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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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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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Coffey A, Leung DH, Quintanilla NM. Erythropoietic Protoporphyria: Initial Diagnosis With Cholestatic Liver Disease. Pediatrics 2018; 141:S445-S450. [PMID: 29610169 DOI: 10.1542/peds.2016-1625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2017] [Indexed: 11/24/2022] Open
Abstract
The porphyrias are a group of rare metabolic disorders that result from defects in heme biosynthesis. Erythropoietic protoporphyria (EPP) is the most common inherited porphyria in children and is diagnosed in most individuals after the onset of cutaneous manifestations. Hepatobiliary disease affects the minority of individuals with EPP and usually manifests in patients with an established diagnosis of EPP. We report on a classic but rare case of EPP that masqueraded as cholestasis. An 8-year-old boy was referred to the Hepatology Clinic after an abrupt onset of jaundice with a longstanding history of dermatitis. The diagnosis of EPP was established with liver biopsy, which revealed dense, dark-brown pigment in hepatocytes and Kupffer cells that, on polarization, displayed bright-red birefringence and centrally located Maltese crosses. Plasma total porphyrins and erythrocyte protoporphyrin were elevated and confirmed a diagnosis of EPP. We hope to raise awareness of this diagnosis among pediatricians, hepatologists, and pathologists and increase the consideration of EPP in patients with cholestatic liver disease and chronic dermatitis.
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Affiliation(s)
- Amy Coffey
- Departments of Pathology and Immunology and.,Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Daniel H Leung
- Pediatrics, Baylor College of Medicine, Houston, Texas; and.,Division of Pediatric Gastroenterology, Hepatology, and Nutrition and
| | - Norma M Quintanilla
- Departments of Pathology and Immunology and .,Department of Pathology, Texas Children's Hospital, Houston, Texas
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[Erythropoietic protoporphyria : Clinical manifestations, diagnosis and new therapeutic possibilities]. DER HAUTARZT 2015; 67:211-5. [PMID: 26669872 DOI: 10.1007/s00105-015-3733-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Erythropoietic protoporphyria, the second most common type of the cutaneous porphyrias, is due to an enzymatic deficiency of ferrochelatase, the last enzyme in heme biosynthesis. The enzyme defect leads to an accumulation of protoporphyrin IX in erythrocytes and an elevated excretion of this metabolite in the feces. CLINICAL PRESENTATION Usually, disease onset is in early infancy, characterized by increased photosensitivity. During or shortly after sunlight exposure, affected individuals suffer from burning, stinging, itching, and pain in sun-exposed skin areas. These symptoms lead to a considerably reduced quality of life and strict avoidance of sunlight exposure. Subacute symptoms include visible changes like edema and erythema. In the further course of the disease, chronic signs such as lichenification and scarring may occur. A severe complication of hepatic protoporphyrin IX accumulation is the development of a potentially life-threatening fulminant liver failure. Therefore, hepatic laboratory tests and ultrasound of the liver should be performed regularly. THERAPY Traditionally, therapy merely consisted of consequent photoprotection and orally administered β-carotene. A novel treatment option is afamelanotide (Scenesse®), a synthetic analogue of the naturally occurring α-melanocyte stimulating hormone. Afamelanotide, administered as a subcutaneous implant, induces eumelanin production, independent of preceding UV light exposure. This may enable patients with erythropoietic protoporphyria to stay in sunlight significantly longer than previously possible without complaints, thus, substantially improving quality of life.
