REPORT A 40-year-old man presented to the Emergency Department (ED) as a major trauma call, having been found in an "acutely confused state" surrounded by broken glass. Primary survey revealed: hypertension, tachycardia, abdominal pain, severe agitation, and confusion with an encephalopathy consistent with acute delirium, a Glasgow Coma Scale score of 13, and head-to-toe "burn-like" abrasions. Computed tomography was unremarkable, and blood tests demonstrated hyponatremia, acute kidney injury, and a neutrophilic leukocytosis. The next of kin eventually revealed a past medical history of variegate porphyria. The patient was experiencing an acute attack and received supportive management prior to transfer to intensive care, subsequently making a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of recognizing acute medical conditions in patients thought to be suffering from major trauma. Acute porphyria should be considered in any patient with abdominal pain in combination with neuropsychiatric features, motor neuropathy, or hyponatremia. Patients often present to the ED without any medical history, and accurate diagnosis can be essential in the acute setting to minimize morbidity and mortality. The label of the major trauma call must be taken with great caution, and a broad differential diagnosis must be maintained throughout a diligent and thorough primary survey.
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Affiliation(s)
- Joel Norton
- School of Medical Education, King's College London, London, UK
| | - Christine Hymers
- Department of Emergency Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Penelope Stein
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Duncan Bew
- Department of Trauma and Emergency Surgery, King's College Hospital NHS Foundation Trust, London, UK
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21
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Ferrer MD, Mestre-Alfaro A, Martínez-Tomé M, Carrera-Quintanar L, Capó X, Jiménez-Monreal AM, García-Diz L, Roche E, Murcia MA, Tur JA, Pons A. Haem Biosynthesis and Antioxidant Enzymes in Circulating Cells of Acute Intermittent Porphyria Patients. PLoS One 2016; 11:e0164857. [PMID: 27788171 PMCID: PMC5082889 DOI: 10.1371/journal.pone.0164857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 10/03/2016] [Indexed: 11/18/2022] Open
Abstract
The aims of the present study were to explore the expression pattern of haem biosynthesis enzymes in circulating cells of patients affected by two types of porphyria (acute intermittent, AIP, and variegate porphyria, VP), together with the antioxidant enzyme pattern in AIP in order to identify a possible situation of oxidative stress. Sixteen and twelve patients affected by AIP and VP, respectively, were analysed with the same numbers of healthy matched controls. Erythrocytes, neutrophils and peripheral blood mononuclear cells (PBMCs) were purified from blood, and RNA and proteins were extracted for quantitative real time PCR (qRT-PCR) and Western-blot analysis, respectively. Porhobilinogen deaminase (PBGD) and protoporphyrinogen oxidase (PPOX) gene and protein expression was analysed. Antioxidant enzyme activity and gene expression were additionally determined in blood cells, together with protein carbonyl content in plasma. PBMCs isolated from AIP patients presented low mRNA levels of PBGD when compared to controls, while PBMCs isolated from VP patients presented a decrease in PPOX mRNA. PPOX protein content was higher in AIP patients and lower in VP patients, compared to healthy controls. Regarding antioxidant enzymes, PBMCs and erythrocyte superoxide dismutase (SOD) presented statistically significant higher activity in AIP patients compared to controls, while catalase activity tended to be lower in these patients. No differences were observed regarding antioxidant gene expression in white blood cells. Circulating cells in AIP and VP patients present altered expression of haem biosynthetic enzymes, which could be useful for the differential diagnosis of these two types of porphyria in certain difficult cases. AIP patients present a condition of potential oxidative stress similar to VP patients, evidenced by the post-transcriptional activation of SOD and possible catalase impairment.
