An investigation of the health effects caused by exposure to arsenic from drinking water and coal combustion: arsenic exposure and metabolism

Few studies have been conducted to compare arsenic exposure, metabolism, and methylation in populations exposed to arsenic in drinking water and from coal combustion. Therefore, arsenic concentrations in the environment and arsenic speciation in the urine of subjects exposed to arsenic as a consequence of coal combustion in a rural area in Shaanxi province (CCA) and in drinking water in a rural area in Inner Mongolia (DWA) were investigated. The mean arsenic concentrations in drinking water, indoor air, and soil in CCA were 4.52 μg/L, 0.03 mg/m³, and 14.93 mg/kg, respectively. The mean arsenic concentrations in drinking water and soil in DWA were 144.71 μg/L and 10.19 mg/kg, respectively, while the level in indoor air was lower than the limit of detection. The total daily intakes of arsenic in DWA and CCA were 4.47 and 3.13 μg/day·kg, respectively. The mean urinary concentrations of inorganic arsenic (iAs), monomethylarsonic acid (MMA), dimethylarsenic acid (DMA), and total arsenic (TAs) for subjects with skin lesions in DWA were 50.41, 47.01, 202.66, and 300.08 μg/L. The concentrations for subjects without skin lesions were 49.76, 44.20, 195.60, and 289.56 μg/L, respectively. The %iAs, %MMA, and %DMA in the TAs in the urine of subjects from CCA were 12.24, 14.73, and 73.03%, while the corresponding values from DWA were 17.54, 15.57, and 66.89%, respectively. The subjects in DWA typically had a higher %iAs and %MMA, and a lower %DMA, and primary and secondary methylation index (PMI and SMI) than the subjects in CCA. It was concluded that the arsenic methylation efficiency of subjects in DWA and CCA was significantly influenced by chronic exposure to high levels of arsenic in the environment. The lower PMI and SMI values in DWA revealed lower arsenic methylation capacity due to ingestion of arsenic in drinking water. However, it remained unclear if the differences in arsenic metabolism between the two groups were due to differences in exposure levels or in exposure route.

Characterization of aminoaciduria and hypoaminoacidemia in dogs with hepatocutaneous syndrome

OBJECTIVE To characterize aminoaciduria and plasma amino acid concentrations in dogs with hepatocutaneous syndrome (HCS). ANIMALS 20 client-owned dogs of various breeds and ages. PROCEDURES HCS was definitively diagnosed on the basis of liver biopsy specimens (n = 12), gross and histologic appearance of skin lesions (4), and examination of skin and liver biopsy specimens (2) and presumptively diagnosed on the basis of cutaneous lesions with compatible clinicopathologic and hepatic ultrasonographic (honeycomb or Swiss cheese pattern) findings (2). Amino acid concentrations in heparinized plasma and urine (samples obtained within 8 hours of each other) were measured by use of ion exchange chromatography. Urine creatinine concentration was used to normalize urine amino acid concentrations. Plasma amino acid values were compared relative to mean reference values; urine-corrected amino acid values were compared relative to maximal reference values. RESULTS All dogs had generalized hypoaminoacidemia, with numerous amino acid concentrations < 50% of mean reference values. The most consistent and severe abnormalities involved glutamine, proline, cysteine, and hydroxyproline, and all dogs had marked lysinuria. Urine amino acids exceeding maximum reference values (value > 1.0) included lysine, 1-methylhistidine, and proline. CONCLUSIONS AND CLINICAL RELEVANCE Hypoaminoacidemia in dogs with HCS prominently involved amino acids associated with the urea cycle and synthesis of glutathione and collagen. Marked lysinuria and prolinuria implicated dysfunction of specific amino acid transporters and wasting of amino acids essential for collagen synthesis. These findings may provide a means for tailoring nutritional support and for facilitating HCS diagnosis.

