Diagnosis and management of porphyria

The Effects of Diet, Dietary Supplements, Drugs and Exercise on Physical, Diagnostic Values of Urine Characteristics

Background/Objectives: This review summarizes the current knowledge about factors that affect the physical characteristics of urine. It highlights proper urine sample collection and displays factors like diet, hydration status, and medications that can alter urine color, odor, clarity, specific gravity and pH. Results: Urinalysis is a minimally invasive examination of a patient's health, especially concerning nephrological and endocrinological abnormalities, as well as dietary habits and stimulants used. Certain deviations in appearance, composition or frequency/pain during urination may indicate an ongoing disease process in the body. Based on laboratory results, further medical treatment is determined. The reason for a change in the color of the urine, for its clouding or intense odor may be a disease, as well as the consumption of food, medication, intensive physical exercise or inadequate hydration of the body. Well-standardized procedures for collecting, transporting, preparing and analyzing samples should become the basis for an effective diagnostic strategy in urinalysis. It is worth noting that pharmacists in pharmaceutical care are often the first people to whom a patient turns for health advice and for the interpretation of simple laboratory tests. Acquiring the ability to interpret the results of laboratory tests and the principles of proper sampling for laboratory tests is indispensable in the process of possible counseling and providing reliable answers to patients' questions. Conclusions: Although urinalysis is not recommended as a routine screening tool for the general population, it can prove to be a valuable source of patient health data in some cases as the data will be useful to physicians and pharmacists to more effectively diagnose and better care for patients.

Palliative Care Aspects of Acute Intermittent Porphyria - A Case Report

Acute intermitttent porphyria belongs to a rare group of diseases hallmarked by deficient biosynthesis of heme. It carries a significant symptom burden, both physical and emotional,and therefore palliative care has emerged as an essential tool in the armamentarium of porphyria management . It takes care of the patient as a whole and caters to all aspects that the disease process demands. There are many lacunae in the literature regarding the palliative management of porphyria. We are reporting a case of a 16-year-old female who presented with severe abdominal pain, lower backache and symmetrical bilateral lower limb pain to the palliative ward referred by the neurology department for supportive care. This case describes the palliative care aspects of porphyria management which was successfully provided in the palliative care unit right from referral till the last. A multidisciplinary palliative care team managed the patient, and the necessary interventions were provided to the patient and family. Palliative acre in AIP needs to be emphasized, and palliative care services need to be utilized in these cases. The unavailability of specific treatment measure, heme, in countries like India further emphasizes the need for long-term supportive care for the patient and family. The case shows the importance of palliative care throughout the disease course as it is a chronic disease with significant morbidity and carries a heavy symptom burden. This case provides the insight that rather than conventional management alone for such chronic diseases, palliative care should be incorportated. Early integration with palliative care helps in exploring all the domains of disease. This is one of the first cases reported highlighting palliative care in porphyria , bridging the gap in the literature.

Understanding Hepatic Porphyrias: Symptoms, Treatments, and Unmet Needs

Hepatic porphyrias are a group of metabolic disorders that are characterized by overproduction and accumulation of porphyrin precursors in the liver. These porphyrins cause neurologic symptoms as well as cutaneous photosensitivity, and in some cases patients can experience life-threatening acute neurovisceral attacks. This review describes the acute hepatic porphyrias in detail, including acute intermittent porphyria, hereditary coproporphyria, and variegate porphyria, as well as the hepatic porphyrias with cutaneous manifestations such as porphyria cutanea tarda and hepatoerythropoietic porphyria. Each section will cover disease prevalence, clinical manifestations, and current therapies, including strategies to manage symptoms. Finally, we review new and emerging treatment modalities, including gene therapy through use of adeno-associated vectors and chaperone therapies such as lipid nanoparticle and small interfering RNA-based therapeutics.

[Rare diseases in anesthesia : Knowledge mining and core points of perioperative anesthesiological care]

Due to refined and new diagnostic possibilities and improved medical care, in the future anesthesiologists will be more frequently confronted with patients suffering from rare diseases. As the physicians providing perioperative care often have little or no experience with the diseases of such patients, the access to high-quality specific literature is essential. In this respect they must be able to assess and classify the quality of the information which is predominantly available online, especially as when evidence-based knowledge is available, it is only available to a very limited extent. Patients with rare diseases mostly present with recurring problem constellations. A systematic assignment to the most important problem areas (airway, circulation, metabolism, etc.) as well as a structured and interdisciplinary approach are decisive for a successful perioperative treatment of these patients. Due to low prevalence, lack of personal experience and lack of evidence-based data, anesthesia in patients with SE is an absolute challenge, especially in time-critical situations.