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Affiliation(s)
- Miguel D. Ferrer
- Laboratory for Physical Activity Sciences. Research Group in Community Nutrition and Oxidative Stress. Department of Basic Biology and Health Sciences. IUNICS, University of Balearic Islands, Palma, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Antonia Mestre-Alfaro
- Laboratory for Physical Activity Sciences. Research Group in Community Nutrition and Oxidative Stress. Department of Basic Biology and Health Sciences. IUNICS, University of Balearic Islands, Palma, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Magdalena Martínez-Tomé
- Department of Nutrition and Food Science, Regional Campus of International Excellence “Campus Mare Nostrum”, University of Murcia, Murcia, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Lucrecia Carrera-Quintanar
- Biochemistry and Cell Therapy Unit, Institute of Bioengineering, University Miguel Hernandez, Elche, Spain
| | - Xavier Capó
- Laboratory for Physical Activity Sciences. Research Group in Community Nutrition and Oxidative Stress. Department of Basic Biology and Health Sciences. IUNICS, University of Balearic Islands, Palma, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Antonia M. Jiménez-Monreal
- Department of Nutrition and Food Science, Regional Campus of International Excellence “Campus Mare Nostrum”, University of Murcia, Murcia, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Luis García-Diz
- Department of Nutrition I, University Complutense of Madrid, Madrid, Spain
| | - Enrique Roche
- Biochemistry and Cell Therapy Unit, Institute of Bioengineering, University Miguel Hernandez, Elche, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - María A. Murcia
- Department of Nutrition and Food Science, Regional Campus of International Excellence “Campus Mare Nostrum”, University of Murcia, Murcia, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Josep A. Tur
- Laboratory for Physical Activity Sciences. Research Group in Community Nutrition and Oxidative Stress. Department of Basic Biology and Health Sciences. IUNICS, University of Balearic Islands, Palma, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
| | - Antoni Pons
- Laboratory for Physical Activity Sciences. Research Group in Community Nutrition and Oxidative Stress. Department of Basic Biology and Health Sciences. IUNICS, University of Balearic Islands, Palma, Spain
- CIBEROBN (Fisiopatología de la Obesidad y la Nutrición CB12/03/30038) Instituto de Salud Carlos III, Madrid, Spain
- * E-mail:
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22
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D'Avola D, López-Franco E, Sangro B, Pañeda A, Grossios N, Gil-Farina I, Benito A, Twisk J, Paz M, Ruiz J, Schmidt M, Petry H, Harper P, de Salamanca RE, Fontanellas A, Prieto J, González-Aseguinolaza G. Phase I open label liver-directed gene therapy clinical trial for acute intermittent porphyria. J Hepatol 2016; 65:776-783. [PMID: 27212246 DOI: 10.1016/j.jhep.2016.05.012] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Acute intermittent porphyria (AIP) results from porphobilinogen deaminase (PBGD) haploinsufficiency, which leads to hepatic over-production of the neurotoxic heme precursors porphobilinogen (PBG) and delta-aminolevulinic acid (ALA) and the occurrence of neurovisceral attacks. Severe AIP is a devastating disease that can only be corrected by liver transplantation. Gene therapy represents a promising curative option. The objective of this study was to investigate the safety of a recombinant adeno-associated vector expressing PBGD (rAAV2/5-PBGD) administered for the first time in humans for the treatment of AIP. METHODS In this phase I, open label, dose-escalation, multicenter clinical trial, four cohorts of 2 patients each received a single intravenous injection of the vector ranging from 5×10(11) to 1.8×10(13) genome copies/kg. Adverse events and changes in urinary PBG and ALA and in the clinical course of the disease were periodically evaluated prior and after treatment. Viral shedding, immune response against the vector and vector persistence in the liver were investigated. RESULTS Treatment was safe in all cases. All patients developed anti-AAV5 neutralizing antibodies but no cellular responses against AAV5 or PBGD were observed. There was a trend towards a reduction of hospitalizations and heme treatments, although ALA and PBG levels remained unchanged. Vector genomes and transgene expression could be detected in the liver one year after therapy. CONCLUSIONS rAAV2/5-PBGD administration is safe but AIP metabolic correction was not achieved at the doses tested in this trial. Notwithstanding, the treatment had a positive impact in clinical outcomes in most patients. LAY SUMMARY Studies in an acute intermittent porphyria (AIP) animal model have shown that gene delivery of PBGD to hepatocytes using an adeno-associated virus vector (rAAV2/5-PBG) prevent mice from suffering porphyria acute attacks. In this phase I, open label, dose-escalation, multicenter clinical trial we show that the administration of rAAV2/5-PBGD to patients with severe AIP is safe but metabolic correction was not achieved at the doses tested; the treatment, however, had a positive but heterogeneous impact on clinical outcomes among treated patients and 2 out of 8 patients have stopped hematin treatment. CLINICAL TRIAL NUMBER The observational phase was registered at Clinicaltrial.gov as NCT 02076763. The interventional phase study was registered at EudraCT as n° 2011-005590-23 and at Clinicaltrial.gov as NCT02082860.