Arsenic groundwater contamination and its health effects in Patna district (capital of Bihar) in the middle Ganga plain, India

We investigated the extent and severity of groundwater arsenic (As) contamination in five blocks in Patna district, Bihar, India along with As in biological samples and its health effects such as dermatological, neurological and obstetric outcome in some villages. We collected 1365 hand tube-well water samples and analyzed for As by the flow injection hydride generation atomic absorption spectrometer (FI-HG-AAS). We found 61% and 44% of the tube-wells had As above 10 and 50 μg/l, respectively, with maximum concentration of 1466 μg/l. Our medical team examined 712 villagers and registered 69 (9.7%) with arsenical skin lesions. Arsenical skin lesions were also observed in 9 children of 312 screened. We analyzed 176 biological samples (hair, nail and urine). Out of these, 69 people had arsenical skin lesions and rest without skin lesions. We found 100% of the biological samples had As above the normal levels (concentrations of As in hair, nail and urine of unexposed individuals usually ranges from 20 to 200 μg/kg, 20-500 μg/kg and <100 μg/l, respectively), indicating many people are sub-clinically affected. Arsenical neuropathy was observed in 40.5% of 37 arsenicosis patients with 73.3% prevalence for predominant sensory neuropathy and 26.7% for sensor-motor. Among patients, different clinical and electrophysiological neurological features and abnormal quantitative sensory perception thresholds were also noted. The study also found that As exposed women with severe skin lesions had adversely affected their pregnancies. People including children in the affected areas are in danger. To combat As situation in affected areas, villagers urgently need (a) provision of As-safe water for drinking and cooking, (b) awareness about the danger of As toxicity, and (c) nutritious food.

Differences of urinary arsenic metabolites and methylation capacity between individuals with and without skin lesions in Inner Mongolia, Northern China

Incomplete arsenic (As) methylation has been considered a risk factor of As-related diseases. This study aimed to examine the difference of urinary As metabolites and the methylation capacity between subjects with and without skin lesions. Urinary inorganic arsenic (iAs), monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA) were analyzed. The percentage of each As species (iAs%, MMA%, and DMA%), the primary methylation index (PMI) and secondary methylation index (SMI) were calculated. The results showed that subjects with skin lesions have higher levels of urinary iAs (99.08 vs. 70.63 μg/g Cr, p = 0.006) and MMA (69.34 vs. 42.85 μg/g Cr, p = 0.016) than subjects without skin lesions after adjustment for several confounders. Significant differences of urianry MMA% (15.49 vs. 12.11, p = 0.036) and SMI (0.74 vs. 0.81, p = 0.025) were found between the two groups. The findings of the present study suggest that subjects with skin lesions may have a lower As methylation capacity than subjects without skin lesions.

Biomarkers for the evaluation of population health status 16 years after the intervention of arsenic-contaminated groundwater in Xinjiang, China

The arsenicosis endemic area in the region of Kuitun and Chepaizi, Dzungaria district, Xinjiang, People Republic of China was the first identified arsenic endemic area in China where arsenic concentration of up to 850 μg/L in the groundwater was reported. An intervention was put in place in 1985 by government to provide an alternative water source at a centralized community level. Sixteen years on since the intervention, we evaluated the health status of 178 villagers from endemic and 179 villagers from control sites. Biomarkers in their urine, included arsenic, porphyrins and malondialdehyde (MDA) were measured and the prevalence of skin lesions was also assessed. The average urinary arsenic (117 ± 8.3 μg/g of creatinine) from the endemic-villages was significantly higher (p<0.001) than that of the controls (73.6 ± 3.2 μg/g of creatinine) while no significant difference was found in urinary porphyrins and malondialdehyde concentrations in the overall studies subjects from these two areas. However when the urinary arsenic was higher than 150 μg/g of creatinine, MDA and porphyrins were higher in the endemic-villagers compared to the controls. Fifty-one out of 178 people from the arsenic endemic area showed skin lesions related to arsenicosis but these were absent among villagers from the control site. Of particular concern, skin lesions related to arsenicosis were observed in 4 out of 9 subjects 16 years of age or younger who were from different villages and born after the completion of water intervention. Although sporadic exposure and/or voluntary drinking contaminated water were thought to be a contributor of arsenicosis after the water intervention, the contribution from other dietary arsenic intakes remain unclear.

