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Kumar AB, Asamoah EM, Wetter DA, Davis MDP, Alavi A. Clinical Characteristics and Inciting Agents for Pseudoporphyria: The Mayo Clinic Experience, 1996-2020. Adv Skin Wound Care 2024; 37:406-411. [PMID: 39037094 DOI: 10.1097/asw.0000000000000176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
GENERAL PURPOSE To raise awareness regarding the clinical presentations of patients with pseudoporphyria. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Describe the clinical presentation of pseudoporphyria.2. Identify the differential diagnoses of blistering lesions on hands and feet.3. Outline the management options for patients with porphyria.
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Aarsand AK, To-Figueras J, Whatley S, Sandberg S, Schmitt C. Practical recommendations for biochemical and genetic diagnosis of the porphyrias. Liver Int 2024. [PMID: 38940544 DOI: 10.1111/liv.16012] [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: 01/08/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 06/29/2024]
Abstract
The porphyrias are a group of rare inborn errors of metabolism associated with various clinical presentations and long-term complications, making them relevant differential diagnoses to consider for many clinical specialities, especially hepatologists, gastroenterologists and dermatologists. To diagnose a patient with porphyria requires appropriate biochemical investigations, as clinical features alone are not specific enough. Furthermore, it is important to be aware that abnormalities of porphyrin accumulation and excretion occur in many other disorders that are collectively far more common than the porphyrias. In this review, we provide an overview of porphyria-related tests with their strengths and limitations, give recommendations on requesting and diagnostic approaches in non-expert and expert laboratories for different clinical scenarios and discuss the role of genetic testing in the porphyrias. To diagnose porphyria in a currently symptomatic patient requires analysis of biochemical markers to demonstrate typical patterns of haem precursors in urine, faeces and blood. The use of genomic sequencing in diagnostic pathways for porphyrias requires careful consideration, and the demonstration of increased porphyrin-related markers is necessary prior to genomic testing in symptomatic patients. In the acute porphyrias, genomic testing is presently a useful adjunct for genetic counselling of asymptomatic family members and the most common cutaneous porphyria, porphyria cutanea tarda, is usually a sporadic, non-hereditary disease. Getting a correct and timely porphyria diagnosis is essential for delivering appropriate care and ensuring best patient outcome.
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Affiliation(s)
- Aasne K Aarsand
- Norwegian Porphyria Centre and Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Jordi To-Figueras
- Biochemistry and Molecular Genetics Unit, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Sharon Whatley
- Cardiff Porphyria Service, Department of Medical Biochemistry and Immunology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Sverre Sandberg
- Norwegian Porphyria Centre and Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations (NOKLUS), Haraldsplass Deaconess Hospital, Bergen, Norway
- Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Caroline Schmitt
- Department of Medical Biochemistry, Université Paris Cité and INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France
- French Centre of Porphyrias, Assistance Publique-Hôpitaux de Paris, Hôpital Louis Mourier, Colombes, France
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Jangid SD, Saoji V, Madke B, Bhatt DM. Drug-Induced Pseudoporphyria: A Case Report. Cureus 2024; 16:e57574. [PMID: 38707054 PMCID: PMC11069038 DOI: 10.7759/cureus.57574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/02/2024] [Indexed: 05/07/2024] Open
Abstract
Pseudoporphyria is an uncommon dermatosis resembling porphyria cutanea tarda (PCT). The exclusion of true porphyria, especially PCT, is critically essential for diagnosing pseudoporphyria. It has an unknown underlying pathophysiology with a normal or near-normal porphyrin profile. Pseudoporphyria has been associated with chronic renal failure and hemodialysis, medications, and tanning beds. In drug-induced pseudoporphyria cases, eliminating the suspected photosensitizing drug improves the disease typically within weeks to months (on average eight weeks). In genetically predisposed individuals, phototoxic metabolites may trigger the development of skin fragility, bullae, milia, and scarring on the dorsum of the hands and other sun-exposed areas. Wearing a broad-spectrum sunscreen and maintaining strict ultraviolet protection is essential in cases of pseudoporphyria. We report the case of a 20-year-old male who presented to us with complaints of photosensitivity and multiple erosions with irregular scars over photo-exposed areas involving the dorsum of the hands and face predominantly. The patient was evaluated further to determine the underlying cause. A wood's lamp examination of the urine was done, which did not show fluorescence. Based on clinical and laboratory findings, the diagnosis of pseudoporphyria was made, and the patient was started on the oral antimalarial agent hydroxychloroquine sulfate with strict sun protection.
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Affiliation(s)
- Shivani D Jangid
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vikrant Saoji
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Bhushan Madke
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Drishti M Bhatt
- Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Arriaga Escamilla D, Lakhani A, Antony S, Salazar Villegas KN, Gupta M, Ramnath P, Murillo Pineda MI, Bedor A, Banegas D, Calderon Martinez E. Dermatological Manifestations in Patients With Chronic Kidney Disease: A Review. Cureus 2024; 16:e52253. [PMID: 38352109 PMCID: PMC10863542 DOI: 10.7759/cureus.52253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/16/2024] Open
Abstract
Chronic kidney disease (CKD) is a progressive disease and has multiple clinical manifestations; when CKD reaches the end stage, at least one cutaneous manifestation appears due to some increased toxin levels or a constant proinflammatory state. Nonspecific manifestations include pruritus, xerosis, pigmentation disorders, acquired ichthyosis, purpuric spots, and nail disorders. Some specific manifestations are bullous dermatoses, acquired perforating dermatoses (APD), eruptive xanthoma, access site infections, calcifying disorders, and nephrogenic systemic fibrosis (NSF). All these cutaneous changes negatively impact patients; early recognition and diagnosis of these dermatoses will make a difference in their quality of treatment. Exploring a patient's skin is fundamental to suspect some diseases and increased toxin levels; pruritus occurs when uremic toxins are raised, and nail disorders are associated with hypoalbuminemia. This review provides the clinician with information on the clinical manifestations that occur in CKD, including epidemiology, pathophysiology, clinical manifestations, diagnosis, histopathology, treatment, and life impact of the dermatoses in CKD.
