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Petrides PE, Klein M, Schuhmann E, Torkler H, Molitor B, Loehr C, Obermeier Z, Beykirch MK. Severe homocysteinemia in two givosiran-treated porphyria patients: is free heme deficiency the culprit? Ann Hematol 2021; 100:1685-1693. [PMID: 34050373 PMCID: PMC8195940 DOI: 10.1007/s00277-021-04547-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/01/2021] [Indexed: 12/11/2022]
Abstract
Givosiran is a novel approach to treat patients with acute intermittent porphyrias (AIP) by silencing of ∂-ALA-synthase 1, the first enzyme of heme biosynthesis in the liver. We included two patients in the Envision study who responded clinically well to this treatment. However, in both patients, therapy had to be discontinued because of severe adverse effects: One patient (A) developed local injection reactions which continued to spread all over her body with increasing number of injections and eventually caused a severe systemic allergic reaction. Patient B was hospitalized because of a fulminant pancreatitis. Searching for possible causes, we also measured the patients plasma homocysteine (Hcy) levels in fluoride-containing collection tubes: by LC-MS/MS unexpectedly, plasma Hcy levels were 100 and 200 in patient A and between 100 and 400 μmol/l in patient B. Searching for germline mutations in 10 genes that are relevant for homocysteine metabolism only revealed hetero- and homozygous polymorphisms in the MTHFR gene. Alternatively, an acquired inhibition of cystathionine-beta-synthase which is important for homocysteine metabolism could explain the plasma homocysteine increase. This enzyme is heme-dependent: when we gave heme arginate to our patients, Hcy levels rapidly dropped. Hence, we conclude that inhibition of ∂-ALA-synthase 1 by givosiran causes a drop of free heme in the hepatocyte and therefore the excessive increase of plasma homocysteine. Hyperhomocysteinemia may contribute to the adverse effects seen in givosiran-treated patients which may be due to protein-N-homocysteinylation.
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Affiliation(s)
- Petro E. Petrides
- EPNET Center Munich, Hematology Oncology Center, University of Munich Medical School, Zweibrückenstr.2, 80331 Munich, Germany
| | - Michael Klein
- Klinikum Vest, Dorstener Strasse 151, 45657 Recklinghausen, Germany
| | - Elfriede Schuhmann
- Homocysteine Laboratory, Labor Becker und Kollegen, Führichstr.70, 81671 Munich, Germany
| | - Heike Torkler
- Genetics Laboratory, MVZ Eberhard, Brauhausstr.4, 44137 Dortmund, Germany
| | - Brigitte Molitor
- Eurofin Laboratories, Rotthauser Str 19, 45879 Gelsenkirchen, Germany
| | - Christian Loehr
- Department of Radiology, Klinikum Vest, Dorstener Strasse 151, 45657 Recklinghausen, Germany
| | - Zahra Obermeier
- EPNET Center Munich, Hematology Oncology Center, University of Munich Medical School, Zweibrückenstr.2, 80331 Munich, Germany
| | - Maria K. Beykirch
- EPNET Center Munich, Hematology Oncology Center, University of Munich Medical School, Zweibrückenstr.2, 80331 Munich, Germany
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Lahiji AP, Anderson KE, Chan A, Simon A, Desnick RJ, Ramanujam VMS. 5-Aminolevulinate dehydratase porphyria: Update on hepatic 5-aminolevulinic acid synthase induction and long-term response to hemin. Mol Genet Metab 2020; 131:418-423. [PMID: 33199206 DOI: 10.1016/j.ymgme.2020.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND 5-Aminolevulinic acid dehydratase (ALAD) porphyria (ADP) is an ultrarare autosomal recessive disease, with only eight documented cases, all of whom were males. Although classified as an acute hepatic porphyria (AHP), induction of the rate limiting hepatic enzyme 5-aminolevulinic acid synthase-1 (ALAS1) has not been demonstrated, and the marrow may also contribute excess 5-aminolevulinic acid (ALA). Two patients have died and reported follow up for the others is limited, so the natural history of this disease is poorly understood and treatment experience limited. METHODS We report new molecular findings and update the clinical course and treatment of the sixth reported ADP patient, now 31 years old and the only known case in the Americas, and review published data regarding genotype-phenotype correlation and treatment. RESULTS Circulating hepatic 5-aminolevulinic acid synthase-1 (ALAS1) mRNA was elevated in this case, as in other AHPs. Gain of function mutation of erythroid specific ALAS2 - an X-linked modifying gene in some other porphyrias - was not found. Seven reported ADP cases had compound heterozygous ALAD mutations resulting in very low residual ALAD activity and symptoms early in life or adolescence. One adult with a germline ALAD mutant allele developed ADP in association with a clonal myeloproliferative disorder, polycythemia vera. CONCLUSIONS Elevation in circulating hepatic ALAS1 and response to treatment with hemin indicate that the liver is an important source of excess ALA in ADP, although the marrow may also contribute. Intravenous hemin was effective in most reported cases for treatment and prevention of acute attacks of neurological symptoms.