Endogenous Photosensitizers in Human Skin

Endogenous photosensitizers play a critical role in both beneficial and harmful light-induced transformations in biological systems. Understanding their mode of action is essential for advancing fields such as photomedicine, photoredox catalysis, environmental science, and the development of sun care products. This review offers a comprehensive analysis of endogenous photosensitizers in human skin, investigating the connections between their electronic excitation and the subsequent activation or damage of organic biomolecules. We gather the physicochemical and photochemical properties of key endogenous photosensitizers and examine the relationships between their chemical reactivity, location within the skin, and the primary biochemical events following solar radiation exposure, along with their influence on skin physiology and pathology. An important take-home message of this review is that photosensitization allows visible light and UV-A radiation to have large effects on skin. The analysis presented here unveils potential causes for the continuous increase in global skin cancer cases and emphasizes the limitations of current sun protection approaches.

[Trigger-free anesthesia : Indications and safe application]

The safe anesthesiological care of patients with neuromuscular diseases poses a particular challenge for anesthetists. Only a small group of muscle diseases and syndromes are associated with an increased risk of malignant hyperthermia and therefore require trigger-free anesthetic procedures avoiding volatile anesthetics and succinylcholine. These diseases are frequently associated with mutations in the RYR1, CACNA1S or STAC-3 genes. In other neuromuscular diseases, anesthetic-induced rhabdomyolysis can occur. Therefore, volatile anesthetics should be avoided in these patients in addition to the contraindication for succinylcholine. In other neuromuscular diseases the risk of a propofol infusion syndrome or myotonic crises can be elevated or the duration of the effect of non-depolarizing muscle relaxants can be changed in an incalculable way. In every case an individual anesthetic aproach including the avoidance of potential pharmacological or non-pharmacological triggers is essential for the safety of the patients.

Clinical features of Japanese patients with acute hepatic porphyria

Acute hepatic porphyria (AHP) is a family of rare genetic diseases of heme biosynthesis characterized by severe neurovisceral attacks. The clinical characteristics of patients with AHP as well as the prevalence of AHP in Japan are not well understood. The objectives of this study were to describe clinical characteristics of AHP at time of diagnosis in Japanese patients and to estimate the prevalence of AHP. Patients with porphyria were selected from Japan's Medical Data Vision health care claims database between April 2008 and June 2020. Patient characteristics before and at time of AHP diagnosis were evaluated. Prevalence per 100 000 was estimated during the study period. A total of 391 cases of AHP were included. At time of AHP diagnosis, mean age was 44 years, and the most common type was acute intermittent porphyria. Median time to diagnosis was 3 months, but some patients remained undiagnosed for several years. The most common complications included metabolic disorders (54%) and diabetes mellitus (39%). In addition, the well-known complications of AHP, including hypertension (22%) and malignant neoplasms of digestive organs (22%), were observed. About 10% of patients received medications that may have aggravated porphyria attacks. The estimated prevalence of AHP in Japan during the study period was 1.18 cases per 100 000 population. At time of diagnosis, many patients with AHP in Japan are already experiencing a high burden of disease-related complications. Raising AHP awareness may aid physicians in providing an earlier diagnosis and reducing lifetime disease burden.

Porphyrin Accumulation and Biliary Lithiasis Causing Diffusely Black Livers in Broiler Chickens

Two 7-wk-old broiler chickens presented with uniformly black livers upon postslaughter examination, while all other organs as well as their carcasses were grossly normal. No clinical signs were reported by the field veterinarian prior to slaughter. Other broiler chickens within the same flock were unaffected. Microscopically, the liver exhibited variably sized, globoid concrements that were dark brown to green-brown and birefringent under polarized light. Ultrastructurally, concrements consisted of radially arranged electron-dense crystal spicules. Concrements were located in hepatocytes, within ecstatic bile canaliculi, or surrounded by small clusters of macrophages. Liquid chromatography assay determined the presence of protoporphyrin IX in the affected liver.