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Sachar M, Anderson KE, Ma X. Protoporphyrin IX: the Good, the Bad, and the Ugly. J Pharmacol Exp Ther 2015; 356:267-75. [PMID: 26588930 DOI: 10.1124/jpet.115.228130] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/20/2015] [Indexed: 01/10/2023] Open
Abstract
Protoporphyrin IX (PPIX) is ubiquitously present in all living cells in small amounts as a precursor of heme. PPIX has some biologic functions of its own, and PPIX-based strategies have been used for cancer diagnosis and treatment (the good). PPIX serves as the substrate for ferrochelatase, the final enzyme in heme biosynthesis, and its homeostasis is tightly regulated during heme synthesis. Accumulation of PPIX in human porphyrias can cause skin photosensitivity, biliary stones, hepatobiliary damage, and even liver failure (the bad and the ugly). In this work, we review the mechanisms that are associated with the broad aspects of PPIX. Because PPIX is a hydrophobic molecule, its disposition is by hepatic rather than renal excretion. Large amounts of PPIX are toxic to the liver and can cause cholestatic liver injury. Application of PPIX in cancer diagnosis and treatment is based on its photodynamic effects.
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Affiliation(s)
- Madhav Sachar
- Department of Pharmaceutical Sciences, Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania (M.S., X.M.); and Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (K.E.A.)
| | - Karl E Anderson
- Department of Pharmaceutical Sciences, Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania (M.S., X.M.); and Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (K.E.A.)
| | - Xiaochao Ma
- Department of Pharmaceutical Sciences, Center for Pharmacogenetics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania (M.S., X.M.); and Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (K.E.A.)
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Schiekofer C, Vogt T, Reichrath J. [Erythropoietic protoporphyria. A rare differential diagnosis among photosensitive diseases]. Hautarzt 2015; 63:961-4. [PMID: 22802217 DOI: 10.1007/s00105-012-2423-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 31-year-old woman presented with recurrent swelling, burning, prickling and itching of the arms and the hands which appeared after UV exposure in the summer. Simultaneously she often had chills, malaise, nausea and circulatory problems lasting for hours. She did not have erythema or wheals. She had been seen by a number of specialties but to no avail. Her deceased mother suffered from the same symptoms. On presentation she had no skin lesions. Laboratory testing showed a dramatic increase in total protoporphyrin, enabling us to diagnose erythropoietic protoporphyria. This is a rare, genetic metabolic disturbance in hematopoiesis, whose true prevalence is probably underestimated. Because of abnormal or absent function of ferrochelatase, protoporphyrin accumulates in blood, erythrocytes and tissue usually causing photosensitivity as the first clinical symptom. The prognosis depends on the severity of liver involvement. Because of the marked restrictions on activity, especially in avoiding UV exposition, the quality of life of the patients and their families are strongly influenced. The odyssey of our patient and her mother in finding a diagnosis demonstrates impressively that the EPP is an important photosensitizing disease which must not be forgotten.
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Affiliation(s)
- C Schiekofer
- Hautklinik und Poliklinik, Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, 66421, Homburg/Saar, Deutschland.
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Experimental protoporphyria: effect of bile acids on liver damage induced by griseofulvin. BIOMED RESEARCH INTERNATIONAL 2015; 2015:436319. [PMID: 25945334 PMCID: PMC4405217 DOI: 10.1155/2015/436319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/06/2015] [Accepted: 01/13/2015] [Indexed: 11/25/2022]
Abstract
The effect of bile acids administration to an experimental mice model of Protoporphyria produced by griseofulvin (Gris) was investigated. The aim was to assess whether porphyrin excretion could be accelerated by bile acids treatment in an attempt to diminish liver damage induced by Gris. Liver damage markers, heme metabolism, and oxidative stress parameters were analyzed in mice treated with Gris and deoxycholic (DXA), dehydrocholic (DHA), chenodeoxycholic, or ursodeoxycholic (URSO). The administration of Gris alone increased the activities of glutathione reductase (GRed), superoxide dismutase (SOD), alkaline phosphatase (AP), gamma glutamyl transpeptidase (GGT), and glutathione-S-transferase (GST), as well as total porphyrins, glutathione (GSH), and cytochrome P450 (CYP) levels in liver. Among the bile acids studied, DXA and DHA increased PROTO IX excretion, DXA also abolished the action of Gris, reducing lipid peroxidation and hepatic GSH and CYP levels, and the activities of GGT, AP, SOD, and GST returned to control values. However, porphyrin accumulation was not prevented by URSO; instead this bile acid reduced ALA-S and the antioxidant defense enzymes system activities. In conclusion, we postulate that DXA acid would be more effective to prevent liver damage induced by Gris.