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MESH Headings
- 5-Aminolevulinate Synthetase/blood
- 5-Aminolevulinate Synthetase/genetics
- Adolescent
- Adult
- Child
- Child, Preschool
- Female
- Heme/genetics
- Hemin/administration & dosage
- Humans
- Infant
- Infant, Newborn
- Liver/metabolism
- Liver/pathology
- Male
- Middle Aged
- Mutation/genetics
- Porphobilinogen/metabolism
- Porphobilinogen Synthase/blood
- Porphobilinogen Synthase/deficiency
- Porphobilinogen Synthase/genetics
- Porphyria, Acute Intermittent/blood
- Porphyria, Acute Intermittent/drug therapy
- Porphyria, Acute Intermittent/genetics
- Porphyria, Acute Intermittent/pathology
- Porphyrias, Hepatic/blood
- Porphyrias, Hepatic/drug therapy
- Porphyrias, Hepatic/genetics
- Porphyrias, Hepatic/pathology
- RNA, Messenger/blood
- Young Adult
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Affiliation(s)
- Arian Pourmehdi Lahiji
- Departments of Preventive Medicine and Population Health, and Internal Medicine (Division of Gastroenterology and Hepatology), University of Texas Medical Branch, Galveston, Texas, USA
| | - Karl E Anderson
- Departments of Preventive Medicine and Population Health, and Internal Medicine (Division of Gastroenterology and Hepatology), University of Texas Medical Branch, Galveston, Texas, USA.
| | - Amy Chan
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Amy Simon
- Alnylam Pharmaceuticals, Cambridge, MA, USA
| | - Robert J Desnick
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - V M Sadagopa Ramanujam
- Departments of Preventive Medicine and Population Health, and Internal Medicine (Division of Gastroenterology and Hepatology), University of Texas Medical Branch, Galveston, Texas, USA
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Abstract
OBJECTIVE Penetrance, predictive value and female patients' perspectives on genetic testing were evaluated among Finnish patients with acute porphyria. We conducted a retrospective study to evaluate prognosis among at-risk female family members depending on the primary method of diagnosis. METHODS The penetrance was calculated among 23 genetically heterogeneous families selected from the Finnish porphyria registry (n = 515, AIP 333; VP 182). We included kindreds with ≥9 patients in a family (range 9-23 patients, total 216 AIP; 129 VP). In 2015, the registry included 164 living female subjects between 14 and 85 years of age. A questionnaire was sent to 143 women, of whom 107 (75%, AIP 67; VP 40) replied. Female at-risk relatives (AIP 54; VP 30) were divided into two groups based on the primary method of diagnosis: mutation analysis (Group A, n = 40) or biochemical analysis (Group B, n = 44). RESULTS Mean penetrance for all acute symptoms was 35% among AIP and 40% among VP families. In both study groups, the penetrance was higher among female (AIP 50%; VP 44%) than male patients (AIP 17%; VP 33%). Penetrance for hospitalized attacks was 30% among AIP families (range 10-80%, for women 41%) and 25% in VP (range 0-50%, for women 27%) demonstrating wide variations among families even with the similar genotype. Acute porphyria was diagnosed at the median age of 26 years (range 0-76 years) among female patients, commonly after the onset of acute symptoms. Diagnostic delay was an average of 7.4 years (range 1-30 years). Acute symptoms occurred at the median age of 24 years (range 10-57 years) and the first hospitalization at the median age of 26.5 years (range 15-57 years). At the onset of symptoms, 38% of the women were ≤ 20 years of age. According to the life table analysis, acute attacks occurred mainly during the following five years after the diagnosis and the attack risk diminished after 35 years of age. The annual risk for hospitalization due to an acute attack during fertile years was lower in Group A than Group B (0.002 vs. 0.010, p = .018), but the risk of all subsequent acute symptoms did not diminish (Group A 0.017 vs. Group B 0.019, p = .640). The cumulative risk of acute symptoms among asymptomatic patients at the time of diagnosis was 26.7% for Group A and 58.3% for Group B. The cumulative risk of the first subsequent attack requiring hospitalization after the diagnosis among all at-risk relatives was similarly less frequent in Group A than in Group B (OR 0.180; 95% CI 0.041-0.789, p = .041). If attacks were followed among symptomatic patients only, attack-free years were more frequent in Group A than in Group B. Patients preferred genetic screening before puberty to minimize the risk of acute symptoms and genetic discrimination was rare. 44% of the patients reported social, psychological or physical impairment due to acute hepatic porphyria, emphasizing the importance of supporting patients' emotional and resilience capacity. CONCLUSIONS Among female at-risk relatives the annual risk for hospitalization due to an acute attack is <1% and for acute symptoms <2% during the fertile years. Genetic testing of relatives diminishes the risk of acute attacks. Diagnosis before symptom onset is key for subjects to remain asymptomatic during follow-up, and genetic screening should be done earlier than currently.
