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Erwin AL, Desnick RJ. Congenital erythropoietic porphyria: Recent advances. Mol Genet Metab 2019; 128:288-297. [PMID: 30685241 PMCID: PMC6597325 DOI: 10.1016/j.ymgme.2018.12.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder characterized by photosensitivity and by hematologic abnormalities in affected individuals. CEP is caused by mutations in the uroporphyrinogen synthase (UROS) gene. In three reported cases, CEP has been associated with a specific X-linked GATA1 mutation. Disease-causing mutations in either gene result in absent or markedly reduced UROS enzymatic activity. This in turn leads to the accumulation of the non-physiologic and photoreactive porphyrinogens, uroporphyrinogen I and coproporphyrinogen I, which damage erythrocytes and elicit a phototoxic reaction upon light exposure. The clinical spectrum of CEP depends on the level of residual UROS activity, which is determined by the underlying pathogenic loss-of-function UROS mutations. Disease severity ranges from non-immune hydrops fetalis in utero to late-onset disease with only mild cutaneous involvement. The clinical characteristics of CEP include exquisite photosensitivity to visible light resulting in bullous vesicular lesions which, when infected lead to progressive photomutilation of sun-exposed areas such as the face and hands. In addition, patients have erythrodontia (brownish discoloration of teeth) and can develop corneal scarring. Chronic transfusion-dependent hemolytic anemia is common and leads to bone marrow hyperplasia, which further increases porphyrin production. Management of CEP consists of strict avoidance of exposure to visible light with sun-protective clothing, sunglasses, and car and home window filters. Adequate care of ruptured vesicles and use of topical antibiotics is indicated to prevent superinfections and osteolysis. In patients with symptomatic hemolytic anemia, frequent erythrocyte cell transfusions may be necessary to suppress hematopoiesis and decrease marrow production of the phototoxic porphyrins. In severe transfection-dependent cases, bone marrow or hematopoietic stem cell transplantation has been performed, which is curative. Therapeutic approaches including gene therapy, proteasome inhibition, and pharmacologic chaperones are under investigation.
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Affiliation(s)
| | - Robert J. Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
- Address all Correspondence to: R. J. Desnick, PhD, MD, Dean for Genetic and Genomic Medicine Professor and Chairman Emeritus, Department of Genetic and Genomic Sciences Icahn School of Medicine at Mount Sinai New York, NY 10029, Phone: (212) 659-6700 Fax: (212) 360-1809
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Maakaron J, Abdel Malak O, Itani S, Cappellini M, Di Pierro E, Brancaleoni V, Granata F, Taher A. A puzzling mutation in congenital erythropoietic porphyria and an association with β-thalassaemia trait. Br J Dermatol 2012; 167:697-9. [DOI: 10.1111/j.1365-2133.2012.10954.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kontos AP, Ozog D, Bichakjian C, Lim HW. Congenital erythropoietic porphyria associated with myelodysplasia presenting in a 72-year-old man: report of a case and review of the literature. Br J Dermatol 2003; 148:160-4. [PMID: 12534613 DOI: 10.1046/j.1365-2133.2003.05040.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disease owing to the deficient activity of uroporphyrinogen III synthase, the fourth enzyme in the porphyrin-haem synthetic pathway. Of the porphyrias, it is the most mutilating type, usually presenting early in life. To date, 12 documented cases of adult onset CEP have been reported. We report the second oldest documented patient with late onset CEP with incidental findings of thrombocytopenia and myelodysplasia with bone-marrow sideroblasts. We further discuss several current and future treatment options for this therapeutically challenging disease.
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Affiliation(s)
- A P Kontos
- Department of Dermatology, Henry Ford Health System, Detroit, MI 48202, USA
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Affiliation(s)
- Robert J Desnick
- Department of Human Genetics, Mount Sinai School of Medicine, Box 1498, New York University, Fifth Avenue and 100th Street, New York, NY 10029, USA.