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Martinez MDC, Afonso SG, Buzaleh AM, Batlle A. Protective action of antioxidants on hepatic damage induced by griseofulvin. ScientificWorldJournal 2014; 2014:982358. [PMID: 24523661 PMCID: PMC3913521 DOI: 10.1155/2014/982358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 10/10/2013] [Indexed: 11/17/2022] Open
Abstract
Erythropoietic protoporphyria (EPP) is a disease associated with ferrochelatase deficiency and characterized by the accumulation of protoporphyrin IX (PROTO IX) in erythrocytes, liver, and skin. In some cases, a severe hepatic failure and cholestasis were observed. Griseofulvin (Gris) develops an experimental EPP with hepatic manifestations in mice such as PROTO IX accumulation followed by cellular damage as wells as necrotic and inflammatory processes. The antioxidant defense system was also altered. The aim was to evaluate the possible protective effect of different antioxidant compounds: trolox (Tx), ascorbic acid (Asc), the combination Tx and Asc, melatonin (Mel), and the polyphenols: ellagic acid, quercetin, chlorogenic acid, caffeic acid, gallic acid, and ferulic acid on liver damage and oxidative stress markers in a mouse model of EPP. Coadministration of Gris with Tx, Asc, and its combination, or Mel mainly affected heme biosynthetic pathway, resulting in a decrease in ALA-S activity which was increased by Gris, while the tested polyphenols exerted a protective effect on oxidative stress, decreasing lipid peroxidation and the activity of some antioxidant enzymes. In conclusion, antioxidant compounds can only protect partially against the liver damage induced by Gris, reducing oxidative stress or acting on heme regulation.
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Affiliation(s)
- M. del C. Martinez
- Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Intendente Guiraldes 2160 Pab II, 1428 Buenos Aires, Argentina
| | - S. G. Afonso
- Centro de Investigaciones Sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Avenida, Córdoba 2351 1er subsuelo, 1120 Buenos Aires, Argentina
| | - A. M. Buzaleh
- Departamento de Química Biológica, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Intendente Guiraldes 2160 Pab II, 1428 Buenos Aires, Argentina
- Centro de Investigaciones Sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Avenida, Córdoba 2351 1er subsuelo, 1120 Buenos Aires, Argentina
| | - A. Batlle
- Centro de Investigaciones Sobre Porfirinas y Porfirias (CIPYP), CONICET, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Avenida, Córdoba 2351 1er subsuelo, 1120 Buenos Aires, Argentina
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Shedding light on a painful rash. Arab J Gastroenterol 2013; 14:83-4. [PMID: 23820507 DOI: 10.1016/j.ajg.2013.01.006] [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: 05/26/2012] [Accepted: 01/29/2013] [Indexed: 11/20/2022]
Abstract
We present a case of a rare inherited disorder--erythropoietic protoporphyria--with typical clinical manifestations. The diagnosis was suspected on the basis of a history of a light-sensitive rash and characteristic liver biopsy, and confirmed with genetic testing. The patient was followed up for more than 20 years, and ultimately developed the uncommon associated complication of liver cirrhosis. The clinical features, pathogenesis and management of erythropoietic protoporphyria are discussed herein.