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Affiliation(s)
- Delia D'Avola
- Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (Ciberehd), Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Calle Irunlarrea 3, Pamplona 31008, Spain
| | - Esperanza López-Franco
- Gene therapy and regulation of Gene Expression Program, Centro de Investigación Médica Aplicada, Universidad de Navarra, Avda. Pio XII 55, Pamplona 31008, Spain
| | - Bruno Sangro
- Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (Ciberehd), Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Calle Irunlarrea 3, Pamplona 31008, Spain
| | - Astrid Pañeda
- DIGNA BIOTECH S.L. C/Boix y Morer 6-8°, Madrid 28003, Spain
| | - Nadina Grossios
- UniQure biopharma B.V., Meibegdreef 61, 1105 BA Amsterdam, The Netherlands
| | - Irene Gil-Farina
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Alberto Benito
- Radiology, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain
| | - Jaap Twisk
- UniQure biopharma B.V., Meibegdreef 61, 1105 BA Amsterdam, The Netherlands
| | - María Paz
- DIGNA BIOTECH S.L. C/Boix y Morer 6-8°, Madrid 28003, Spain
| | - Juan Ruiz
- DIGNA BIOTECH S.L. C/Boix y Morer 6-8°, Madrid 28003, Spain
| | - Manfred Schmidt
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg 69120, Germany
| | - Harald Petry
- UniQure biopharma B.V., Meibegdreef 61, 1105 BA Amsterdam, The Netherlands
| | - Pauline Harper
- Porphyria Centre Sweden, Karolinska University Hospital, Stockholm, Sweden
| | | | - Antonio Fontanellas
- Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (Ciberehd), Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Calle Irunlarrea 3, Pamplona 31008, Spain; Hepatology Program, Centro de Investigación Médica Aplicada, Universidad de Navarra, Avda. Pio XII 55, Pamplona 31008, Spain
| | - Jesús Prieto
- Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (Ciberehd), Liver Unit, Clínica Universidad de Navarra, Avda. Pio XII 36, Pamplona 31008, Spain; Gene therapy and regulation of Gene Expression Program, Centro de Investigación Médica Aplicada, Universidad de Navarra, Avda. Pio XII 55, Pamplona 31008, Spain.
| | - Gloria González-Aseguinolaza
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Calle Irunlarrea 3, Pamplona 31008, Spain; Gene therapy and regulation of Gene Expression Program, Centro de Investigación Médica Aplicada, Universidad de Navarra, Avda. Pio XII 55, Pamplona 31008, Spain.
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23
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Bharti S, Malhotra P, Hirsch B. Acute intermittent porphyria precipitated by atazanavir/ritonavir. Int J STD AIDS 2016; 27:1234-1235. [PMID: 26872826 DOI: 10.1177/0956462416633981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/28/2016] [Indexed: 11/15/2022]
Abstract
Porphyrias are a group of metabolic disorders that are relatively uncommon and underdiagnosed. Although the association between HIV infection and antiretrovirals with porphyria cutanea tarda is well established, there are fewer data linking HIV and the acute hepatic porphyrias. We report the first case of acute intermittent porphyria precipitated by the drugs atazanavir and ritonavir, presenting with unexplained abdominal pain.