Methylation capacity of arsenic and skin lesions in smelter plant workers

Potential occupational arsenic exposure is a significant problem in smelting plants. The metabolites containing arsenic with an oxidation of +3 have been considered more cytotoxic and genotoxic than their parent inorganic species. The current study examined the capacity of arsenic methylation and its risk on skin lesions. The primary aim of this study is to determine if methylation capacity, as measured by urinary arsenic metabolites, differed in workers with skin lesions compared to workers without skin lesions. Hydride generation-atomic absorption spectrometry was used to determine three arsenic species in urine of workers who had been working in arsenic plants, and primary and secondary methylation indexes were calculated. Skin lesions were examined at the same time. Many workers had obvious skin lesions (36/91). The mean concentrations of inorganic arsenic (iAs), monomethylarsonic acid (MMA) and dimethylarsinic acid (DMA) in urine of workers are obviously higher than those of the control group. There are more iAs, MMA, and DMA in urine, higher MMA%, lower iAs% for workers with skin lesions compared with those without skin lesions. Workers with skin lesions have the lowest SMI (3.50±1.21), and they may be in danger. Our results support the viewpoint that individuals who metabolize inorganic arsenic to MMA easily, but metabolize MMA to DMA difficulty have more risk of skin lesions.

Impact of smoking and chewing tobacco on arsenic-induced skin lesions

BACKGROUND

We recently reported that the main reason for the documented higher prevalence of arsenic-related skin lesions among men than among women is the result of less efficient arsenic metabolism.

OBJECTIVE

Because smoking has been associated with less efficient arsenic methylation, we aimed to elucidate interactions between tobacco use and arsenic metabolism for the risk of developing skin lesions.

METHODS

We used a population-based case-referent study that showed increased risk for skin lesions in relation to chronic arsenic exposure via drinking water in Bangladesh and randomly selected 526 of the referents (random sample of inhabitants > 4 years old; 47% male) and all 504 cases (54% male) with arsenic-related skin lesions to measure arsenic metabolites [methylarsonic acid (MA) and dimethylarsinic acid (DMA)] in urine using high-performance liquid chromatography (HPLC) and inductively coupled plasma mass spectrometry (ICPMS).

RESULTS

The odds ratio for skin lesions was almost three times higher in the highest tertile of urinary %MA than in the lowest tertile. Men who smoked cigarettes and bidis (locally produced cigarettes; 33% of referents, 58% of cases) had a significantly higher risk for skin lesions than did nonsmoking men; this association decreased slightly after accounting for arsenic metabolism. Only two women smoked, but women who chewed tobacco (21% of referents, 43% of cases) had a considerably higher risk of skin lesions than did women who did not use tobacco. The odds ratio (OR) for women who chewed tobacco and who had < or = 7.9%MA was 3.8 [95% confidence interval (CI), 1.4-10] compared with women in the same MA tertile who did not use tobacco. In the highest tertile of %MA or %inorganic arsenic (iAs), women who chewed tobacco had ORs of 7.3 and 7.5, respectively, compared with women in the lowest tertiles who did not use tobacco.

CONCLUSION

The increased risk of arsenic-related skin lesions in male smokers compared with nonsmokers appears to be partly explained by impaired arsenic methylation, while there seemed to be an excess risk due to interaction between chewing tobacco and arsenic metabolism in women.

The total body burden of chromium associated with skin disease and smoking among cement workers

BACKGROUND

Hand eczema and other skin diseases have been associated with the exposure of chromium among cement workers. Studies on skin disease and other factors associated with the body burden of chromium are limited.

OBJECTIVE

The present study investigated the role of skin disease and smoking in the association with body burden of chromium among cement workers.

METHODS

Forty-five workers (38 men and 7 women) were recruited for this study and interviewed to obtain information on demographic status, lifestyle, employment history, and affecting factors. Urine samples were collected to measure the urinary chromium concentration to represent the body burden of chromium.

RESULTS

The average urinary chromium concentration was approximately 6 times higher in non-smoking workers with hand eczema than in non-smoking workers with no skin disease (45.5 vs. 7.6 microg/L). The average chromium level increase to 87.0 microg/L for smokers with the disease. Compared with workers with no hand eczema, the odds ratio of having urinary chromium concentration exceeding the biological exposure index level significantly increased to 11.6 (95% CI=1.3-102.2) for non-smoking workers with skin disease, and to 48.0 (95% CI=4.5-510.8) for smoking workers with skin disease. The multiple regression analysis showed that the use of gloves may reduce significantly the chromium exposure.

CONCLUSIONS

Inadequate protection and personal behavior increase the internal dose of chromium in cement workers. Total body burden of chromium are higher among cement workers with skin disease and smoking habit. These workers deserve intervention education on personal hygiene to reduce the exposure of chromium.