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Casanova-González MJ, Trapero-Marugán M, Jones EA, Moreno-Otero R. Liver disease and erythropoietic protoporphyria: A concise review. World J Gastroenterol 2010; 16:4526-31. [PMID: 20857522 PMCID: PMC2945483 DOI: 10.3748/wjg.v16.i36.4526] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The porphyries are a group of metabolic disorders characterized by deficiencies in the activity of enzymes involved in the biosynthesis of heme. In erythropoietic protoporphyria (EPP), in the majority of cases an autosomal dominant disease, there is a mutation of the gene that encodes ferrochelatase (FECH). FECH deficiency is associated with increased concentrations of protoporphyrin in erythrocytes, plasma, skin and liver. The prevalence of this inherited disorder oscillates between 1:75 000 and 1:200 000. Clinical manifestations of EPP appear in early infancy upon first exposure to the sun. Nevertheless, approximately 5%-20% of patients with EPP develop liver manifestations. Retention of protoporphyrin in the liver is associated with cholestatic phenomena and oxidative stress that predisposes to hepatobiliary disease of varying degrees of severity, such as cholelithiasis, mild parenchymal liver disease, progressive hepatocellular disease with end-stage liver disease and acute liver failure. Liver damage is the major risk in EPP patients, so surveillance and frequent clinical and biochemical liver follow-up is mandatory. The diagnostic approach consists in detecting increased levels of protoporphyrin, decreased activity of FECH and genetic analysis of the FECH gene. A variety of non-surgical therapeutic approaches have been adopted for the management of EPP associated with liver disease, but none of these has been shown to be unequivocally efficacious. Nevertheless, some may have a place in preparing patients for liver transplantation. Liver transplantation does not correct the constitutional deficiency of FECH. Consequently, there is a risk of recurrence of liver disease after liver transplantation as a result of continuing overproduction of protoporphyrin. Some authors recommend that bone marrow transplantation should be considered in liver allograft recipients to prevent recurrence of hepatic disease.
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Lecha M, Puy H, Deybach JC. Erythropoietic protoporphyria. Orphanet J Rare Dis 2009; 4:19. [PMID: 19744342 PMCID: PMC2747912 DOI: 10.1186/1750-1172-4-19] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 09/10/2009] [Indexed: 01/29/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) is an inherited disorder of the haem metabolic pathway characterised by accumulation of protoporphyrin in blood, erythrocytes and tissues, and cutaneous manifestations of photosensitivity. EPP has been reported worldwide, with prevalence between 1:75,000 and 1:200,000. It usually manifests in early infancy upon the first sun exposures. EPP is characterised by cutaneous manifestations of acute painful photosensitivity with erythema and oedema, sometimes with petechiae, together with stinging and burning sensations upon exposure to sunlight, without blisters. These episodes have a variable severity depending on the exposure duration and may result in chronic permanent lesions on exposed skin. As protoporphyrin is a lipophilic molecule that is excreted by the liver, EPP patients are at risk of cholelithiasis with obstructive episodes, and chronic liver disease that might evolve to rapid acute liver failure. In most patients, EPP results from a partial deficiency of the last enzyme of the haem biosynthetic pathway, ferrochelatase, EC 4.99.1.1/FECH (encoded by the FECH gene). EPP appears to be inherited as an autosomal dominant disease, the clinical expression of which is modulated by the presence of the hypomorphic FECH IVS3-48C allele trans, but recessive inheritance with two mutated FECH alleles has also been described. In about 2% of patients, overt disease was recently shown to be caused by gain-of-function mutations in the erythroid-specific aminolevulinic acid synthase 2 (ALAS2/ALAS, EC 2.3.1.27) gene and named X-linked dominant protoporphyria. Diagnosis is established by finding increased levels of protoporphyrin in plasma and red blood cells, and detection of a plasma fluorescence peak at 634 nm. Investigations for hepatic involvement, ferrochelatase activity level, genetic analysis (FECH mutations, presence of the hypomorphic FECH IVS3-48C allele trans and ALAS2 mutations) and family studies are advisable. Differential diagnosis includes phototoxic drug reactions, hydroa vacciniforme, solar urticaria, contact dermatitis, angio-oedema and, in some cases, other types of porphyria. Management includes avoidance of exposure to light, reduction of protoporphyrin levels and prevention of progression of possible liver disease to liver failure. As the major risk in EPP patients is liver disease, a regular follow-up of hepatic involvement is essential. Sequential hepatic and bone marrow transplantation should be considered as a suitable treatment for most severe cases of EPP with hepatic involvement. EPP is a lifelong disorder whose prognosis depends on the evolution of the hepatic disease. However, photosensitivity may have a significant impact on quality of life of EPP patients.
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Affiliation(s)
- Mario Lecha
- Department of Dermatology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
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