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Affiliation(s)
- Sheena Bharti
- Division of Infectious Diseases, Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Prashant Malhotra
- Division of Infectious Diseases, Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Bruce Hirsch
- Division of Infectious Diseases, Department of Medicine, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
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24
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Affiliation(s)
- J Frank
- Hautklinik und Europäisches Porphyriezentrum, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
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Willandt B, Langendonk JG, Biermann K, Meersseman W, D'Heygere F, George C, Verslype C, Monbaliu D, Cassiman D. Liver Fibrosis Associated with Iron Accumulation Due to Long-Term Heme-Arginate Treatment in Acute Intermittent Porphyria: A Case Series. JIMD Rep 2015; 25:77-81. [PMID: 26093628 DOI: 10.1007/8904_2015_458] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/08/2015] [Accepted: 05/12/2015] [Indexed: 12/25/2022] Open
Abstract
UNLABELLED Acute intermittent porphyria (AIP) is an autosomal dominant disorder of heme biosynthesis due to a mutation in the porphobilinogen deaminase gene. The mutation causes a deficiency in the porphobilinogen deaminase enzyme, thereby causing an accumulation of heme precursors (δ-aminolevulinic acid and porphobilinogen). These neurotoxic heme precursors elicit acute neurovisceral attacks, which can be treated with heme-arginate infusions. Some patients require heme-arginate infusions on a regular basis for many years, which ultimately leads to an iron accumulation (increased serum ferritin and iron accumulation in the liver, spleen, and bone marrow on MRI). We report three AIP patients, who developed iron accumulation (with serum ferritin up to 7,850 microgram/liter) due to multiple heme-arginate infusions. We report for the first time that the iron accumulation in these patients was associated with fibrosis on liver histology. CONCLUSION Regular heme-arginate treatment in AIP does not only lead to increased serum ferritin but may also induce liver fibrosis. This should be taken into account, when weighing the risks and benefits of repeated heme-arginate treatment against the risk and benefits of treating refractory AIP by liver transplantation.
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Affiliation(s)
- Barbara Willandt
- Department of Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Janneke G Langendonk
- Department of Internal Medicine, Center for Lysosomal and Metabolic Diseases, Nederlands Porphyria Center, Erasmus MC, Rotterdam, The Netherlands
| | | | | | | | | | - Chris Verslype
- Department of Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Diethard Monbaliu
- Abdominal Transplantation Unit, University Hospitals Leuven, Leuven, Belgium
| | - David Cassiman
- Department of Hepatology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Metabolic Center, University Hospitals Leuven, Leuven, Belgium.
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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.
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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,
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27
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High prevalence of and potential mechanisms for chronic kidney disease in patients with acute intermittent porphyria. Kidney Int 2015; 88:386-95. [PMID: 25830761 DOI: 10.1038/ki.2015.97] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/13/2015] [Accepted: 02/19/2015] [Indexed: 01/19/2023]
Abstract
Acute intermittent porphyria (AIP) is a genetic disorder of the synthesis of heme caused by a deficiency in hydroxymethylbilane synthase (HMBS), leading to the overproduction of the porphyrin precursors δ-aminolevulinic acid and porphobilinogen. The aim of this study is to describe the clinical and biological characteristics, the renal pathology, and the cellular mechanisms of chronic kidney disease associated with AIP. A total of 415 patients with HMBS deficiency followed up in the French Porphyria Center were enrolled in 2003 in a population-based study. A follow-up study was conducted in 2013, assessing patients for clinical, biological, and histological parameters. In vitro models were used to determine whether porphyrin precursors promote tubular and endothelial cytotoxicity. Chronic kidney disease occurred in up to 59% of the symptomatic AIP patients, with a decline in the glomerular filtration rate of ~1 ml/min per 1.73 m(2) annually. Proteinuria was absent in the vast majority of the cases. The renal pathology was a chronic tubulointerstitial nephropathy, associated with a fibrous intimal hyperplasia and focal cortical atrophy. Our experimental data provide evidence that porphyrin precursors promote endoplasmic reticulum stress, apoptosis, and epithelial phenotypic changes in proximal tubular cells. In conclusion, the diagnosis of chronic kidney disease associated with AIP should be considered in cases of chronic tubulointerstitial nephropathy and/or focal cortical atrophy with severe proliferative arteriosclerosis.