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Affiliation(s)
- K Baumann
- Helsinki University Hospital, Department of Obstetrics and Gynecology, Finland; Helsinki University Hospital, Department of Medicine, Finland
| | - R Kauppinen
- Helsinki University Hospital, Department of Medicine, Finland.
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Yang J, Han F, Chen Q, Zhu T, Zhao Y, Yu X, Zhu H, Cao J, Li X. Reversible splenial lesion syndrome (RESLES) due to acute intermittent porphyria with a novel mutation in the hydroxymethylbilane synthase gene. Orphanet J Rare Dis 2020; 15:98. [PMID: 32306994 PMCID: PMC7168860 DOI: 10.1186/s13023-020-01375-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/01/2020] [Indexed: 02/06/2023] Open
Abstract
Background Reversible splenial lesion syndrome (RESLES) is a clinico-radiological syndrome characterized by the presence of reversible lesions specifically involving the splenium of the corpus callosum (SCC). The cause of RESLES is unknown. However, infectious-related mild encephalitis/encephalopathy (MERS) with a reversible splenial lesion remains the most common cause of reversible splenial lesions. Acute intermittent porphyria (AIP) is an autosomal dominant disorder caused by a partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the heme biosynthetic pathway. It can affect the autonomic, peripheral, and central nervous system. Result In this study, we report a 20-year-old woman with AIP who presented with MRI manifestations suggestive of RESLES, she had a novel HMBS nonsense mutation, a G to A mutation in base 594, which changed tryptophan to a stop codon (W198*). Conclusion: To the best of our knowledge, this is only one published case of RELES associated with AIP.
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Affiliation(s)
- Jing Yang
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fei Han
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qianlong Chen
- State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tienan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongqiang Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Cao
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoqing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Tabaro I, Reimondo G, Osella G, Aurizi C, Caraci P, Barbieri L, Giachino DF, Sirchia F, Terzolo M. Novel mutation of PPOX gene in a patient with abdominal pain and syndrome of inappropriate antidiuresis. Endocrine 2018. [PMID: 29516370 DOI: 10.1007/s12020-018-1569-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Acute porphyrias are metabolic disorders of heme biosynthesis characterized by acute life-threatening attacks. The diagnosis is often missed since clinical presentation is aspecific mimicking other medical and surgical conditions. Variegate porphyria (VP) is an autosomal dominant inherited disease with incomplete penetrance due to decreased activity of the Protoporphyrinogen Oxydase (PPOX) gene; most VP mutations are family specific. We report the case of a 40 year-old woman who presented many times to the emergency department complaining of unexplained abdominal pain and laboratory investigations showed repeatedly hyponatremia. Syndrome of inappropriate antidiuresis (SIAD) was confirmed and measurement of urine porphobilinogen and delta-aminolevulinic acid disclosed the diagnosis of acute porphyria. The genetic analysis of PPOX gene was performed. METHODS The entire coding sequence and exon/intron boundaries of PPOX gene were amplified in 5 different Polymerase Chain Reaction (PCR) fragments. In silico prediction of the pathogenicity of the mutation was determined by using different tools, Polyphen2, SNPs&GO, SNPs3D. RESULTS The genetic analysis of PPOX gene revealed a novel missense variant c.1376 G > A (p.Cys459Tyr) in heterozygous state. The same variant was later found in one of her cousins with skin lesions and other three younger asymptomatic relatives. We provided evidence that this novel mutation is likely to be pathogenetic. CONCLUSIONS Our case highlights the importance of considering VP in the differential diagnosis of SIAD and underlines the role of genetic screening in the management of such patients. The finding of a novel mutation of PPOX gene in our index case has allowed to recognize an affected family.