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Affiliation(s)
| | - Alisha Lakhani
- Medicine, Research MD, Vadodara, IND
- Medicine, Shantabaa Medical College, Amreli, IND
| | - Sneha Antony
- Pharmacology, K S Hegde Medical Academy, Mangalore, IND
| | | | - Manasvi Gupta
- General Practice, Jawaharlal Nehru Medical College, Aligarh, IND
| | | | | | - Alexandra Bedor
- Internal Medicine, Instituto Salvadoreño del Seguro Social, San Salvador, SLV
| | - Douglas Banegas
- General Medicine, Universidad Nacional Autonoma de Honduras, San Pedro Sula, HND
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Caro-Chang LA, Fung MA. The role of eosinophils in the differential diagnosis of inflammatory skin diseases. Hum Pathol 2023; 140:101-128. [PMID: 37003367 DOI: 10.1016/j.humpath.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023]
Abstract
Eosinophils are known to be present in inflammatory skin diseases, but their diagnostic utility is not well established. Upon review of the published status of lesional eosinophils, several categories were identified. 1) Lesional eosinophils highly characteristic such that, in their absence, the pathologist may question the diagnosis. These include arthropod bite reactions and scabies, urticarial dermatitis, and other eosinophilic dermatoses. 2) Lesional eosinophils rare or absent, such that, in their presence, the pathologist may question the diagnosis. These include pityriasis lichenoides, graft versus host disease, and connective tissue disorders. 3) Lesional eosinophils variable and, while in some cases expected, are not required for diagnosis. These include drug reactions, atopic dermatitis and allergic contact dermatitis. 4) Lesional eosinophils variable and not expected but may be seen to a limited extent. These include lichen planus and psoriasis.
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Clark A, Weissman AS, Crowson AN, Hirshburg J. Olaparib-induced pseudoporphyria in a patient with ovarian cancer. JAAD Case Rep 2023; 39:58-60. [PMID: 37583835 PMCID: PMC10424066 DOI: 10.1016/j.jdcr.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023] Open
Affiliation(s)
- Abigale Clark
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Amanda S. Weissman
- Department of Dermatology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Arthur Neil Crowson
- Department of Dermatology and Pathology Laboratories Inc, University of Oklahoma, Tulsa, Oklahoma
| | - Jason Hirshburg
- Department of Dermatology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
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Rusiñol L, Carmona-Rocha E, Spertino J. Bullous eruption in a pluripathological patient. Int J Dermatol 2023; 62:e312-e313. [PMID: 36683133 DOI: 10.1111/ijd.16590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/04/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023]
Affiliation(s)
- Lluís Rusiñol
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona
| | - Elena Carmona-Rocha
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona
| | - Jorge Spertino
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona
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Gil-Lianes J, Luque-Luna M, Morgado-Carrasco D, Aguilera-Peiró P. Pseudoporphyria-a diagnostic challenge: A case series and a proposed diagnostic algorithm. PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE 2022; 38:604-607. [PMID: 35165937 DOI: 10.1111/phpp.12781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/24/2022] [Accepted: 02/07/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Javier Gil-Lianes
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Mar Luque-Luna
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Daniel Morgado-Carrasco
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Paula Aguilera-Peiró
- Dermatology Department, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Plasma porphyrins among end stage renal disease patients and cutaneous symptoms- is there still an association? Mol Genet Metab Rep 2022; 33:100928. [PMID: 36281443 PMCID: PMC9587357 DOI: 10.1016/j.ymgmr.2022.100928] [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] [Received: 08/19/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Several abnormalities of porphyrin metabolism leading to Porphyria Cutanea Tarda (PCT) have been described in early studies of End Stage Renal Disease (ESRD) patients, with a reported prevalence of 5-18%. We aimed to evaluate porphyrin levels and correlation to skin manifestations in modern dialysis era. Methods The study cohort included adult hemodialysis patients from a single center tertiary medical center. All patients underwent a full skin examination, completed the Dermatology Life Quality Index questioner, and provided a blood sample for porphyrin levels assessment. Results A total of 94 adult hemodialysis patients were recruited to the study. No clinical PCT was diagnosed. Porphyrin levels did not correlate with any clinical or dialysis quality parameters. Conclusions In modern hemodialysis era, possibly due to improved porphyrins' metabolism and dialysis removal, PCT is much less prevalent among hemodialysis patients than previously reported in the past.
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Barua SK, Patel S, Sarma D, Phukan M, Bagchi PK. Renal Transplantation Could Reverse Dialysis-Associated Porphyria. Cureus 2022; 14:e28482. [PMID: 36176837 PMCID: PMC9512316 DOI: 10.7759/cureus.28482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/20/2022] Open
Abstract
Pseudoporphyria (PP) is a relatively infrequent, photodistributed bullous dermatosis that clinically, histopathologically, and immunologically resembles porphyria cutanea tarda (PCT), but is not accompanied by porphyrin abnormalities in the serum, urine, or stool. It was initially described in patients with renal failure on dialysis as 'bullous dermatosis of hemodialysis.' Pseudoporphyria has been seen in patients with end-stage renal disease on hemodialysis. No treatment has proved efficacious in the management of pseudoporphyria. However, N-acetylcysteine has been anecdotally reported to be effective in the management of hemodialysis-related pseudoporphyria and other porphyric diseases. Our patient had developed multiple skin lesions all over the body when hemodialysis started. The lesions were erythematous with fluid-filled vesicles, and bullae with cutaneous fragility that were evaluated and diagnosed as pseudoporphyria. The patient was treated with available all medication in the literature but was not relieved. However, all skin lesions completely healed within 22 days post renal transplantation. Renal transplantation proved to be the cure for dialysis-induced pseudoporphyria resistant to conventional drug therapy.