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28
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Valle Feijóo ML, Bermúdez Sanjurjo JR, González Vázquez L, Rey Martínez M, de la Fuente Aguado J. Abdominal pain and syndrome of inappropriate antidiuretic hormone secretion as clinical presentation of acute intermittent porphyria. Rev Clin Esp 2015; 215:349-51. [PMID: 25796467 DOI: 10.1016/j.rce.2015.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 02/05/2015] [Indexed: 11/27/2022]
Abstract
Acute intermittent porphyria (AIP) is a rare condition characterized by abdominal pain and a wide range of nonspecific symptoms. We report the case of a woman with abdominal pain and syndrome of inappropriate antidiuretic hormone secretion (SIADH) as clinical presentation of AIP. The diagnosis was achieved through the etiologic study of the SIADH.
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Affiliation(s)
- M L Valle Feijóo
- Servicio de Medicina Interna, Hospital Povisa, Vigo, Pontevedra, España.
| | | | | | - M Rey Martínez
- Unidad de Cuidados Intensivos, Hospital Povisa, Vigo, Pontevedra, España
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29
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Zhang S, Xu M, Huang J, Tang L, Zhang Y, Wu J, Lin S, Wang H. Heme acts through the Bach1b/Nrf2a-MafK pathway to regulate exocrine peptidase precursor genes in porphyric zebrafish. Dis Model Mech 2014; 7:837-45. [PMID: 24652768 PMCID: PMC4073273 DOI: 10.1242/dmm.014951] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Using a zebrafish model of hepatoerythropoietic porphyria (HEP), we identify a previously unknown mechanism underlying heme-mediated regulation of exocrine zymogens. Zebrafish bach1b, nrf2a and mafK are all expressed in the zebrafish exocrine pancreas. Overexpression of bach1b or knockdown of nrf2a result in the downregulation of the expression of the exocrine zymogens, whereas overexpression of nrf2a or knockdown of bach1b cause their upregulation. In vitro luciferase assays demonstrate that heme activates the zymogens in a dosage-dependent manner and that the zymogen promoter activities require the integral Maf recognition element (MARE) motif. The Bach1b-MafK heterodimer represses the zymogen promoters, whereas the Nrf2a-MafK heterodimer activates them. Furthermore, chromatin immunoprecipitation (ChIP) assays show that MafK binds to the MARE sites in the 5' regulatory regions of the zymogens. Taken together, these data indicate that heme stimulates the exchange of Bach1b for Nrf2a at MafK-occupied MARE sites and that, particularly in heme-deficient porphyria, the repressive Bach1b-MafK heterodimer dominates, which can be exchanged for the activating Nrf2a-MafK heterodimer upon treatment with hemin. These results provide novel insights into the regulation of exocrine function, as well as the pathogenesis of porphyria, and should be useful for designing new therapies for both types of disease.
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Affiliation(s)
- Shuqing Zhang
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China
| | - Minrui Xu
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China
| | - Jian Huang
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China
| | - Lili Tang
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China
| | - Yanqing Zhang
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China
| | - Jingyao Wu
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China
| | - Shuo Lin
- Department of Molecular, Cell and Developmental Biology, University of California, Los Angeles, CA 90095-1606, USA
| | - Han Wang
- Center for Circadian Clocks, Soochow University, Suzhou 215123, Jiangsu, China. School of Biology & Basic Medical Sciences, Medical College, Soochow University, Suzhou 215123, Jiangsu, China.