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Affiliation(s)
- Isabella Tabaro
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Torino, Italy
| | - Giuseppe Reimondo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Torino, Italy.
| | - Giangiacomo Osella
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Torino, Italy
| | - Caterina Aurizi
- Porphyria Centre San Gallicano Institute IRCCS IFO, Rome, Italy
| | - Pasquale Caraci
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Torino, Italy
| | - Luca Barbieri
- Porphyria Centre San Gallicano Institute IRCCS IFO, Rome, Italy
| | - Daniela Francesca Giachino
- Department of Clinical and Biological Sciences, Medical Genetics Unit, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Torino, Italy
| | - Fabio Sirchia
- Department of Medical Sciences, Medical Genetics Unit, AOU Città della Scienza e della Salute, Turin, University of Turin, Torino, Italy
| | - Massimo Terzolo
- Department of Clinical and Biological Sciences, Internal Medicine, San Luigi Gonzaga Hospital, Orbassano, University of Turin, Torino, Italy
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Indika NLR, Kesavan T, Dilanthi HW, Jayasena KLSPKM, Chandrasiri NDPD, Jayasinghe IN, Piumika UMT, Vidanapathirana DM, Gunarathne KDAV, Dissanayake M, Jasinge E, Arachchi WK, Doheny D, Desnick RJ. Many pitfalls in diagnosis of acute intermittent porphyria: a case report. BMC Res Notes 2018; 11:552. [PMID: 30071891 PMCID: PMC6071335 DOI: 10.1186/s13104-018-3615-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute intermittent porphyria is a rare autosomal dominant disorder caused by a deficiency of the enzyme, hydroxymethylbilane synthase. Recognition of acute neurovisceral attacks can be difficult due to the nonspecific nature of symptoms. CASE PRESENTATION We report a case of 33-year-old male patient who presented with recurrent episodes of severe abdominal pain, nausea, vomiting, constipation and numbness of bilateral lower limb extremities. These nonspecific neurovisceral attacks were subject to medical and surgical misdiagnoses of acute appendicitis, sinus tachycardia, renal calculi, drug-induced acute interstitial nephritis and two episodes of partial intestinal obstruction. The sixth acute attack raised the suspicion of an acute porphyria. Watson and Schwartz test was positive for porphobilinogen in urine. Mutation analysis by DNA sequencing of the extracted DNA of the proband revealed a previously reported missense mutation, c.517C>T encoding p.R173W in the HMBS gene, confirming the diagnosis of Acute Intermittent Porphyria. Four out of five family members who underwent targeted mutation analyses were mutation-positive. CONCLUSION The most common clinical presentation of Acute Intermittent Porphyria is abdominal pain with neurovisceral manifestations which are common to several medical, psychiatric and surgical pathologies. This leads to underdiagnosis and misdiagnosis of this disorder, incorrect management, and severe complications. Therefore, a high index of suspicion and awareness of front line laboratory investigations are important for diagnosis. Definitive diagnosis enables implementation of strategies to prevent acute attacks, and also triggers genetic testing and genetic counseling of at-risk family members.