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Shaw PH, Mancini AJ, McConnell JP, Brown D, Kletzel M. Treatment of congenital erythropoietic porphyria in children by allogeneic stem cell transplantation: a case report and review of the literature. Bone Marrow Transplant 2001; 27:101-5. [PMID: 11244446 DOI: 10.1038/sj.bmt.1702738] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Congenital erythropoietic porphyria (CEP) is a rare autosomal recessive disorder of porphyrin metabolism in which the genetic defect is the deficiency of uroporphyrinogen III cosynthase (UIIIC). Deficiency of this enzyme results in an accumulation of high amounts of uroporphyrin I in all tissues leading to hemolytic anemia, splenomegaly, erythrodontia, bone fragility, exquisite photosensitivity and mutilating skin lesions. We describe the case of a 23-month-old boy who was cured of his CEP by a matched-sibling allogeneic bone marrow transplant, and review the published clinical experience regarding transplantation in this disease. He is alive and disease-free 15 months post transplant. All of his disease manifestations except for the erythrodontia have resolved. His UIIIC level and stool and erythrocyte porphyrin metabolites have almost completely corrected. He is the sixth child reported to be cured of this disease by stem cell transplantation, five cases being long-term survivors. If patients with this disease have an HLA-matched sibling, then stem cell transplantation should be strongly considered because this is currently the only known curative therapy.
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Affiliation(s)
- P H Shaw
- Departments of Pediatrics and Dermatology, Northwestern University Medical School and Children's Memorial Hospital, Chicago, IL, USA
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Abstract
Congenital erythropoietic porphyria is a rare autosomal-recessive disorder of the porphyrin metabolism caused by the homozygous defect of uroporphyrinogen III cosynthase. High amounts of uroporphyrin I accumulate in all cells and tissues, reflected by an increased erythrocyte porphyrin concentration and excretion of high porphyrin amounts in urine and feces. Dermal deposits of uroporphyrin frequently induce a dramatic phototoxic oxygen-dependent skin damage with extensive ulcerations and mutilations. Splenomegaly and hemolytic anemia are typical internal symptoms. Skeletal changes such as osteolysis and calcifications are frequent. To date 130 cases of congenital erythropoietic porphyria have been published and are summarized here. Splenectomy, erythrocyte transfusions, and bone marrow transplantation have shown some beneficial effect. The best therapy is the avoidance of sunlight. In the two patients with congenital erythropoietic porphyria described here, oral administration of the oxygen quenchers ascorbic acid and alpha-tocopherol resulted in an improvement in the reduced hemoglobin and erythrocyte concentrations.
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Affiliation(s)
- C Fritsch
- Department of Dermatology, Heinrich Heine University, Düsseldorf, Germany
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Murphy A, Gibson G, Elder GH, Otridge BA, Murphy GM. Adult-onset congenital erythropoietic porphyria (Günther's disease) presenting with thrombocytopenia. J R Soc Med 1995; 88:357P-358P. [PMID: 7629774 PMCID: PMC1295249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Cutaneous signs of Günther's disease (congenital erythropoietic porphyria) developing 5 years after the onset of symptomatic thrombocytopenia are described in a 65-year-old man. Persistent thrombocytopenia unresponsive to corticosteroids and immunoglobulin necessitated a splenectomy.
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Affiliation(s)
- A Murphy
- Regional Centre of Dermatology, Mater Hospital, Dublin, Eire
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Verstraeten L, Van Regemorter N, Pardou A, de Verneuil H, Da Silva V, Rodesch F, Vermeylen D, Donner C, Noël JC, Nordmann Y. Biochemical diagnosis of a fatal case of Günther's disease in a newborn with hydrops foetalis. EUROPEAN JOURNAL OF CLINICAL CHEMISTRY AND CLINICAL BIOCHEMISTRY : JOURNAL OF THE FORUM OF EUROPEAN CLINICAL CHEMISTRY SOCIETIES 1993; 31:121-8. [PMID: 8490057 DOI: 10.1515/cclm.1993.31.3.121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The birth of a male baby was induced at 32 weeks. In utero, the child presented, inter alia, signs of hydrops, hepatosplenomegaly and anaemia. Two in utero transfusions for correction of the anaemia were performed at 28 and 29 weeks, respectively. The baby rapidly presented respiratory distress with mixed acidosis. Three hours after birth, pink urine was excreted. Signs of icterus necessitated phototherapy, after which photosensitivity occurred. Erythrocytes were fluorescent under long-wavelength UV light. The baby died 24 hours after birth, displaying severe acidosis, a diffuse haemorrhagic syndrome, and repeated brady-cardia which did not respond to isoprenaline. The analysis of porphyrins in urine, blood and faeces of the baby gave the following results: 1) uroporphyrin (I and III isomeric series) was increased in urine and faeces, with traces in erythrocytes and plasma; 2) heptacarboxyporphyrin I was found mainly in urine and much less in erythrocytes, plasma and faeces; 3) coproporphyrin I was increased in urine, erythrocytes, plasma and faeces, and 4) 5-aminolaevulinic acid and porphobilinogen in urine and plasma were within the reference ranges. Determination of the enzymes of haem biosynthesis in erythrocytes and lymphocytes showed that both parents possessed only 50% of the normal activity of cosynthase. A previously described point mutation in codon 73 was observed in one parent. Fatal cases of neonatal Günther's disease are extremely rare and such an observation, according to our knowledge, is probably one of the first described.