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30
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Telkes G, Pusztai A, Földes K, Langer RM. Kidney transplantation in hereditary coproporphyria using tacrolimus and mycophenolate mofetil: a case report. Transplant Proc 2013; 45:3703-4. [PMID: 24315002 DOI: 10.1016/j.transproceed.2013.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The porphyrias are a group of disorders of the heme biosynthesis pathway that may present with acute life-threatening attacks, commonly exacerbated by a wide variety of medications. Many newer immunosuppressive medications, which are in use following kidney transplantation, have not been fully explored in acute porphyrias. CASE REPORT A 53-year-old woman received a kidney from a deceased donor, after being on hemodialysis for 4 years. Hereditary coproporphyria was diagnosed at age 19 years. We administered tacrolimus, mycophenolate mofetil and steroid immunosuppression. In the immediate post-transplant periods she displayed abdominal pain and transient uroporphyrin elevation in parallel with slightly elevated (15 ng/mL) tacrolimus concentrations. As the target tacrolimus level was achieved, these findings disappeared. CONCLUSIONS Tacrolimus, mycophenolate- mofetil, and steroid therapy for hereditery coproporphyri was safe, in the long term.
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Affiliation(s)
- G Telkes
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
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31
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Tsuchiya Y, Hoshino J, Suwabe T, Sumida K, Hiramatsu R, Mise K, Hasegawa E, Yamanouchi M, Hayami N, Sawa N, Arizono K, Hara S, Takaichi K, Fujii T, Ubara Y. Variegate porphyria complicated by systemic AA amyloidosis: a case report. Amyloid 2013; 20:272-4. [PMID: 24131077 PMCID: PMC3836393 DOI: 10.3109/13506129.2013.837390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report a Japanese woman with variegate porphyria accompanied by amyloid A (AA) amyloidosis. Arthropathy involving multiple joints occurred at 35 years old and persisted. C-reactive protein was 4.0 mg/dL, but rheumatoid factor was negative. Radiographs did not reveal any loss or narrowing of the joint spaces. Two years later, blister formation after sun exposure and reddish urine were first noted. At the age of 45 years, she developed abdominal pain, nausea, vomiting and seizures. After administration of phenobarbital, reddish urine was noted and muscular weakness progressed to atonic quadraparesis. Porphyria attack was diagnosed from high urinary levels of ∂ aminolevulinic acid and porphobilinogen. At the age of 47 years, hemodialysis was started. At the age of 49 years, progression of her gastrointestinal event resulted in death. Autopsy showed massive deposits of AA amyloidosis in various organs, including the kidneys and digestive tract. Thus, amyloid deposition may have contributed to both end-stage renal failure and her gastrointestinal symptoms. This is the first report about the coexistence of porphyria and AA amyloidosis. Chronic inflammation related to this patient's seronegative arthropathy, although atypical for porphyria, might have contributed to the development of AA amyloidosis.
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32
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Manifestations and treatment of the hand in adult congenital erythropoietic porphyria. J Clin Rheumatol 2013; 19:402-4. [PMID: 24048109 DOI: 10.1097/rhu.0b013e3182a70073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare enzymatic disorder of heme metabolism, leading to the accumulation of porphyrins in the skin and subdermal structures. We present the case of a 34-year-old, right-hand-dominant, male patient with CEP. The patient had developed a chronic open subluxation of the left index finger proximal interphalangeal joint due to skin necrosis. We successfully treated the patient with proximal interphalangeal arthrodesis. This case demonstrates that childhood-onset CEP can also manifest in the adult hand. Considering the patient's age, the destructive nature of the disease, and the poor quality of function in older patients with childhood CEP, surgical intervention was necessary to avoid further digital length loss. Although the treatment described in this case report is not uncommon, we found it essential to present this case because the clinical presentation of CEP is rare.