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Affiliation(s)
- N L R Indika
- Department of Biochemistry, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, 10250, Sri Lanka.
| | - T Kesavan
- Teaching Hospital Karapitiya, Galle, Sri Lanka
| | - H W Dilanthi
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - K L S P K M Jayasena
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - N D P D Chandrasiri
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - I N Jayasinghe
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - U M T Piumika
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - D M Vidanapathirana
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - K D A V Gunarathne
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | | | - E Jasinge
- Department of Chemical Pathology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | | | - D Doheny
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, USA
| | - R J Desnick
- Department of Genetics and Genomic Sciences, Mount Sinai School of Medicine, New York, USA
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7
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Abstract
PURPOSE OF REVIEW The aim of this paper is to review psychiatric manifestations, comorbidities, and psychopharmacological management in individuals with acute porphyria (AP). RECENT FINDINGS Recent literature begins to clarify associations between AP, schizophrenia, bipolar disorder, and other psychopathology. Broad psychiatric symptoms have been associated to acute porphyria (AP) and correspond to a spectrum of heterogeneous manifestations such as anxiety, affective alterations, behavioral changes, personality, and psychotic symptoms. These symptoms may be difficult to identify as being related to porphyria since symptoms may arise at any time during the disease process. In addition, these patients may present psychiatric conditions secondary to the disease, such as adjustment disorder and substance use disorders. Timely diagnosis and appropriate treatment of psychiatric manifestations positively impact the course of the disease.
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8
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Yang J, Yang H, Chen Q, Hua B, Zhu T, Zhao Y, Yu X, Zhu H, Zhou Z. Reversible MRI findings in a case of acute intermittent porphyria with a novel mutation in the porphobilinogen deaminase gene. Blood Cells Mol Dis 2016; 63:21-24. [PMID: 28011390 DOI: 10.1016/j.bcmd.2016.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/15/2016] [Accepted: 12/16/2016] [Indexed: 11/25/2022]
Abstract
Acute intermittent porphyria (AIP) is an autosomal dominant disorder caused by a partial deficiency of porphobilinogen deaminase (PBGD), the third enzyme in the of heme biosynthetic pathway. It can affect the autonomic, peripheral, and central nervous system. Posterior reversible encephalopathy syndrome is a clinicoradiological entity characterized by headache, seizures, altered consciousness, and visual disorder associated with potentially reversible neuroradiological abnormalities predominantly in the parieto-occipital lobes. Establishing accurate diagnoses of the patient and asymptomatic family members with AIP involves identifying the PBGD enzyme mutations directly. In this study, we report a 28-year-old woman with acute intermittent porphyria who presented with radiological manifestations suggestive of posterior reversible encephalopathy syndrome, she had a novel PBGD frame shift mutation, base 875 and 876 have been deleted resulting in glutamine to a stop codon (Gln292fs), in a Chinese family.
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Affiliation(s)
- Jing Yang
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Hang Yang
- State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Qianlong Chen
- State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Baolai Hua
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Tienan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Yongqiang Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
| | - Zhou Zhou
- State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Diagnostic Laboratory Service, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, China
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9
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Balwani M, Singh P, Seth A, Debnath EM, Naik H, Doheny D, Chen B, Yasuda M, Desnick RJ. Acute Intermittent Porphyria in children: A case report and review of the literature. Mol Genet Metab 2016; 119:295-299. [PMID: 27769855 PMCID: PMC5154763 DOI: 10.1016/j.ymgme.2016.10.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/13/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
Acute Intermittent Porphyria (AIP), an autosomal dominant inborn error of heme metabolism, typically presents in adulthood, most often in women in the reproductive age group. There are limited reports on the clinical presentation in children, and in contrast to the adults, most of the reported pediatric cases are male. While acute abdominal pain is the most common presenting symptom in children, seizures are commonly seen and may precede the diagnosis of AIP. As an example, we report a 9year old developmentally normal pre-pubertal boy who presented with acute abdominal pain, vomiting and constipation followed by hyponatremia, seizures, weakness and neuropathy. After a diagnostic odyssey, his urine porphobilinogen was found to be significantly elevated and genetic testing showed a previously unreported consensus splice-site mutation IVS4-1G>A in the HMBS gene confirming the diagnosis of AIP. Here, we discuss the clinical presentation in this case, and 15 reported pediatric cases since the last review 30years ago and discuss the differential diagnosis and challenges in making the diagnosis in children. We review the childhood-onset cases reported in the Longitudinal Study of the Porphyrias Consortium. Of these, genetically and biochemically confirmed patients, 11 of 204 (5%) reported onset of attacks in childhood. Most of these patients (91%) reported recurrent attacks following the initial presentation. Thus, AIP should be considered in the differential diagnosis of children presenting with unexplained abdominal pain, seizures, weakness and neuropathy.