Two 7-wk-old broiler chickens presented with uniformly black livers upon postslaughter examination, while all other organs as well as their carcasses were grossly normal. No clinical signs were reported by the field veterinarian prior to slaughter. Other broiler chickens within the same flock were unaffected. Microscopically, the liver exhibited variably sized, globoid concrements that were dark brown to green-brown and birefringent under polarized light. Ultrastructurally, concrements consisted of radially arranged electron-dense crystal spicules. Concrements were located in hepatocytes, within ecstatic bile canaliculi, or surrounded by small clusters of macrophages. Liquid chromatography assay determined the presence of protoporphyrin IX in the affected liver.

[Anesthesia in patients with acute porphyria]

Porphyrias are a group of rare, mostly inherited metabolic disorders of heme biosynthesis. Each type of porphyria results from a specific deficiency of one of the pathway enzymes, causing a characteristic accumulation and excretion of heme precursors. Diagnosis is confirmed by the biochemical detection of these porphyrins and the precursors in urine, feces and blood. Porphyrias can be classified into acute and non-acute forms. The clinical presentation is unspecific and includes acute neurovisceral and/or cutaneous symptoms. The latent phase can evolve into a potentially life-threatening acute crisis, which is often misdiagnosed. The four acute hepatic porphyrias are relevant for anesthesiologists as precipitating factors are commonly found in the perioperative setting. Safe anesthetic management in cases of known porphyria is possible by adherence to current recommendations. The immediate administration of heme arginate as specific treatment for acute attacks is decisive for the outcome.

Optical clearing of tissues: Issues of antimicrobial phototherapy and drug delivery

This review presents principles and novelties in the field of tissue optical clearing (TOC) technology, as well as application for optical monitoring of drug delivery and effective antimicrobial phototherapy. TOC is based on altering the optical properties of tissue through the introduction of immersion optical cleaning agents (OCA), which impregnate the tissue of interest. We also analyze various methods and kinetics of delivery of photodynamic agents, nanoantibiotics and their mixtures with OCAs into the tissue depth in the context of antimicrobial and antifungal phototherapy. In vitro and in vivo studies of antimicrobial phototherapies, such as photodynamic, photothermal plasmonic and photocatalytic, are summarized, and the prospects of a new TOC technology for effective killing of pathogens are discussed.

The effects of alcohol and illicit drug use on the skin

Early identification of cutaneous manifestations of alcohol and illicit drug use can aid in the diagnosis and management of these uses, as well as their sequelae. In addition, the effects of alcohol and illicit drug use on the skin can result in significant morbidity. Alcohol misuse can present with jaundice, pruritus, pigmentary alterations, urticaria, hair and nail changes, and oral changes. It is also a risk factor for skin cancer and infections. Vascular disturbances associated with alcohol misuse include telangiectasias, palmar erythema, caput medusae, and flushing. Diseases related to alcohol misuse include nutritional deficiencies, porphyria cutanea tarda, psoriasis, seborrheic dermatitis, nummular dermatitis, and rosacea. Other conditions seen in alcohol misuse include Dupuytren contracture, Peyronie disease, and pancreatitis. Dermatologists should also be aware of hepatotoxic medications that are commonly prescribed for skin diseases so as to avoid initiating hepatoxicity in patients who use alcohol. Illicit drug use can manifest with cutaneous fibrosis, scarring, granulomas, ulceration, pruritus, infections, cocaine-levamisole-induced vasculitis, tooth decay, and oral disease. By recognizing the cutaneous stigmata of alcohol and illicit drug use, dermatologists can aid in the identification and treatment of patients suffering from these addictions.

Healthcare Utilization and Cost Burden of Porphyria in Commercially Insured Adults in the United States

OBJECTIVES

The healthcare burden associated with porphyria remains unevaluated despite the associated increased risks of morbidity and mortality. We aimed to assess the healthcare utilization and cost burdens of porphyria in the United States (US) using real-world claims data.

METHODS

We performed a case-control analysis of adults in the Truven Health MarketScan^® Commercial Claims database (2010-2015). Using propensity scores, 2788 porphyria cases were matched 1:1 to porphyria-free controls with chronic liver disease. Total and service-specific parameters were quantified for the 12 months before porphyria diagnosis versus the 12 months after diagnosis and over the 12 months following a randomly selected date for controls. Wilcoxon signed rank tests and McNemar tests were used to examine incremental differences in burden between cases and controls. Adjusted multivariable generalized linear regression models were used to compare healthcare burdens for cases versus controls.