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Affiliation(s)
| | | | - Debanga Sarma
- Urology, Gauhati Medical College & Hospital, Guwahati, IND
| | - Mandeep Phukan
- Urology, Gauhati Medical College & Hospital, Guwahati, IND
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Di Bartolomeo L, Irrera N, Campo GM, Borgia F, Motolese A, Vaccaro F, Squadrito F, Altavilla D, Condorelli AG, Motolese A, Vaccaro M. Drug-Induced Photosensitivity: Clinical Types of Phototoxicity and Photoallergy and Pathogenetic Mechanisms. FRONTIERS IN ALLERGY 2022; 3:876695. [PMID: 36238932 PMCID: PMC9552952 DOI: 10.3389/falgy.2022.876695] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Drug-induced photosensitivity (DIP) is a common cutaneous adverse drug reaction, resulting from the interaction of ultraviolet radiations, mostly ultraviolet A, with drugs. DIP includes phototoxicity and photoallergy. A phototoxic reaction is obtained when topical and systemic drugs or their metabolites absorb light inducing a direct cellular damage, while a photoallergic reaction takes place when the interaction between drugs and ultraviolet radiations causes an immune cutaneous response. Clinically, phototoxicity is immediate and appears as an exaggerated sunburn, whereas photoallergy is a delayed eczematous reaction. DIP may show several clinical subtypes. In this mini-review we report the pathogenetic mechanisms and causative drugs of DIP. We offer a detailed description of DIP clinical features in its classical and unusual subtypes, such as hyperpigmentation/dyschromia, pseudoporphyria, photo-onycolysis, eruptive teleangiectasia, pellagra-like reaction, lichenoid reaction, photodistributed erythema multiforme and subacute/chronic cutaneous lupus erythematosus. We described how physicians may early recognize and manage DIP, including diagnostic tests to rule out similar conditions. We made suggestions on how to improve sun exposure behaviors of patients at risk of DIP by means of an aware use of sunscreens, protective clothing and recent technologic tools. We highlighted the lack of sun safety programs addressed to patients at risk of DIP, who need a formal education about their condition.
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Affiliation(s)
- Luca Di Bartolomeo
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, Pharmacology, University of Messina, Messina, Italy
| | - Giuseppe Maurizio Campo
- Laboratory of Clinical Biochemistry, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Borgia
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Alfonso Motolese
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
| | - Federico Vaccaro
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, Pharmacology, University of Messina, Messina, Italy
| | - Domenica Altavilla
- Department of Clinical and Experimental Medicine, Pharmacology, University of Messina, Messina, Italy
| | - Alessandra Grazia Condorelli
- S.C. Dermatologia, Azienda USL di Reggio Emilia-IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
- *Correspondence: Alessandra Grazia Condorelli
| | - Alberico Motolese
- S.C. Dermatologia, Azienda USL di Reggio Emilia-IRCCS, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Dermatology, University of Messina, Messina, Italy
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Kowalska J, Rok J, Rzepka Z, Wrześniok D. Drug-Induced Photosensitivity-From Light and Chemistry to Biological Reactions and Clinical Symptoms. Pharmaceuticals (Basel) 2021; 14:723. [PMID: 34451820 PMCID: PMC8401619 DOI: 10.3390/ph14080723] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 02/07/2023] Open
Abstract
Photosensitivity is one of the most common cutaneous adverse drug reactions. There are two types of drug-induced photosensitivity: photoallergy and phototoxicity. Currently, the number of photosensitization cases is constantly increasing due to excessive exposure to sunlight, the aesthetic value of a tan, and the increasing number of photosensitizing substances in food, dietary supplements, and pharmaceutical and cosmetic products. The risk of photosensitivity reactions relates to several hundred externally and systemically administered drugs, including nonsteroidal anti-inflammatory, cardiovascular, psychotropic, antimicrobial, antihyperlipidemic, and antineoplastic drugs. Photosensitivity reactions often lead to hospitalization, additional treatment, medical management, decrease in patient's comfort, and the limitations of drug usage. Mechanisms of drug-induced photosensitivity are complex and are observed at a cellular, molecular, and biochemical level. Photoexcitation and photoconversion of drugs trigger multidirectional biological reactions, including oxidative stress, inflammation, and changes in melanin synthesis. These effects contribute to the appearance of the following symptoms: erythema, swelling, blisters, exudation, peeling, burning, itching, and hyperpigmentation of the skin. This article reviews in detail the chemical and biological basis of drug-induced photosensitivity. The following factors are considered: the chemical properties, the influence of individual ranges of sunlight, the presence of melanin biopolymers, and the defense mechanisms of particular types of tested cells.
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Affiliation(s)
| | | | | | - Dorota Wrześniok
- Department of Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Jagiellońska 4, 41-200 Sosnowiec, Poland; (J.K.); (J.R.); (Z.R.)
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PLASMA VORICONAZOLE CONCENTRATIONS FOLLOWING SINGLE- AND MULTIPLE-DOSE SUBCUTANEOUS INJECTIONS IN WESTERN POND TURTLES ( ACTINEMYS MARMORATA). J Zoo Wildl Med 2021; 52:538-547. [PMID: 34130396 DOI: 10.1638/2020-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2021] [Indexed: 11/21/2022] Open
Abstract
A recently characterized fungal pathogen, Emydomyces testavorans, has been associated with ulcerative shell disease and significant morbidity in Western pond turtles. Voriconazole is a second-generation triazole antifungal medication that prevents fungal growth through disruption of ergosterol synthesis, causing abnormalities in the fungal cell membrane. Preliminary reports of minimum inhibitory concentrations (MIC) indicate that voriconazole is effective in vitro against E. testavorans. Ultraperformance liquid chromatography was used to measure voriconazole plasma concentrations in blood samples from healthy Western pond turtles after administration of a single SC injection of 10 mg/kg and after multiple doses (10 mg/kg SC q48h for seven doses). The data were analyzed using a naïve pooled approach. Mean (SE) observed time to maximum concentration was 2 (0.18) h for a single dose and 50 (2.2) h for multiple doses; the multiple-dose trial observed mean (SE) maximum concentration was 12.4 (2.2) µg/ml, and observed mean (SE) trough concentration was 1.7 (0.7) µg/ml. Multifocal skin sloughing following the single-dose trial was observed in one turtle and there was a significant increase in polychromatophilic cells amongst the study turtles after the multiple-dose voriconazole trial. No other adverse effects were observed. When voriconazole was administered at 10 mg/kg SC q48h, observed trough plasma concentrations were consistently higher than reported E. testavorans MIC concentrations. Further study is needed to determine the clinical safety and in vivo efficacy of this dose in Western pond turtles.