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Affiliation(s)
- Manisha Balwani
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, United States
| | - Preeti Singh
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, India
| | - Anju Seth
- Department of Pediatrics, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, India
| | - Ekta Malik Debnath
- Department of Biochemistry, Kalawati Saran Children's Hospital, Lady Hardinge Medical College, India
| | - Hetanshi Naik
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, United States
| | - Dana Doheny
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, United States
| | - Brenden Chen
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, United States
| | - Makiko Yasuda
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, United States
| | - Robert J Desnick
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, United States.
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10
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Abstract
Acute intermittent porphyria (AIP) is an inherited metabolic disorder characterized by the accumulation of toxic metabolites of the heme pathway. It rarely presents in the prepubertal age group. AIP often presents with nonspecific and nonlocalizing symptoms. Moreover, several commonly used medications and stress states are known to precipitate an attack. We present the case of a previously healthy 5 years female who was diagnosed as acute central nervous system infection/inflammation at admission. It was the presence of red flags that led to a correct diagnosis. Besides supportive management, a dedicated search for intravenous hemin (chemically heme arginate, aminolevulinic acid synthase inhibitor, and drug of choice) was attempted. Unexpected help was rendered by doctors from a medical college in Gujarat, and two ampoules could be obtained. The patient received three doses of intravenous hemin; however, she succumbed later. This case is presented for the diagnostic and therapeutic challenges faced in developing countries.
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Affiliation(s)
- Chhaya Divecha
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Milind S Tullu
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Akanksha Gandhi
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Chandrahas T Deshmukh
- Department of Pediatrics, Pediatric Intensive Care Unit, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Lelli SM, Mazzetti MB, San Martín de Viale LC. Melatonin modulates drug-induced acute porphyria. Toxicol Rep 2016; 3:141-147. [PMID: 28959532 PMCID: PMC5615779 DOI: 10.1016/j.toxrep.2015.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/29/2015] [Accepted: 12/29/2015] [Indexed: 01/10/2023] Open
Abstract
Melatonin partially eliminates the AIA/DDC-induced decrease in the activity of the gluconeogenic enzymes PEPCK and G6Pase. Melatonin favors a glucose-mediated down-regulating effect on AIA/DDC-induced ALA-S. Melatonin reduces AIA/DDC-increases in lipid peroxidation. Melatonin partially reverts the AIA/DDC-induced increase in ALA and PBG levels. The results obtained suggest the hypothetical use of Mel as co-treatment for acute porphyria.
This work investigated the modulation by melatonin (Mel) of the effects of the porphyrinogenic drugs 2-allyl-2-isopropylacetamide (AIA) and 3,5-diethoxycarbonyl-1,4-dihydro-2,4,6-collidine (DDC) on oxidative environment, glucose biosynthesis and heme pathway parameters. Administration of Mel before rat intoxication with AIA/DDC showed a clear beneficial effect in all cases. Mel induced decreases of 42% and 35% in the excretion of the hemeprecursors 5-aminolevulinic acid (ALA) and porphobilinogen (PBG), respectively, and a 33% decrease in the induction of the heme regulatory enzyme 5-aminolevulinic acid-synthase (ALA-S). The activity of the glucose metabolism enzyme phosphoenolpyruvate carboxykinase (PEPCK), which had been diminished by the porphyrinogenic treatment, was restored by 45% when animals were pre-treated with Mel. Mel abolished the modest decrease in glucose 6-phospatase (G6Pase) activity caused by AIA/DDC treatment. The oxidative status of lipids was attenuated by Mel treatment in homogenates by 47%, whereas no statistically significant AIA/DDC-induced increase in thiobarbituric acid reactive substances (TBARS) was observed in microsomes after Mel pre-treatment. We hypothesize that Mel may be scavenging reactive species of oxygen (ROS) that could be damaging lipids, PEPCK, G6Pase and ferrochelatase (FQ). Additionally, Mel administration resulted in the repression of the key enzyme ALA-S, and this could be due to an increase in glucose levels, which is known to inhibit ALA-S induction. The consequent decrease in levels of the heme precursors ALA and PBG had a beneficial effect on the drug-induced porphyria. The results obtained open the possibility of further research on the use of melatonin as a co-treatment option in acute porphyria.