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Clinical manifestations and diagnostic challenges in acute porphyrias. Case Rep Hematol 2013; 2013:628602. [PMID: 23476835 PMCID: PMC3583083 DOI: 10.1155/2013/628602] [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] [Received: 11/21/2012] [Accepted: 01/08/2013] [Indexed: 12/21/2022] Open
Abstract
The porphyrias are a group of disorders characterized by an enzyme deficiency in the heme biosynthetic pathway. These can be classified into either erythropoietic or hepatic forms depending on the site of the major enzyme deficiency. The diagnosis of acute porphyrias, however, can be very challenging due to overlapping features amongst the various types. Initial suspicion is based on a myriad of clinical manifestations, which then are confirmed by laboratory testing where available. Genetic testing is now also available for the different types of porphyrias, aiding in the definitive diagnosis. Here, we present a challenging case of porphyria in a patient with end-stage renal disease and present the diagnostic challenges associated with the case and the ways forward.
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Harris C, Hartsilver E. Anaesthetic management of an obstetric patient with variegate porphyria. Int J Obstet Anesth 2013; 22:156-60. [PMID: 23473551 DOI: 10.1016/j.ijoa.2013.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 01/10/2013] [Accepted: 01/19/2013] [Indexed: 10/27/2022]
Abstract
Porphyria is an uncommon disease that can produce life-threatening attacks with a mortality rate of up to 10%, specifically as the result of administration of porphyrinogenic medications. In obstetric anaesthesia there are many situations where drugs are given in an emergency and it is therefore important to be prepared for complications to avoid inadvertently inducing an iatrogenic porphyric crisis. We discuss the case of a 20-year-old nulliparous woman with variegate porphyria who required an emergency caesarean section in labour, and the drugs that are commonly used in obstetric practice.
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Affiliation(s)
- C Harris
- Department of Anaesthesia, Royal Devon and Exeter Hospital, Exeter, UK
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35
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The potential role of cell penetrating peptides in the intracellular delivery of proteins for therapy of erythroid related disorders. Pharmaceuticals (Basel) 2013; 6:32-53. [PMID: 24275786 PMCID: PMC3816679 DOI: 10.3390/ph6010032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/20/2012] [Accepted: 12/27/2012] [Indexed: 01/08/2023] Open
Abstract
The erythroid related disorders (ERDs) represent a large group of hematological diseases, which in most cases are attributed either to the deficiency or malfunction of biosynthetic enzymes or oxygen transport proteins. Current treatments for these disorders include histo-compatible erythrocyte transfusions or allogeneic hematopoietic stem cell (HSC) transplantation. Gene therapy delivered via suitable viral vectors or genetically modified HSCs have been under way. Protein Transduction Domain (PTD) technology has allowed the production and intracellular delivery of recombinant therapeutic proteins, bearing Cell Penetrating Peptides (CPPs), into a variety of mammalian cells. Remarkable progress in the field of protein transduction leads to the development of novel protein therapeutics (CPP-mediated PTs) for the treatment of monogenetic and/or metabolic disorders. The “concept” developed in this paper is the intracellular protein delivery made possible via the PTD technology as a novel therapeutic intervention for treatment of ERDs. This can be achieved via four stages including: (i) the production of genetically engineered human CPP-mediated PT of interest, since the corresponding native protein either is missing or is mutated in the erythroid progenitor cell (ErPCs) or mature erythrocytes of patients; (ii) isolation of target cells from the peripheral blood of the selected patients; (iii) ex vivo transduction of cells with the CPP-mediated PT of interest; and (iv) re-administration of the successfully transduced cells back into the same patients.
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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.