RESULTS

Relative to the 12 months before porphyria diagnosis, the following 12 months had more claims per patient (35.94 vs 39.67; p < 0.0001) and increased per-patient healthcare costs (US$21,308 vs US$27,270; p < 0.0001). Porphyria cases incurred US$7839 more in total unadjusted costs compared with controls in the 12 months after index date. Compared with controls, cases also had more claims (39.67 vs 34.81), primarily due to inpatient admissions (1.80 vs 0.78) and outpatient visits (21.41 vs 17.98). Cases also had higher healthcare costs for inpatient admissions (US$8882 vs US$4674) and outpatient visits (US$12,378 vs US$9801).

CONCLUSION

Porphyria is associated with significant healthcare costs and utilization burdens driven by increased inpatient admissions, outpatient visits, and pharmaceutical claims.

Comparative characterization of sun exposed and sun protected skin-derived mesenchymal-like stem cells in variegate porphyria and healthy individuals

BACKGROUND AND PURPOSE

We hypothesized that upon sun exposure, a sub-population of primary skin-derived mesenchymal-like cells is deleteriously affected and thus contribute to the chronic inflammatory state in autosomal recessive variegate porphyria patients. The aim of this study was to isolate and characterize the mesenchymal-like stem cells from different areas of the skin in a porphyria patient (sun exposed, SE, and sun protected, SP) and to compare them with cells from a healthy individual.

METHODS

The proliferation rate and the migration ability of SE and SP cells were evaluated in the presence of an antioxidant compound, N-acetylcysteine. A co-culture of SE-damaged cells with the conditioned medium from the enriched mesenchymal cell-like SP population was performed in order to regenerate the dermal injured tissue after sun exposure in patients.

RESULTS

Results showed that the percentage of CD105⁺ cells varies between 3.9% in SP and 5% in SE of the healthy individual and between 3.6% and 1.4% in SP and SE in the porphyria patient, respectively. The osteogenic differentiation potential was lower in the porphyria patient when compared to the control. Furthermore, the expression of stem cell markers was more pronounced in SE than in SP cells of both control and porphyria. The use of N-acetyl cysteine did not show any beneficial effects on porphyria SE cells. Treatment with SP-conditioned medium slightly increased the expression of stem cell markers in SE of porphyria patient.

CONCLUSION

In conclusion, the pool of mesenchymal stem-like SE cells is affected in variegate porphyria patient along with modification of their self-renewal and differentiation properties.

Porfiria intermitente aguda como desencadenante de síndrome de Guillain-Barre

Introducción. La porfiria es un conjunto de enfermedades metabólicas que tienen como base fisiopatológica la acumulación de precursores tóxicos. Su similitud clínica con enfermedades como el síndrome de Guillain-Barre puede retrasar el diagnostico, aumentando la posibilidad de complicaciones.Presentación del caso. Paciente femenino quien presentó síntomas inespecíficos de porfiria y síndrome de Guillain-Barre. La mujer fue evaluada de manera integral y recibió tratamiento para ambas patologías, respondiendo de manera inusual.Conclusión. La respuesta farmacológica atípica encontrada y la relación causa-efecto entre ambas entidades se justifica a la luz de sus procesos fisiopatológicos y la respuesta inmune desencadenada por los mismos.

Structure–activity relationship of porphyrin-induced photoinactivation with membrane function in bacteria and erythrocytes

We analyzed the structure–activity relationship of natural porphyrins and the related analogs with the photoinactivation of membrane function in bacteria and erythrocytes.