A review of evidence from short-term studies leading to the prediction that diazoaminobenzene (1,3-diphenyltriazine) is a carcinogen

The National Toxicology Program (NTP) is responsible for providing comprehensive toxicology evaluations of substances, while at the same time incorporating approaches to reduce, refine or replace laboratory animals in routine toxicity/carcinogenicity studies. Consistent with this, a series of metabolism studies in rodents and human liver slices, electron spin resonance spectroscopy (ESR) studies, short-term dermal toxicity studies in rodents, and acute bone marrow micronucleus studies in mice were performed on diazoaminobenzene (DAAB, also known as 1,3-diphenyltriazine). These studies demonstrated that DAAB is metabolized and shares similar genotoxic and toxicological properties to the known human carcinogen, benzene, and the known rodent carcinogen, aniline. These data were used to evaluate the potential carcinogenicity of DAAB without doing a 2-year rodent bioassay. Based on this analysis, DAAB was predicted to be carcinogenic if evaluated in a 2-year rodent bioassay. These data were evaluated to support listing DAAB in the NTP Report on Carcinogens as a substance 'reasonably anticipated to be a human carcinogen'. The purpose of this article is to review the data developed for predicting the carcinogenicity of DAAB.

Influence of metabolic genotype GSTM1 on levels of urinary mutagens in patients treated topically with coal tar

Fifteen hospitalized, non-smoking, dermatological patients were treated with ointment containing 2% coal tar (CT) in order to assess the influence of metabolic genotype GSTM1 on urinary mutagen levels. Urinary 1-pyrenol, the main metabolite of pyrene, was used to check the high exposure to PAH of this population. The mean levels of urinary 1-pyrenol found in the 24-h urine of our patients were 467. 8+/-211.0 nmoles-24 h (range 94.6-890.1 nmoles-24 h). Mutagenicity was assessed on urine samples collected over a period of 24 h, after three consecutive days of topical application, using the bacterial mutagenesis test on Salmonella typhimurium strains TA98 and YG1024 in the presence of microsomal enzymes. The latter strain turned out to be more sensitive than the former in revealing urinary mutagens in these patients (42 693+/-30 867 vs. 6877+/-6040 net revertants-24 h). The mutagenicity on YG1024 strain and 1-pyrenol levels of urine samples were correlated (Spearman's rank correlation coefficient=0. 6678, P<0.01, z=2.795). The influence of genotype GSTM1 on urinary mutagen levels was assessed on strain YG1024. The values of urinary mutagenicity of subjects with genotype GSTM1-null (n=6) were on average higher than those of GSTM1-positive subjects (n=9) (55 498+/-45 957 vs. 34 156+/-11 933 net rev.-24 h), a non-significant statistical difference. The mean total excretion of mutagens corrected for PAH exposure (net rev./nmoles of urinary 1-pyrenol) in GSTM1-null patients was double that of GSTM1-positive ones (136. 8+/-34.7 vs. 70.8+/-23.3 net rev./nmoles of urinary 1-pyrenol; one-tailed Mann-Whitney U-test, U=11.5, P<0.05). These results indicate a greater body burden of promutagens, resulting from skin application of CT, in GSTM1-null subjects.

[Longitudinal study of the excretion of 1-hydroxypyrene in urine after external treatment with coal tar]

In order to study the dermal uptake, time course, and urinary excretion of polycyclic aromatic hydrocarbons, the concentration of 1-hydroxypyrene in urine was determined by means of high performance liquid chromatography with fluorescence detection before, during, and after the topical treatment with coal tar in 19 patients suffering from prurigo simplex subacuta, microbial eczema, atopic dermatitis, eczematization after scabies, exanthematous lichen ruber, pityriasis lichenoides and cutaneous sarcoidosis. Beginning with a value of 6.04 +/- 2.06 micrograms 1-hydroxypyrene/g creatinine before treatment, the urinary excretion significantly increased during the therapy with coal tar (p < 0.0001 at 3rd, 5th, and 6th day of therapy). A maximum was reached at day 8 of topical treatment with a value of 584.35 +/- 191.96 micrograms 1-hydroxypyrene/g creatinine (p < 0.002). Already during treatment at day 10 there was a beginning decrease of 1-hydroxypyrene to 361.63 +/- 170.13 micrograms/g creatinine. After the end of treatment, the excretion further decreased reaching a value of 5.31 +/- 2.85 micrograms 1-hydroxypyrene/g creatinine at the 10th day after therapy. Skin carcinomas due to therapeutical use of coal tar occur extremely rarely and only after vergoten, non-controlled use. We suggest that the duration of exposure is the most important factor for the carcinogenic effect of coal tar.