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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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15
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Doolan BJ, Mellerio JE, Semkova K, McGrath JA, Morris-Jones R. Pseudoporphyria induced by ultraviolet radiation. Australas J Dermatol 2019; 61:177-179. [PMID: 31820441 DOI: 10.1111/ajd.13212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Brent J Doolan
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jemima E Mellerio
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kristina Semkova
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John A McGrath
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rachael Morris-Jones
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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16
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Johnson OR, Stewart MF, Bakshi A, Weston P. An unusual bullous eruption: olanzapine induced pseudoporphyria. BMJ Case Rep 2019; 12:12/11/e232263. [DOI: 10.1136/bcr-2019-232263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 27-year-old man with a background of schizophrenia presented during the summer months with a 2-day history of a blistering eruption predominantly affecting his hands, forearms and face. He had not knowingly been exposed to any chemicals or toxins and was otherwise well. Clinical examination revealed multiple, large, tense blisters affecting the sun-exposed sites. Histology subsequently demonstrated subepidermal blisters with minimal inflammation and negative immunofluorescence. Porphyrin biochemistry including faecal, urinary and serum samples were unremarkable and thus a diagnosis of pseudoporphyria was reached. There were no obvious triggers, however, olanzapine (an atypical antipsychotic) had been commenced 2 months previously and was deemed to be the most likely cause. This is the first report of pseudoporphyria being associated with an atypical antipsychotic and highlights the importance of eliciting an accurate drug history by specifically enquiring about any recent medication changes that could account for the clinical presentation.
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17
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Sporadic Porphyria Cutanea Tarda as the Initial Manifestation of Hereditary Hemochromatosis. ACG Case Rep J 2019; 6:e00247. [PMID: 32309465 PMCID: PMC7145215 DOI: 10.14309/crj.0000000000000247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/11/2019] [Indexed: 11/17/2022] Open
Abstract
Porphyria cutanea tarda (PCT) is a skin disorder characterized by abnormal heme synthesis. We present a 45-year-old man with intermittent skin lesions recurring annually for years. Skin biopsy and measurement of serum heme precursors confirmed a diagnosis of PCT. He had persistently elevated alanine and aspartate transferase. He was referred to hematology and had genetic testing with iron studies which also revealed hereditary hemochromatosis (HH). Therapeutic phlebotomy was initiated, which led to resolution of iron overload and skin lesions. We highlight the associated conditions of PCT and HH, their common therapy of phlebotomy, and initial manifestations of HH.
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18
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Chen KL, Kuemmet TJ, Chiu YE. Progressive blistering and hypertrichosis in a young child. Pediatr Dermatol 2019; 36:951-952. [PMID: 31778569 DOI: 10.1111/pde.13977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kristen L Chen
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Travis J Kuemmet
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yvonne E Chiu
- Departments of Dermatology (Pediatric Dermatology) and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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19
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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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20
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Rodriguez-Nava G, Patel A, Youssef D, Youngberg GA, Gonzalez-Estrada A. A Case of Voriconazole-Induced Pseudoporphyria. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:653-654. [PMID: 30266284 DOI: 10.1016/j.jaip.2018.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 08/17/2018] [Accepted: 08/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Archi Patel
- Department of Pathology, Department of Medicine, East Tennessee State University, Johnson City, Tenn
| | - Dima Youssef
- Division of Infectious Diseases, Department of Medicine, East Tennessee State University, Johnson City, Tenn
| | - George A Youngberg
- Department of Pathology, Department of Medicine, East Tennessee State University, Johnson City, Tenn
| | - Alexei Gonzalez-Estrada
- Division of Allergy and Clinical Immunology, Department of Medicine, East Tennessee State University, Johnson City, Tenn.
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21
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Pavanelli GM, Milano SS, Sevignani G, Jung JE, Funke VAM, Nascimento MMD. Furosemide-induced pseudoporphyria in a patient with chronic kidney disease: case report. J Bras Nefrol 2018; 40:287-290. [PMID: 30010691 PMCID: PMC6533947 DOI: 10.1590/2175-8239-jbn-2017-0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/03/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction: Pseudoporphyria is a rare photodermatosis with characteristics similar to
those of porphyria cutanea tarda, without, however, presenting abnormalities
in porphyrin metabolism. Its etiology is related to chronic kidney disease,
ultraviolet radiation and certain medications. The aim of the present study
is to describe a case of furosemide-related pseudoporphyria in a patient
with chronic kidney disease. Case description: A 76-year-old male patient with stage 4 chronic kidney disease and in
continuous use of furosemide presented ulcerated lesions with peripheral
erythema and central hematic crust in the legs. On a skin infection
suspicion, treatment with quinolone and neomycin sulfate was initiated,
without improvement. A biopsy of the lesion was performed, with
histopathological examination demonstrating findings compatible with
porphyria, although the patient did not present high porphyrin levels. The
diagnosis of furosemide-induced pseudoporphyria was then established, with
medication suspension, and there was a significant improvement of the
lesions. Discussion: There are few cases of pseudoporphyria described, but it is believed that
this condition is underdiagnosed, especially in patients with chronic kidney
disease. Both clinical and histopathological findings closely resemble
porphyria, differentiating it from normal levels of porphyrin in plasma,
urine, or feces. Conclusions: Although the lesions are mostly benign, they may increase the morbidity and
mortality of these patients, so a proper diagnosis and early treatment are
extremely important.
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22
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Pallet N, Karras A, Thervet E, Gouya L, Karim Z, Puy H. Porphyria and kidney diseases. Clin Kidney J 2018; 11:191-197. [PMID: 29644058 PMCID: PMC5888040 DOI: 10.1093/ckj/sfx146] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/20/2017] [Indexed: 01/03/2023] Open
Abstract
The kidneys, after the bone marrow and liver, are third in terms of the amounts of haem synthesized daily. Haem is incorporated into haemoproteins that are critical to renal physiology. In turn, disturbances in haem metabolism interfere with renal physiology and are tightly interrelated with kidney diseases. Acute intermittent porphyria causes kidney injury, whereas medical situations associated with end-stage renal disease, such as porphyrin accumulation, iron overload and hepatitis C, participate in the inhibition of uroporphyrinogen decarboxylase and predispose the individual to porphyria cutanea tarda. Even if some of these interactions have been known for a long time, the clinical situations associated with these interrelations have strikingly evolved over time with the advent of new therapeutic strategies for dialysis therapy and a better understanding of the pathophysiological mechanisms of porphyria-associated kidney disease. Physicians should be aware of these interactions. The aim of this review is to summarize the complex interactions between kidney physiology and pathology in the settings of porphyria and to emphasize their often-underestimated importance.