Antiepileptic Drugs and Liver Disease

Acute, symptomatic seizures or epilepsy may complicate the course of hepatic disease. Choosing the most appropriate antiepileptic drug in this setting represents a difficult challenge, as most medications are metabolized by the liver. This article focuses on the acute and chronic treatment of seizures in patients with advanced liver disease and reviews the hepatotoxic potential of specific antiepileptic drugs. Newer antiepileptic drugs without, or with minimal, hepatic metabolism, such as levetiracetam, lacosamide, topiramate, gabapentin, and pregabalin should be used as first-line therapy. Medications undergoing extensive hepatic metabolism, such as valproic acid, phenytoin, and felbamate should be used as drugs of last resort. In special circumstances, as in patients affected by acute intermittent porphyria, exposure to most antiepileptic drugs could precipitate attacks. In this clinical scenario, bromides, levetiracetam, gabapentin, and vigabatrin constitute safe choices. For the treatment of status epilepticus, levetiracetam and lacosamide, available in intravenous preparations, are good second-line therapies after benzodiazepines fail to control seizures. Hepatotoxicity is also a rare and unexpected side effect of some antiepileptic drugs. Drugs such as valproic acid, phenytoin, and felbamate, have a well-recognized association with liver toxicity. Other antiepileptic drugs, including phenobarbital, benzodiazepines, ethosuximide, and the newer generations of antiepileptic drugs, have only rarely been linked to hepatotoxicity. Thus physicians should be mindful of the pharmacokinetic profile and the hepatotoxic potential of the different antiepileptic drugs available to treat patients affected by liver disease.

A Comprehensive Rehabilitation Program and Follow-up Assessment for Acute Intermittent Porphyria

Acute intermittent porphyria (AIP) is an infrequent metabolic disease that can cause severe disability or death without timely treatment. A porphyric attack occurs when genetic factors combine with trigger factors, and diagnosis may be delayed owing to nonspecific symptoms. Recovery from AIP can be nearly or fully complete with proper treatment, which includes intravenous hematin administration, the control of trigger factors, and a comprehensive rehabilitation program. The aim of this case report was to describe the clinical evolution of a 43-year-old woman with AIP and a polyneuropathy. The patient was treated through a comprehensive rehabilitation program, with outcomes evaluated by the Functional Independence Measure and the Berg scales during rehabilitation and postdischarge follow-up. After completing the comprehensive rehabilitation program, the patient achieved a satisfactory level of functional independence, allowing for social and work reintegration. We conclude that an early and multidisciplinary approach is essential for regaining optimal functionality after AIP.

Acute intermittent porphyria presenting with posterior reversible encephalopathy syndrome and lateralized periodic discharges plus fast activity on EEG

We report on a 20-year-old patient with a 6-month history of recurrent abdominal pain and a 3-day history of vomiting, hypertension, seizures, and encephalopathy. The brain MRI showed posterior reversible encephalopathy syndrome, and continuous EEG (cEEG) monitoring showed lateralized periodic discharges plus fast activity. Comprehensive CSF studies were negative. Because of severe abdominal pain without a definite etiology, we requested urine porphobilinogen and serum and fecal porphyrins, which suggested acute intermittent porphyria (AIP). The patient had a complete resolution of her symptoms with carbohydrate loading and high caloric diet. Acute intermittent porphyria is potentially life-threatening without proper management and prevention of triggers if it is not recognized.

Methotrexate and actinomycin D chemotherapy in a patient with porphyria: a case report

Background

Despite their broadly recommended use as chemotherapeutic agents, the porphyrogenicity of methotrexate and actinomycin D have not been confirmed. Accordingly, it is not known whether these agents are safe for use in patients with porphyria.

Case presentation

In this report, we present a case of an invasive mole with lung metastasis in a 49-year-old Japanese woman who had previously been diagnosed with acute intermittent porphyria at 27 years of age but had no recent history of acute intermittent porphyria attacks. Her serum human chorionic gonadotropin level was elevated 1 month after hysterectomy, and she was referred to our center for chemotherapy. After she received 100 mg of methotrexate, drug eruptions were observed starting on day 3 and grew progressively worse. Erythema and mucosal erosion spread throughout her body, whereupon she was administered prednisolone. In addition, our patient experienced febrile neutropenia and required granulocyte colony- stimulating factor treatment. No changes in our patient’s urinary coproporphyrin or uroporphyrin levels were detected during this entire episode. Methotrexate was replaced by actinomycin D (0.5 mg/body intravenously on days 1–5 every 2 weeks). After five uneventful cycles of actinomycin D, our patient achieved and maintained a normal serum human chorionic gonadotropin level for 3 years.