Altered profile of urinary arsenic metabolites in adults with chronic arsenicism. A pilot study

Relationships between alterations in the profile of urinary arsenic (As) species and the presence of cutaneous signs of arsenicism were studied in Region Lagunera, Mexico. The use of urinary concentrations of putative substrates and products of the As metabolism pathway, as indicators of metabolic efficiency is also discussed. Arsenic was determined by hydride generation atomic absorption spectrophotometry and separation of As species was performed by ion exchange chromatography. The exposed group had an average of 0.408 mg As/l of total As (TAs) in their drinking water, whereas "control' individuals had 0.031 mg/l. Urinary concentrations of arsenic species and TAs were 20 to 95 times higher in the exposed group. Significant increases in the relative proportions of inorganic arsenic (Asi) and monomethylarsonic acid (MMA), accompanied by decreases of dimethylarsinic acid (DMA) were also found in exposed individuals. Therefore, significant decreases in the value of the MMA/Asi, DMA/MMA and DMA/ Asi ratios were observed, suggesting a decreased As methylating ability. Exposed individuals bearing cutaneous signs had a significantly longer time of exposure, higher urinary concentrations and proportions of MMA and MMA/Asi values, and significantly lower DMA/ MMA than exposed individuals without cutaneous signs. Further research is needed to identify better parameters for assessing the efficiency of As metabolism in chronically exposed populations and to confirm the potential relationship between metabolic alterations and overt signs of As toxicity.

Atypical Fabry's disease. An oligosymptomatic variant

Fabry's disease is a rare, inherited, X-linked metabolic storage disease with ceramide hexoside due to alpha-galactosidase A deficiency. Patients with typical Fabry's disease usually present with several clinical manifestations of corneal dystrophy, neurologic abnormalities, cardiovascular disease, heavy proteinuria, and characteristic cutaneous angiokeratoma. However, atypical Fabry's disease with oligosymptomatic phenotype presents with symptoms restricted solely to cardiocytes or kidney and might be diagnosed by chance during a routine endomyocardial or renal biopsy examination. In this article, we report a case of Fabry's disease incidentally diagnosed in a 34-year-old man who presented with intermittent trace or 1(+) proteinuria only. This patient had no history of renal disease in any other family member. A renal biopsy to evaluate trace proteinuria revealed histologic and ultrastructural findings compatible with Fabry's disease. Subsequent to the renal biopsy, a skin biopsy on a few initially unrecognized, scattered, dark-pinkish scrotal papules showed typical angiokeratoma. A biochemical enzymatic assay of alpha-galactosidase in urine and plasma revealed a markedly decreased enzyme level in the hemizygous range.

Acute scleritis in porphyria cutanea tarda

We examined three patients who had dermatologic and biochemical manifestations of porphyria cutanea tarda and localized thinning or excavation in the sun-exposed interpalpebral sclera, adjacent to the cornea. All three patients had signs of acute scleritis. The acute scleritis responded to oral indomethacin in one patient, but systemic corticosteroids were required to control the inflammation in the other two patients. Phlebotomy, protection from sunlight, and refraining from alcohol played an important part in the treatment of the patients.

[Results of treatment of porphyria cutanea tarda with bloodletting and chloroquine]

In 59 patients showing clear clinical and biochemical signs of porphyria cutanea tarda (PCT), we tested 3 different modes of therapy: 20 patients received combined treatment with repeated bleeding and chloroquine, 24 patients were exclusively treated with oral chloroquine in low doses, and 15 patients underwent repeated phlebotomy only. On an average, the time necessary for remission amounted to 3.5, 10.2, and 12.5 months, respectively. So the combined therapy proved the quickest. In patients with the acquired form of PCT, the pattern of urinary porphyrin normalized; those suffering from hereditary PCT retained the typically high uro/copro ratio. The values of the plasma porphyrin count and the plasma porphyrin index (PPI), which had been greatly enhanced before, went down to normal after therapy.