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Affiliation(s)
- Nicolas Pallet
- INSERM U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France.,Service de Néphrologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Biochimie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Karras
- INSERM U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France.,Service de Néphrologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Thervet
- INSERM U1147, Centre Universitaire des Saints Pères, Paris, France.,Université Paris Descartes, Paris, France.,Service de Néphrologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Gouya
- Centre Francais des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France.,INSERM U1149, CNRS ERL 8252, Centre de Recherche sur l'inflammation, Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Zoubida Karim
- INSERM U1149, CNRS ERL 8252, Centre de Recherche sur l'inflammation, Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
| | - Hervé Puy
- Centre Francais des Porphyries, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France.,INSERM U1149, CNRS ERL 8252, Centre de Recherche sur l'inflammation, Université Paris Diderot, Site Bichat, Sorbonne Paris Cité, Paris, France.,Laboratory of Excellence, GR-Ex, Paris, France
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23
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Handler NS, Handler MZ, Stephany MP, Handler GA, Schwartz RA. Porphyria cutanea tarda: an intriguing genetic disease and marker. Int J Dermatol 2017; 56:e106-e117. [PMID: 28321838 DOI: 10.1111/ijd.13580] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 08/10/2016] [Accepted: 01/10/2017] [Indexed: 12/21/2022]
Abstract
Porphyrias are a group of intriguing genetic diseases of the heme pathway, of which porphyria cutanea tarda (PCT) is the most common. Resulting from a defect in enzymes in the porphyria pathway, PCT has been linked to several conditions. Recent studies have demonstrated a change in thinking regarding the human immunodeficiency virus (HIV) and development of PCT. The exacerbation of PCT with contraction of HIV is now believed to result from coinfection from the hepatitis C virus (HCV). Blistering of sun-exposed skin, a classic presenting sign of PCT, is not exclusive to the condition. Cutaneous findings must also trigger physicians to consider additional types of porphyrias, such as variegate porphyria. The diagnosis of pseudoporphyria, which does not result from enzymatic absence, must be considered in patients with photosensitivity and cutaneous bullae. Recent health food trends, such as chlorophyll, have been linked to pseudoporphyria. PCT is a serious condition in which accurate diagnosis is necessary for appropriate management.
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Affiliation(s)
| | - Marc Z Handler
- Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Glenn A Handler
- Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
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24
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Woolf J, Marsden JT, Degg T, Whatley S, Reed P, Brazil N, Stewart MF, Badminton M. Best practice guidelines on first-line laboratory testing for porphyria. Ann Clin Biochem 2017; 54:188-198. [DOI: 10.1177/0004563216667965] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The porphyrias are disorders of haem biosynthesis which present with acute neurovisceral attacks or disorders of sun-exposed skin. Acute attacks occur mainly in adults and comprise severe abdominal pain, nausea, vomiting, autonomic disturbance, central nervous system involvement and peripheral motor neuropathy. Cutaneous porphyrias can be acute or chronic presenting at various ages. Timely diagnosis depends on clinical suspicion leading to referral of appropriate samples for screening by reliable biochemical methods. All samples should be protected from light. Investigation for an acute attack: • Porphobilinogen (PBG) quantitation in a random urine sample collected during symptoms. Urine concentration must be assessed by measuring creatinine, and a repeat requested if urine creatinine <2 mmol/L. • Urgent porphobilinogen testing should be available within 24 h of sample receipt at the local laboratory. Urine porphyrin excretion (TUP) should subsequently be measured on this urine. • Urine porphobilinogen should be measured using a validated quantitative ion-exchange resin-based method or LC-MS. • Increased urine porphobilinogen excretion requires confirmatory testing and clinical advice from the National Acute Porphyria Service. • Identification of individual acute porphyrias requires analysis of urine, plasma and faecal porphyrins. Investigation for cutaneous porphyria: • An EDTA blood sample for plasma porphyrin fluorescence emission spectroscopy and random urine sample for TUP. • Whole blood for porphyrin analysis is essential to identify protoporphyria. • Faeces need only be collected, if first-line tests are positive or if clinical symptoms persist. Investigation for latent porphyria or family history: • Contact a specialist porphyria laboratory for advice. Clinical, family details are usually required.
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Affiliation(s)
- Jacqueline Woolf
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
| | - Joanne T Marsden
- Reference Biochemistry Laboratories, Viapath, King’s College Hospital, London, UK
| | - Timothy Degg
- Department of Clinical Biochemistry, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Sharon Whatley
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
| | - Paul Reed
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Salford, UK
| | - Nadia Brazil
- Department of Biochemistry, St James Hospital, Dublin, Ireland
| | - M Felicity Stewart
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Salford, UK
| | - Michael Badminton
- Department of Medical Biochemistry and Immunology, University Hospital of Wales, Cardiff, UK
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25
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Dodiuk-Gad RP, Chung WH, Shear NH. Adverse Medication Reactions. CLINICAL AND BASIC IMMUNODERMATOLOGY 2017. [PMCID: PMC7123512 DOI: 10.1007/978-3-319-29785-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cutaneous adverse drug reactions (ADRs) are among the most frequent adverse reactions in patients receiving drug therapy. They have a broad spectrum of clinical manifestations, are caused by various drugs, and result from different pathophysiological mechanisms. Hence, their diagnosis and management is challenging. Severe cutaneous ADRs comprise a group of diseases with major morbidity and mortality, reaching 30 % mortality rate in cases of Toxic Epidermal Necrolysis. This chapter covers the terminology, epidemiology, pathogenesis and classification of cutaneous ADR, describes the severe cutaneous ADRs and the clinical and laboratory approach to the patient with cutaneous ADR and presents the translation of laboratory-based discoveries on the genetic predisposition and pathogenesis of cutaneous ADRs to clinical management guidelines.