Conclusions

Methotrexate and actinomycin D did not induce acute porphyric attacks in this patient with acute intermittent porphyria; however, severe adverse effects were noted with methotrexate. Although further investigation is required, our data suggest that these agents are nonporphyrinogenic and can therefore be used to treat patients with comorbid porphyria.

The eye and the skin in nonendocrine metabolic disorders

As metabolism is controlled by the input of genes and the environment, metabolic disorders result from some disturbance in the interaction between genes and environmental factors. Many metabolic disorders consist in congenital enzyme deficiencies, also known as "inborn errors of metabolism," that may be disabling or cause severe illness and death and are predominantly inherited in an autosomal recessive fashion. The deposit in cells and tissues of storage substances from errors in metabolic processes may produce a wide variety of disorders affecting different organs and functions, with different degrees of severity, and often present around the time of birth or early childhood. Distinctive ocular and skin manifestations accompany many metabolic diseases and may provide clues for their diagnosis and evolution.

Mitochondrial energetic defects in muscle and brain of a Hmbs-/- mouse model of acute intermittent porphyria

Acute intermittent porphyria (AIP), an autosomal dominant metabolic disease (MIM #176000), is due to a deficiency of hydroxymethylbilane synthase (HMBS), which catalyzes the third step of the heme biosynthetic pathway. The clinical expression of the disease is mainly neurological, involving the autonomous, central and peripheral nervous systems. We explored mitochondrial oxidative phosphorylation (OXPHOS) in the brain and skeletal muscle of the Hmbs(-/-) mouse model first in the basal state (BS), and then after induction of the disease with phenobarbital and treatment with heme arginate (HA). The modification of the respiratory parameters, determined in mice in the BS, reflected a spontaneous metabolic energetic adaptation to HMBS deficiency. Phenobarbital induced a sharp alteration of the oxidative metabolism with a significant decrease of ATP production in skeletal muscle that was restored by treatment with HA. This OXPHOS defect was due to deficiencies in complexes I and II in the skeletal muscle whereas all four respiratory chain complexes were affected in the brain. To date, the pathogenesis of AIP has been mainly attributed to the neurotoxicity of aminolevulinic acid and heme deficiency. Our results show that mitochondrial energetic failure also plays an important role in the expression of the disease.

Mass-spectrometric profiling of porphyrins in complex biological samples with fundamental, toxicological, and pharmacological applications

Rapid, high-throughput, and quantitative evaluations of biological metabolites in complex milieu are increasingly required for biochemical, toxicological, pharmacological, and environmental analyses. They are also essential for the development, testing, and improvement of new commercial chemical products. We demonstrate the application of ultra-high performance liquid chromatography-mass spectrometry (uHPLC-MS), employing an electrospray ionization source and a high accuracy quadrupole time-of-flight mass analyzer, for the identification and quantification of a series of porphyrin derivatives in liver: a matrix of particular relevance in toxicological or pharmacological testing. Exact mass is used to identify and quantify the metabolites. Chromatography enhances sensitivity and alleviates potential saturation issues by fanning out the contents of a complex sample before their injection into the spectrometer, but is not strictly necessary for the analysis. Extraction and sample treatment procedures are evaluated and matrix effects discussed. Using this method, the known mechanism of action of a well-characterized porphyrinogenic agent was verified in liver extracts from treated rats. The method was also validated for use with bacterial cells. This exact-mass method uses workhorse instruments available in many laboratories, providing a highly flexible alternative to existing HPLC- and MS/MS-based approaches for the simultaneous analysis of multiple compounds in biological media.

Propofol and sevoflurane induce distinct burst suppression patterns in rats

Burst suppression is an EEG pattern characterized by alternating periods of high-amplitude activity (bursts) and relatively low amplitude activity (suppressions). Burst suppression can arise from several different pathological conditions, as well as from general anesthesia. Here we review current algorithms that are used to quantify burst suppression, its various etiologies, and possible underlying mechanisms. We then review clinical applications of anesthetic-induced burst suppression. Finally, we report the results of our new study showing clear electrophysiological differences in burst suppression patterns induced by two common general anesthetics, sevoflurane and propofol. Our data suggest that the circuit mechanisms that generate burst suppression activity may differ among general anesthetics.