An epidemiologic study of acute intermittent porphyria in Maheshwari community of Sri-Dungargarh municipal area

Fifteen patients of acute intermittent porphyria (AIP) were detected out of 2500 persons of Maheshwari community surveyed. These 15 patients belonged to 11 families. The prevalence of AIP in Maheshwari population came out to be 1:640 which is considerably higher than the figures reported from many other areas of our country. AIP was more common in females than males, the ratio being 9:6. Maximum number of cases (6) were encountered in the age group of 11-20 years. AIP was observed to be inherited as an autosomal dominant disease in 3 families. Spontaneous mutation of gene may be considered to be the mode of inheritance in the remaining 8 families. The disease was found to be more common in Daga and Tapadia subcastes. There were 5 cases belonging to Daga subcaste and 3 belonging to Tapadia subcaste.

Development of porphyria cutanea tarda after treatment with cyclophosphamide

Porphyria cutanea tarda, a metabolic disorder of heme biosynthesis, is characterized by cutaneous hyperpigmentation, facial hypertrichosis, dark urine, and a distinctive pattern of excess porphyrin production. Hepatic uroporphyrinogen decarboxylase activity is markedly reduced in patients with this disorder. Although porphyria cutanea tarda may be familial, it is more often sporadic in occurrence, and has been associated with excess alcohol ingestion, estrogen administration, iron overload, and several environmental hepatotoxins. It has also been associated on occasion with malignancy. We report a 46-yr-old woman with ovarian carcinoma who developed porphyria cutanea tarda while undergoing treatment with cisplatin and cyclophosphamide. The temporal course of the porphyrin abnormality suggested that cyclophosphamide was the pathogenic agent, and symptoms regressed after cessation of this drug with continued administration of cisplatin. The pathogenesis of the porphyria is not clear; however, cyclophosphamide is a substrate for cytochrome P450, and may produce metabolites that destroy this protein. The resulting increased turnover of heme might then result in overproduction of porphyrin precursors, resulting in the clinical syndrome. Studies of porphyrin metabolism in patients treated with cyclophosphamide may help to elucidate this possibility.

The isolation and identification of indigoid pigments from urine

A purple pigment, phyriaviolin, and a blue pigment, phyriaazulin, have been found in relatively large amounts in the urine of patients suffering from two diverse pathological conditions, porphyria cutanea tarda and Crohn's disease. The two pigments have been characterised by chemical, spectroscopic, and chromatographic studies and identified to be indirubin and indigo (indigotin). Possible reasons for their formation are discussed.

Methylprednisolone pulses and urine electrolyte excretion

The mineralocorticoid activity of methylprednisolone pulses was assessed by measurement of urine electrolyte excretion prior to and during alternate day pulsing in patients with skin or joint disease. Two groups were studied: the first receiving pulses, but no other steroid; the second having taken oral prednisolone prior to and during pulsing. Urine sodium excretion in 24 hr urine specimens from both groups was suppressed, with no rebound between pulses, but a gradual "escape" occurred from the effects of continued pulsing. Four hour urine collections demonstrated suppression of urinary sodium excretion for up to 32 hr after pulsing with gradual recovery. The peak recovery in sodium excretion coincided with the subsequent pulse and was insufficient to compensate for the preceding sodium retention. Alternate day pulsing does not, therefore, reduce the risk of sodium retention from large doses of methylprednisolone.

A high-speed liquid-chromatographic method for measuring urinary porphyrins

We describe a rapid quantitative and qualitative "high-performance" liquid-chromatographic (HPLC) method for measuring porphyrins in urine. Direct injection of acidified, filtered urine onto a 3-micron (particle size) 3-cm-long reversed-phase column fully resolves uroporphyrin, hepta-, hexa-, and pentacarboxylic acid porphyrins, and coproporphyrin. Instrument response is linearly related to concentration over the range 25 to 300 nmol/L. The method provides data essential for the differential diagnosis of porphyric states, including porphyria variegata and porphyria cutanea tarda. This relatively inexpensive method requires a run time of only 8 min per sample, making it particularly suitable for routine use in the clinical chemistry laboratory.