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Affiliation(s)
- Cindy Shin-Yi Lin
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
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37
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Chantorn R, Lim HW, Shwayder TA. Photosensitivity disorders in children: part I. J Am Acad Dermatol 2012; 67:1093.e1-18; quiz 1111-2. [PMID: 23158621 DOI: 10.1016/j.jaad.2012.07.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 07/25/2012] [Accepted: 07/29/2012] [Indexed: 11/18/2022]
Abstract
Photosensitivity disorders in children encompass a diverse group of diseases. Compared to adult patients, underlying systemic disorders, including genetic or metabolic defects, are common causes in pediatric photosensitivity disorders. Photosensitivity in a child should be suspected if the child develops a sunburn reaction in sun-exposed sites after limited sun exposure. Diagnosis of a photodermatosis is made based on careful history taking and a physical examination. Early recognition and prompt diagnosis are essential to minimize long-term complications associated with inadequate photoprotection. In part I of this continuing medical education article, immunologically mediated photodermatoses, photodermatoses caused by exogenous photosensitizers, and the cutaneous porphyrias will be covered.
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Affiliation(s)
- Rattanavalai Chantorn
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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38
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León E, Fuentes W, Richarz N, Villegas M, Oussedik L, Armario P. Porfiria aguda intermitente: la hipertensión arterial como signo guía. HIPERTENSION Y RIESGO VASCULAR 2012. [DOI: 10.1016/j.hipert.2012.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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39
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Shankaran P, Vlkova L, Liskova J, Melkova Z. Heme arginate potentiates latent HIV-1 reactivation while inhibiting the acute infection. Antiviral Res 2011; 92:434-46. [PMID: 22001321 DOI: 10.1016/j.antiviral.2011.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 09/28/2011] [Accepted: 09/28/2011] [Indexed: 11/16/2022]
Abstract
Human immunodeficiency virus-1 (HIV-1) successfully escapes from host immune surveillance, vaccines and antiretroviral agents. The available antiretroviral compounds can only control viremia, but it is impossible to eliminate the virus from the organism, namely because HIV-1 provirus persists in the reservoir cells from which the virus repeatedly disseminates into new cells. Current therapeutic approaches, however, do not specifically address the stage of virus reactivation. Heme has been demonstrated as very efficient in inhibiting HIV-1 reverse transcription, while its derivative hemin ameliorated HIV-1 infection via induction of heme oxygenase-1. Normosang (heme arginate; HA) is a human hemin-containing compound used to treat acute porphyria. In this work, we studied the effects of HA in HIV-1-acutely infected T-cell lines, and in cell lines harboring either a complete HIV-1 provirus (ACH-2 cells) or an HIV-1 "mini-virus" (Jurkat clones expressing EGFP under control of HIV LTR). We demonstrate that HA inhibited HIV-1 replication during the acute infection, which was accompanied by the inhibition of reverse transcription. On the other hand, HA alone stimulated the reactivation of HIV-1 "mini-virus" and synergized with phorbol ester or TNF-α in the reactivation of HIV-1 provirus. The stimulatory effects of HA were inhibited by N-acetyl cysteine, suggesting an increased redox stress and activation of NF-κB. Further, HA induced expression of heme oxygenase-1 (HO-1) in ACH-2 cells, while HO-1 was found expressed in untreated Jurkat clones. Inhibitor of HO-1 activity, tin protoporphyrin IX, further increased HA-mediated reactivation of HIV-1 "mini-virus" in Jurkat clones, and this effect was also inhibited by N-acetyl cysteine. The stimulatory effects of HA on HIV-1 reactivation thus seem to involve HO-1 and generation of free radicals. Additionally, the effective concentrations of HA did neither affect normal T-cell activation with PMA nor induce activation of the unstimulated cells. In conclusion, HA appears to possess a combination of unique properties that could help to decrease the pool of latently infected reservoir cells, while simultaneously inhibiting HIV-1 replication in newly infected cells. Our results thus suggest a new direction to explore in treatment of HIV/AIDS disease.
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Affiliation(s)
- Prakash Shankaran
- Department of Immunology and Microbiology, 1st Medical Faculty, Charles University in Prague, Czech Republic
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