Feigning acute intermittent porphyria

Acute intermittent porphyria (AIP) is an autosomal dominant genetic defect in heme synthesis. Patients with this illness can have episodic life-threatening attacks characterized by abdominal pain, neurological deficits, and psychiatric symptoms. Feigning this illness has not been reported in the English language literature to date. Here, we report on a patient who presented to the hospital with an acute attack of porphyria requesting opiates. Diligent assessment of extensive prior treatment records revealed thirteen negative tests for AIP.

Cutaneous porphyrias part I: epidemiology, pathogenesis, presentation, diagnosis, and histopathology

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.

N-alkylprotoporphyrin formation and hepatic porphyria in dogs after administration of a new antiepileptic drug candidate: mechanism and species specificity

A new antiepileptic synaptic vesicle 2a (SV2a) ligand drug candidate was tested in 4-week oral toxicity studies in rat and dog. Brown pigment inclusions were found in the liver of high-dose dogs. The morphology of the deposits and the accompanying liver changes (increased plasma liver enzymes, increased total hepatic porphyrin level, decreased liver ferrochelatase activity, combined induction, and inactivation of cytochrome P-450 CYP2B11) suggested disruption of the heme biosynthetic cascade. None of these changes was seen in rat although this species was exposed to higher parent drug levels. Toxicokinetic analysis and in vitro metabolism assays in hepatocytes showed that dog is more prone to oxidize the drug candidate than rat. Mass spectrometry analysis of liver samples from treated dogs revealed an N-alkylprotoporphyrin adduct. The elucidation of its chemical structure suggested that the drug transforms into a reactive metabolite which is structurally related to a known reference porphyrogenic agent allylisopropylacetamide. That particular metabolite, primarily produced in dog but neither in rat nor in human, has the potential to alkylate the prosthetic heme of CYP. Overall, the data suggested that the drug candidate should not be porphyrogenic in human. This case study further exemplifies the species variability in the susceptibility to drug-induced porphyria.

Variegate porphyria complicated by systemic AA amyloidosis: a case report

We report a Japanese woman with variegate porphyria accompanied by amyloid A (AA) amyloidosis. Arthropathy involving multiple joints occurred at 35 years old and persisted. C-reactive protein was 4.0 mg/dL, but rheumatoid factor was negative. Radiographs did not reveal any loss or narrowing of the joint spaces. Two years later, blister formation after sun exposure and reddish urine were first noted. At the age of 45 years, she developed abdominal pain, nausea, vomiting and seizures. After administration of phenobarbital, reddish urine was noted and muscular weakness progressed to atonic quadraparesis. Porphyria attack was diagnosed from high urinary levels of ∂ aminolevulinic acid and porphobilinogen. At the age of 47 years, hemodialysis was started. At the age of 49 years, progression of her gastrointestinal event resulted in death. Autopsy showed massive deposits of AA amyloidosis in various organs, including the kidneys and digestive tract. Thus, amyloid deposition may have contributed to both end-stage renal failure and her gastrointestinal symptoms. This is the first report about the coexistence of porphyria and AA amyloidosis. Chronic inflammation related to this patient's seronegative arthropathy, although atypical for porphyria, might have contributed to the development of AA amyloidosis.

Manifestations and treatment of the hand in adult congenital erythropoietic porphyria

Congenital erythropoietic porphyria (CEP) is a rare enzymatic disorder of heme metabolism, leading to the accumulation of porphyrins in the skin and subdermal structures. We present the case of a 34-year-old, right-hand-dominant, male patient with CEP. The patient had developed a chronic open subluxation of the left index finger proximal interphalangeal joint due to skin necrosis. We successfully treated the patient with proximal interphalangeal arthrodesis. This case demonstrates that childhood-onset CEP can also manifest in the adult hand. Considering the patient's age, the destructive nature of the disease, and the poor quality of function in older patients with childhood CEP, surgical intervention was necessary to avoid further digital length loss. Although the treatment described in this case report is not uncommon, we found it essential to present this case because the clinical presentation of CEP is rare.

Electrospray ionization on porous spraying tips for direct sample analysis by mass spectrometry: enhanced detection sensitivity and selectivity using hydrophobic/hydrophilic materials as spraying tips

RATIONALE

Despite various porous materials having been widely adopted as spraying tips for direct sample analysis using electrospray ionization mass spectrometry (ESI-MS), the effect of surface property and porosity of spraying tip materials on their analytical performances is not clear. Investigation of their relationships could provide insight into the proper choice and/or design of spraying tip materials for direct sample analysis.