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Affiliation(s)
- Sandra M Lelli
- Laboratorio de Disturbios Metabólicos por Xenobióticos, Salud Humana y Medio Ambiente, Departamento de Química Biológica, IQUIBICEN, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Ciudad Universitaria, Pab. II, 4to Piso, C1428EGA Ciudad Autónoma de Buenos Aires, Argentina
| | - Marta B Mazzetti
- Laboratorio de Disturbios Metabólicos por Xenobióticos, Salud Humana y Medio Ambiente, Departamento de Química Biológica, IQUIBICEN, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Ciudad Universitaria, Pab. II, 4to Piso, C1428EGA Ciudad Autónoma de Buenos Aires, Argentina
| | - Leonor C San Martín de Viale
- Laboratorio de Disturbios Metabólicos por Xenobióticos, Salud Humana y Medio Ambiente, Departamento de Química Biológica, IQUIBICEN, Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Ciudad Universitaria, Pab. II, 4to Piso, C1428EGA Ciudad Autónoma de Buenos Aires, Argentina
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Abstract
BACKGROUND Attacks of neuropathic pain, usually abdominal, are characteristic of the acute porphyrias and accompanied by overproduction of heme-precursor molecules, specifically delta-aminolevulinic acid and porphobilinogen. The basis for the acute symptoms in these diseases has been speculative. METHODS We review genetic acute porphyria, hereditary tyrosinemia, and an acquired condition, lead poisoning. All perturb heme synthesis and present with a similar pain syndrome. RESULTS Although each of these conditions has characteristic urine biochemistry, all exhibit excess delta-aminolevulinic acid. Moreover, in all, treatment with hemin reduces delta-aminolevulinic acid and relieves symptoms. In contrast, use of recombinant porphobilinogen deaminase to knock down porphobilinogen in acute porphyria was ineffective. CONCLUSIONS There is now convincing evidence that delta-aminolevulinic acid is the cause of pain in the acute porphyrias. The efficacy of hemin infusion is due mainly, if not entirely, to its inhibition of hepatic delta-aminolevulinic acid synthase-1, the enzyme that catalyzes delta-aminolevulinic acid formation. Delta-aminolevulinic acid synthase-1 is a rational target for additional therapies to control symptoms in acute porphyria.
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Affiliation(s)
- D Montgomery Bissell
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco.
| | - Jennifer C Lai
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Raymond K Meister
- Occupational Lead Poisoning Prevention Program, California Department of Public Health, Richmond
| | - Paul D Blanc
- Division of Occupational and Environmental Medicine, Department of Medicine, University of California, San Francisco
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Abstract
Purpose The porphyrias are a defect in the biosynthesis of heme which can be associated with different neurological symptoms during acute attacks such as peripheral neuropathy, mental disturbance and seizures. So far, there have only been a few case reports of status epilepticus, none of which were of epilepsia partialis continua (EPC). We present here two cases of hereditary coproporphyria (HCP) manifesting EPC as part of the clinical presentation. Method The patients’ medical charts, EEG and imaging studies were carefully reviewed. Results Case 1 is a 49-year-old male who first presented a tonic-clonic seizure. Case 2 is a 30-year-old male who came to the emergency room for a convulsive status epilepticus. Both evolved to EPC over the next days. EPC persisted despite several antiepileptic drug trials. Diagnosis of HCP was confirmed by a high level of urine, fecal and serum porphyrins in both cases and by genetic testing in one. Over the last 3 years, the first patient has continued to present non-disabling EPC and has had four tonic-clonic seizures associated with alcohol consumption. The second patient died from brain edema one month and half after admission. Conclusion Acute porphyrias should be included in the differential diagnosis of new onset status epilepticus, including EPC. Their recognition is important as it modifies significantly patient management, since many anticonvulsants are porphyrogenic.
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Affiliation(s)
- Thi Phuoc Yen Tran
- Service de Neurologie, Hôpital Notre-Dame, Centre Hospitalier Universitaire de Montréal, Montréal, Qué., Canada
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