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26
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LaDuca JR, Bouman PH, Gaspari AA. Nonsteroidal Antiinflammatory Drug-Induced Pseudoporphyria: A Case Series. J Cutan Med Surg 2016. [DOI: 10.1177/120347540200600402] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Pseudoporphyria is a diagnosis that is used when porphyria-like clinical lesions arise in the setting of normal porphyrin levels. This condition was first described in the 1960s and was initially related to the use of certain antibiotic drugs. In 1985, pseudoporphyria was first attributed to the use of nonsteroidal antiinflammatory drugs (NSAIDs). Subsequently, a host of NSAIDs and other drugs have been found to elicit the same clinical entity. The exact mechanism by which certain drugs create clinical lesions resembling porphyria cutanea tarda or erythropoietic protoporphyria is still unknown. A phototoxic mechanism is hypothesized. Objective: We describe six patients diagnosed with pseudoporphyria and detail the diagnostic tests leading to the eventual diagnosis. Results: The patients ranged in age from 27 to 59 years and had a female:male predominance of 2:1. The offending NSAID was DayPro (oxaprozin) for three of the patients, Relafen (nabumetone) for two of the patients, and Aleve (naproxen) for one patient. For each patient, histology and immunofluorescence was either consistent with the diagnosis of porphyria cutanea tarda or nonspecific, while serum, stool, and urine porphyrins did not support that diagnosis. Withdrawal of the offending agent provided relief from the clinical symptoms for each patient. None of our patients were rechallenged with the putative offending drug. However, prolonged avoidance has provided a sustained remission from symptoms in all six patients. Conclusions: Pseudoporphyria is a relatively rarely reported condition. Clinical suspicion with appropriate laboratory and histopathologic findings help to make this diagnosis, and exclude true porphyrias. Rechallenge with the offending drug to produce symptom relapse has been proposed to be helpful in confirming this diagnosis of exclusion. Since all 6 patients with drug-induced pseudoporphyria experienced resolution of their symptoms after discontinuing the offending agent, we propose that this clinical correlation alone is sufficient to confirm this diagnosis. Our observation of six new cases of NSAID-induced pseudoporphyria over a two-year interval suggests that this is not a rare entity.
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Affiliation(s)
- Jeffrey R. LaDuca
- Department of Dermatology, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Peter H. Bouman
- Department of Dermatology, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Anthony A. Gaspari
- Department of Dermatology, School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
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27
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Monteiro AF, Rato M, Martins C. Drug-induced photosensitivity: Photoallergic and phototoxic reactions. Clin Dermatol 2016; 34:571-81. [PMID: 27638435 DOI: 10.1016/j.clindermatol.2016.05.006] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Drug-induced photosensitivity refers to the development of cutaneous disease due to the interaction between a given chemical agent and sunlight. Photosensitivity reactions can be classified as phototoxic or photoallergic. Sometimes, there is an overlap between these two patterns, making their distinction particularly difficult for the clinician. We review the drugs that have been implicated as photosensitizers, the involved mechanism, and their clinical presentations. The main topical agents that cause contact photosensitivity are the nonsteroidal antiinflammatory drugs, whereas the main systemic drugs inducing photosensitivity are antimicrobials, nonsteroidal antiinflammatory agents, and cardiovascular drugs. Drug-induced photosensitivity remains a common clinical problem and is often underdiagnosed.
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Affiliation(s)
- Ana Filipe Monteiro
- Department of Dermatovenereology, Hospital Distrital de Santarém EPE, Santarém, Portugal.
| | - Margarida Rato
- Department of Dermatovenereology, Hospital Distrital de Santarém EPE, Santarém, Portugal
| | - César Martins
- Department of Dermatovenereology, Hospital Distrital de Santarém EPE, Santarém, Portugal
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28
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Abstract
Pseudoporphyria (PP) is used to describe a photodistributed bullous disorder with clinical and histologic features of porphyria cutanea tarda (PCT) but without accompanying biochemical porphyrin abnormalities. Medications, excessive sun and ultraviolet radiation exposure, have all been reported to develop PP. We report a case of PP in a 49-year-old man with CKD stage 3a, caused due to torsemide intake. This is probably the first reported case of PP developing in a dialysis naive patient CKD due to torsemide intake from India.
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Affiliation(s)
- S Quaiser
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - R Khan
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
| | - A S Khan
- Department of Medicine, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
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29
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Garg T, Barara M, Chander R, Meena S, Agarwal S. Pseudoporphyria: A Case Report. Indian J Dermatol 2015; 60:324. [PMID: 26120194 PMCID: PMC4458981 DOI: 10.4103/0019-5154.156480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Taru Garg
- Department of Dermatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E-mail:
| | - Meenu Barara
- Department of Dermatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E-mail:
| | - Ram Chander
- Department of Dermatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E-mail:
| | - Surekha Meena
- Department of Dermatology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. E-mail:
| | - Shilpi Agarwal
- Department of Pathology, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India
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30
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Velioglu A, Ergun T, Ozener C. Pseudoporphyria in a Peritoneal Dialysis Patient. Perit Dial Int 2015; 35:234-5. [DOI: 10.3747/pdi.2014.00309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Arzu Velioglu
- Department of Internal Medicine, Division of Nephrology School of Medicine Istanbul, Turkey
| | - Tulin Ergun
- Department of Dermatology Marmara University, School of Medicine Istanbul, Turkey
| | - Cetin Ozener
- Department of Internal Medicine, Division of Nephrology School of Medicine Istanbul, Turkey
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31
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Masmoudi A, Hajjaji Darouiche M, Ben Salah H, Ben Hmida M, Turki H. Cutaneous abnormalities in patients with end stage renal failure on chronic hemodialysis. A study of 458 patients. J Dermatol Case Rep 2014; 8:86-94. [PMID: 25621088 DOI: 10.3315/jdcr.2014.1182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 01/13/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cutaneous manifestations occurring in patients with end stage renal failure on hemodialysis are polymorphic and diverse. OBJECTIVE The aim of our study was to assess the prevalence and characteristics of different cutaneous manifestations in patients on hemodialysis. PATIENTS AND METHODS We led a transverse investigation of all patients on hemodialysis in 12 haemodialysis centres of Sfax (Tunisia). We examined 458 patients (254 men and 204 women). The hemodialysis history ranged from 6 months to 24 years. A total of 394/458 (86%) patients had cutaneous abnormalities. These included pruritus (56.6% of patients), paleness (60.7%), xerosis (52.8%), hyperpigmentation or hypopigmentation (38.4%), venous dilation near the fistula (22.2%), eczema in the fistula area (14.8%), half-and-half nails (13.5%), onychodystrophy (6.1%), subungual hemorrhage (4.5%), leukonychia (4.5%), stomatitis (5.6%), xerostomia (3.2%), gingivitis (2.4%), uremic breath (2.1%), and skin calcificatins (0.4%). Nephrogenic fibrosing dermopathy was not detected in any of our patients. CONCLUSIONS Pruritus, paleness, dry skin as well as hyperpigmentation and hypopigmentation are the most frequent skin abnormalities observed in hemodialysis patients. The early recognition of some cutaneous conditions associated with end stage renal failure and hemodialysis may allow early therapeutic intervention and decrease morbidity.