METHODS

The effect of spraying tip materials with different polarities, including polyester and polyethylene (hydrophobic) and wood (hydrophilic), on the detection sensitivity for a variety of compounds, and on the ESI onset voltage, were studied using ESI-MS. The porosity of each type of spraying tip was characterized by scanning electron microscopy (SEM). Factors governing the detection sensitivity were determined based on the correlation of the detection sensitivity to the ESI onset voltage, the polarity, and the porosity of the spraying tip materials.

RESULTS

Hydrophobic tips (i.e., polyester and polyethylene) show better detection sensitivity for polar compounds but not for non-polar compounds, while hydrophilic tips (wooden tips) show the opposite effect. This phenomenon could be due to the difference in interaction between the analytes and the tips, causing the analytes to adsorb on the tip to different extents. In addition, the micro-porous nature of the tips could facilitate solvent diffusion for transporting analytes to the tip and maintain a stable spray for recording MS data. With the proper choice of spraying tip materials, trace amount of analytes at the picomole level can be detected with minimal sample pretreatment.

CONCLUSIONS

Both the polarity and the porosity of the spraying tip materials could significantly affect detection sensitivity for a wide variety of analytes. With proper choice of spraying tip material, ESI on a porous spraying tip could be a sensitive method for the direct analysis of daily life samples.

Schizoaffective disorder with missed diagnosis of acute porphyria: a case report and overview

Acute porphyrias are often misdiagnosed and most commonly present as atypical neuropsychiatric symptoms or acute abdominal pain. Clinicians should suspect acute porphyrias in patients presenting with variable neuropsychiatric symptoms and unexplained pain. Proper identification can lead to less iatrogenicity associated with porphyrinogenic agents, appropriate management, and a better patient outcome. The case of a patient with hereditary coproporphyria, one of the acute porphyrias, is presented to illustrate the broad manifestations, unsuspected diagnosis, and difficulties in management.

Antiepileptic drug monotherapy versus polytherapy: pursuing seizure freedom and tolerability in adults

PURPOSE OF REVIEW

Despite the availability of many new antiepileptic drugs (AEDs), only around 50% of people with epilepsy will become seizure free on their first drug. This article explores treatment options and issues influencing whether AEDs should be substituted or combined in the remainder of the patient population.

RECENT FINDINGS

Prior to the introduction of novel AEDs, it was generally opined that combining traditional agents did not necessarily lead to an improvement in seizure control and might increase the propensity for side effects. Newer AEDs, many with different mechanisms of action, have increased the potential for polytherapy regimens, although robust data to support or refute this therapeutic strategy are sparse. It seems sensible to substitute rather than combine when the first AED produces an idiosyncratic reaction, is poorly tolerated at a low/moderate dose or shows no efficacy. Polytherapy may be preferred if the patient tolerates their first or second AED well, but with a suboptimal response, particularly when there is an identifiable anatomical substrate for the seizures. AED selection requires consideration of many factors some of which are discussed in this study.

SUMMARY

There are no definitive answers on whether to combine or substitute AEDs. Different strategies are required for different scenarios in different patients.

Acute intermittent porphyria: a diagnostic challenge

Acute intermittent porphyria is a metabolic disorder rarely seen in prepubertal children. A delay in diagnosis of acute intermittent porphyria is common because of variable and nonspecific symptoms. We report an 8-year-old boy with right hemimegalencephaly and intractable seizures, who presented with dark-colored urine, hypertension, increasing lethargy, fluctuating seizures, and poor oral intake. He subsequently developed hyponatremia secondary to syndrome of inappropriate antidiuretic hormone secretion. His urinalysis was negative for red blood cells, and a random urine porphobilinogen level was elevated. Further biochemical and molecular testing confirmed the diagnosis of acute intermittent porphyria. His antiepileptic medications were discontinued and hemin administered, with dramatic clinical improvement. The diagnosis of acute intermittent porphyria was challenging because of his underlying neurologic condition. This case highlights the variable presentation of acute intermittent porphyria and emphasizes the importance of considering the diagnosis even in young patients with underlying neurologic conditions when they present with nonspecific neurovisceral symptoms or with unexplained neurologic deterioration.