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Affiliation(s)
- L Verstraeten
- Department of Clinical Biochemistry, Université Catholique de Louvain, Cliniques Universitaries St. Luc, Bruxelles, Belgique
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Affiliation(s)
- D A Paslin
- Department of Dermatology, University of California School of Medicine, San Francisco
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Yamauchi K, Kushibiki Y. Pyridoxal 5-phosphate therapy in a patient with myelodysplastic syndrome and adult onset congenital erythropoietic porphyria. Br J Haematol 1992; 81:614-5. [PMID: 1390252 DOI: 10.1111/j.1365-2141.1992.tb03002.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- K Yamauchi
- Department of Internal Medicine, Tokai University School of Medicine, Japan
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Muniesa AM, Herrero C, Lecha M, Mascaró JM. Usefulness of chromatographic analysis of fecal porphyrins in the diagnosis of porphyrias. J Dermatol 1990; 17:199-204. [PMID: 2365901 DOI: 10.1111/j.1346-8138.1990.tb01626.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- A M Muniesa
- Department of Dermatology, Hospital Clinic, University of Barcelona, Spain
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Abstract
A 51-year-old Japanese man and his 56-year-old sister of consanguineous parents had skin lesions with areas of dark-brown pigmentation and blisters with minimal trauma on sun-exposed skin which resembled those seen in porphyria cutanea tarda. Their fresh urine was wine-red in colour and fluoresced with ultraviolet light. The peripheral blood contained fluorocytes and porphyrin analysis of the red blood cells, urine and faeces of the patients revealed an increase of the isotype I of uro- and coproporphyrin and normal concentrations of delta-aminolaevulinate and porphobilinogen, suggesting the diagnosis of erythropoietic porphyria. No other members of this family had symptoms or biochemical findings suggestive of porphyria. We consider these two cases to be that of late onset erythropoietic porphyria.
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Affiliation(s)
- Y Horiguchi
- Department of Dermatology, Faculty of Medicine, Kyoto University, Japan
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Sassa S, Kappas A. Genetic, metabolic, and biochemical aspects of the porphyrias. ADVANCES IN HUMAN GENETICS 1981; 11:121-231. [PMID: 7023204 DOI: 10.1007/978-1-4615-8303-5_3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Romeo G. Enzymatic defects of hereditary porphyrias: an explanation of dominance at the molecular level. Hum Genet 1977; 39:261-76. [PMID: 340378 DOI: 10.1007/bf00295419] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In four of the five autosomal dominant porphyrias four different partial enzymatic defects of the porphyrin biosynthetic pathway have been discovered in the last few years. With the exception of protoporphyria, the residual enzymatic activity in carriers of these defects is approximately equal to 50% of that found in controls. In each case the pattern of excretion of porphyrin and/or porphyrin precursors reflects the stie of the partial metabolic block. There are indications, at least in intermittent acute porphyria, that the degree of penetrance of the disorder varies according to the level of phenotypic expression, being highest for the enzyme deficiency, lower for the excretion of precursors and lowest for the clinical symptoms. It is proposed that environmental factors, and probably also gene interaction, are the cause of the different degrees of penetrance.
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