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Affiliation(s)
| | | | - Haifa Ben Salah
- Department of Dermatology, Hedi Chaker Hospital, Sfax, Tunisia
| | | | - Hamida Turki
- Department of Dermatology, Hedi Chaker Hospital, Sfax, Tunisia
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32
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Mahon C, Purvis D, Laughton S, Bradbeer P, Teague L. Imatinib mesylate-induced pseudoporphyria in two children. Pediatr Dermatol 2014; 31:603-7. [PMID: 24920470 DOI: 10.1111/pde.12380] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Imatinib mesylate was the first of several tyrosine kinase inhibitors approved for use in the treatment of a number of human cancers. Adverse cutaneous reactions to imatinib are common. Pseudoporphyria has been infrequently reported in adults undergoing imatinib therapy for chronic myeloid leukemia. We present two children with pseudoporphyria induced by imatinib therapy for hematologic malignancies. In view of the burgeoning use of imatinib in children, physicians should be aware that pseudoporphyria may develop as a consequence of imatinib therapy.
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Affiliation(s)
- Caroline Mahon
- Department of Paediatric Dermatology, Starship Children's Health, Auckland, New Zealand
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33
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Rossi E, Borchard K, Cole JM. Pseudoporphyria following self-medication with chlorophyll. Australas J Dermatol 2014; 56:47-8. [PMID: 25123581 DOI: 10.1111/ajd.12198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/12/2014] [Indexed: 11/30/2022]
Abstract
Two cases of pseudoporphyria are described in which the clinical features of porphyria cutanea tarda occurred in the absence of abnormalities in porphyrin metabolism. Both patients presented with skin fragility and bullae on the dorsal aspect of the hands. The patients consumed a commercial liquid chlorophyll drink in which we detected fluorescent compounds with characteristics typical of previously described chlorophyll derived photosensitisers.
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Affiliation(s)
- Enrico Rossi
- Pathwest Laboratory Medicine, QE II Medical Centre, Australia
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Horner ME, Alikhan A, Tintle S, Tortorelli S, Davis DMR, Hand JL. Cutaneous porphyrias part I: epidemiology, pathogenesis, presentation, diagnosis, and histopathology. Int J Dermatol 2014; 52:1464-80. [PMID: 24261722 DOI: 10.1111/ijd.12305] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The porphyrias are a group of disorders characterized by defects in the heme biosynthesis pathway. Many present with skin findings including photosensitivity, bullae, hypertrichosis, and scarring. Systemic symptoms may include abdominal pain, neuropsychiatric changes, anemia, and liver disease. With advances in DNA analysis, researchers are discovering the underlying genetic causes of the porphyrias, enabling family members to be tested for genetic mutations. Here we present a comprehensive review of porphyria focusing on those with cutaneous manifestations. In Part I, we have included the epidemiology, pathogenesis, presentation, diagnosis, and histopathology. Treatment and management options will be discussed in Part II.
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Affiliation(s)
- Mary E Horner
- Department of Dermatology, Baylor University Medical Center, Dallas, TX, USA
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Sanz-Motilva V, Martorell-Calatayud A, Llombart B, Requena C, Serra-Guillén C, Nagore E, Guillén C, Traves V, Sanmartín O. Sunitinib-induced pseudoporphyria. J Eur Acad Dermatol Venereol 2014; 29:1848-50. [PMID: 24813651 DOI: 10.1111/jdv.12539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- V Sanz-Motilva
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
| | | | - B Llombart
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
| | - C Requena
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
| | - C Serra-Guillén
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
| | - E Nagore
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
| | - C Guillén
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
| | - V Traves
- Department of Pathology, Instituto Valenciano de Oncología, Valencia, Spain
| | - O Sanmartín
- Department of Dermatology, Instituto Valenciano de Oncología, Valencia, Spain
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Fotosensibilidad por tiazidas. ACTAS DERMO-SIFILIOGRAFICAS 2014; 105:359-66. [DOI: 10.1016/j.ad.2013.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 01/05/2013] [Accepted: 01/17/2013] [Indexed: 12/27/2022] Open
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Turnbull N, Callan M, Staughton RCD. Diclofenac-induced pseudoporphyria; an under-recognized condition? Clin Exp Dermatol 2014; 39:348-50. [DOI: 10.1111/ced.12313] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- N. Turnbull
- Pathology Department; Warwick Hospital; Warwick UK
| | - M. Callan
- Department of Rheumatology; Chelsea and Westminster Hospital; London UK
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Gyldenløve M, Due E, Jonkman MF, Faurschou A. Pseudoporphyria - a case report. J Eur Acad Dermatol Venereol 2014; 29:827. [PMID: 24612384 DOI: 10.1111/jdv.12433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 01/31/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M Gyldenløve
- Department of Dermato-Allergology, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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Heramb L, Hallan S, Aasarød K. Bruk av diuretika ved nyresykdom. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:840-4. [DOI: 10.4045/tidsskr.13.0721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Pérez NO, Esturo SV, Viladomiu EDA, Moreno AJ, Valls AT. Pseudoporphyria induced by imatinib mesylate. Int J Dermatol 2013; 53:e143-4. [DOI: 10.1111/j.1365-4632.2012.05574.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pseudoporphyria Associated with Nonhemodialyzed Renal Insufficiency, Successfully Treated with Oral N-Acetylcysteine. Case Rep Dermatol Med 2013; 2013:271873. [PMID: 23662216 PMCID: PMC3639704 DOI: 10.1155/2013/271873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 03/18/2013] [Indexed: 11/17/2022] Open
Abstract
Pseudoporphyria (PP) is a relatively rare, photodistributed bullous dermatosis that resembles porphyria cutanea tarda (PCT), but it is not accompanied by porphyrin abnormalities in the serum, urine, or stool. It was initially described in renal failure patients on dialysis. Thereafter, it has been associated with several aetiological factors. We report a case of PP in a 67-year-old woman with mild renal failure, successfully treated with N-acetylcysteine. This is the second reported case of PP developing in nondialyzed chronic renal failure. Such cases support the view that renal impairment itself may play a more important aetiological role in developing PP than it was originally considered.
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Lupi O, Rezende L, Zangrando M, Sessim M, Silveira CB, Sepulcri MAS, Duarte DJ, Cardim P, Fernandes MM, Santos ODR. Cutaneous manifestations in end-stage renal disease. An Bras Dermatol 2012; 86:319-26. [PMID: 21603815 DOI: 10.1590/s0365-05962011000200015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 08/20/2010] [Indexed: 11/21/2022] Open
Abstract
The prevalence of chronic kidney disease has increased over the last years. The effects of this disease are complex and may lead to dysfunction of multiple organs, including the skin, with most patients presenting with at least one dermatologic alteration. Sometimes these symptoms can be the first clear sign of kidney disease. This article discusses the skin manifestations related to severe renal impairment or end-stage renal disease (ESRD), which are divided into nonspecific and specific, and reviews the clinical features, etiopathogenesis and therapeutic options for these dermatoses. Early recognition and treatment reduce morbidity and improve these patients' quality of life.
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Affiliation(s)
- Omar Lupi
- Dermatology Service of the General Polyclinic of Rio de Janeiro and at the Internal Medicine Service (10th Ward) - School of Medicine and Surgery, Federal University of Rio de Janeiro State (UNIRIO) - Rio de Janeiro (RJ), Brazil
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Guiotoku MM, Pereira FDP, Miot HA, Marques MEA. Pseudoporfiria induzida pela diálise tratada com N-acetilcisteína oral. An Bras Dermatol 2011; 86:383-5. [DOI: 10.1590/s0365-05962011000200031] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 07/31/2009] [Indexed: 11/21/2022] Open
Abstract
Pseudoporfiria é dermatose bolhosa rara, semelhante clínica e histopatologicamente à porfiria cutânea tardia. Acomete, principalmente, pacientes renais crônicos em diálise peritoneal ou hemodiálise. Medicamentos também podem ser envolvidos na etiologia. O diagnóstico e o manejo desta entidade é um desafio para os dermatologistas. Os autores demonstram um caso de pseudoporfiria, relacionada à diálise, com evolução favorável após o uso de N-acetilcisteína oral.
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Lee CC, Lin JL, Hsieh HH, Yen TH. Pseudoporphyria in a haemodialysis patient. Clin Kidney J 2010; 3:592-3. [PMID: 25949478 PMCID: PMC4421408 DOI: 10.1093/ndtplus/sfq150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 07/27/2010] [Indexed: 11/14/2022] Open
Affiliation(s)
- Cheng-Chia Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ja-Liang Lin
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsiang-Hung Hsieh
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Abstract
Porphyria cutanea tarda (PCT) is a vesiculobullous skin disorder characterized by a defect in heme biosynthesis. Reduced activity of the hepatic enzyme uroporphyrinogen decarboxylase (URO-D) results in accumulation of photosensitive porphyrins; this ultimately leads to the skin fragility and blistering that is characteristic of this disease. The majority of cases of PCT are associated with acquired deficiencies of the enzyme URO-D, secondary to hepatic injury precipitated by medications or infections. Less commonly, PCT has been documented in patients with end-stage renal disease. The pathogenesis of PCT in long-term hemodialysis (HD) has been attributed to many factors, but the following mechanisms have been implicated: (i) decreased hepatic URO-D activity due to suppressive effects of iron and other hepatotoxins and (ii) poor porphyrin clearance by renal replacement therapies. We report a case of PCT that developed in a patient on maintenance HD for 4 years. He had a history of hepatitis C and evidence of iron overload. However, as the patient was anemic, therapeutic phlebotomy was problematic and therefore erythrocyte-stimulating agents were maximized to mobilize iron stores and allow phlebotomy. With this treatment, the patient's skin lesions improved in conjunction with decreasing ferritin levels.
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Affiliation(s)
- Madhavi E Ryali
- Section of Nephrology, Rush University Medical Center, Chicago, Illinois 60607-1878, USA
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Berghoff AT, English JC. Imatinib mesylate–induced pseudoporphyria. J Am Acad Dermatol 2010; 63:e14-6. [DOI: 10.1016/j.jaad.2010.01.060] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 01/25/2010] [Accepted: 01/27/2010] [Indexed: 11/24/2022]
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Kochs C, Mühlenstädt E, Neumann N, Hanneken S. Solariuminduzierte Pseudoporphyrie und Porphyria variegata als seltene Differenzialdiagnosen der Porphyria cutanea tarda. Hautarzt 2009; 60:790-3. [DOI: 10.1007/s00105-009-1846-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Timmer-de Mik L, Kardaun SH, Kramer MHH, Hayes DP, Bousema MT. Imatinib-induced pseudoporphyria. Clin Exp Dermatol 2009; 34:705-7. [DOI: 10.1111/j.1365-2230.2008.02985.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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