Urinary porphyrins in children exposed transplacentally to polyhalogenated aromatics in Taiwan

In 1979, there was a large (greater than 2,000 cases) outbreak of poisoning due to contaminated rice oil in central Taiwan. The causal agent was a mixture of thermally degraded polychlorinated biphenyls (PCBs), polychlorinated quaterphenyls, and polychlorinated dibenzofurans, which had become mixed with the oil during processing. Patients remained symptomatic for several years afterward, and the chemicals persisted in their tissue. Women who became pregnant had children with high perinatal mortality and a dysmorphic syndrome. We examined urines from 75 children born to exposed mothers after the oil was confiscated, 74 controls, and 12 sibs of the exposed children. Four of the transplacentally exposed children, 2 controls, and 1 sib had a type B hepatic porphyria (i.e., uroporphyrin greater than coproporphyrin); total porphyrin excretion was elevated in the exposed children as a group (95 vs. 81 micrograms/L); and 8 of the 75 exposed children and 2 controls had total urinary porphyrin concentrations of greater than 200 micrograms/L.

Urinary excretion of D-glucaric acid in porphyria cutanea tarda

Twenty patients with porphyria cutanea tarda who had ingested no alcohol for at least 10 days before sampling were found to possess urinary D-glucaric acid levels similar to those of 30 clinically healthy controls. Correlation between urinary excretion of D-glucaric acid on the one hand and plasma or urinary porphyrin concentrations on the other was not statistically significant. These results suggest that the high urinary concentrations of D-glucaric acid found in porphyria cutanea tarda patients by Budillon et al. (Acta Hepato-Gastroenterol. 25 (1978) 267) may have been due to recent consumption of alcohol rather than to the porphyrin pathology.

Two cases of infantile porphyria cutanea tarda: successful treatment with oral S-adenosyl-L-methionine and low-dose oral chloroquine

In a 7-year-old girl and a 12-year-old boy, with photosensitivity and hypertrichosis, the diagnosis of familial porphyria cutanea tarda was confirmed by the characteristic pattern of urinary porphyrin excretion, diminished erythrocyte uroporphyrinogen decarboxylase and elevated plasma porphyrin index with emission maxima at 617-618 nm. The patients were treated with a combination of low-dose oral chloroquine and oral S-adenosyl-L-methionine (SAM); in one case alkalinization of urine was also applied. Complete clinical and biochemical recovery was achieved within 3 months. No adverse ophthalmological or other side-effects were observed. We propose that the treatment of choice should be oral SAM (12 mg/kg/day) for 3 weeks and oral chloroquine (2 X 100 mg weekly) for about 120-150 days or until improvement of clinical and biochemical abnormalities is attained. So far no relapses have occurred. This combined therapy appears to be safe, simple, effective and very convenient for both patients and physicians.

The porphyrias

The porphyrias are caused by hereditary defects in the synthesis of heme. Each porphyria is characterized by a unique enzyme defect and measurable elevations of specific heme precursors. While qualitatively normal, these precursors accumulate to cause protean signs and symptoms. Photosensitivity should raise the suspicion of a porphyria, especially in a child or a young adult. The skin, teeth and eyes may provide clues to the diagnosis in some cases.

Correlation of serum and urinary porphyrin levels in porphyria cutanea tarda

A significant linear correlation was found between serum total porphyrin concentration and 24-hour total urinary porphyrin excretion in 18 patients with porphyria cutanea tarda sampled at diagnosis and during and after treatment on 73 occasions. This confirms that the serum porphyrin level parallels urinary porphyrin excretion and is an appropriate indicator of disease activity useful for monitoring patients in clinical practice.

Sclerodermoid changes of porphyria cutanea tarda: possible relationship to urinary uroporphyrin levels

From 1950 to 1982, fifteen patients were seen at the Mayo Clinic with a diagnosis of sclerodermoid changes of porphyria cutanea tarda. Fourteen patients had changes similar to scleroderma limited to the skin, and one patient had scleroderma-like skin changes accompanied by visceral abnormalities. Both light-exposed and unexposed areas of the body were affected. Areas of involvement included the chest, the V-shaped area of the neck, and the back, face, and shoulders. In six patients, morpheaform changes represented the presenting cutaneous sign of porphyria cutanea tarda. Follow-up examination, after treatment that included abstinence from alcohol and phlebotomy, revealed that the sclerodermoid skin changes had disappeared in six patients and improved in four. Generally, the degree of improvement of the sclerodermoid changes was proportional to the reduction of the urinary uroporphyrin levels toward normal (p = 0.02).

Zinc deficiency as a problem in patients with Crohn's disease and fistula formation

Zinc deficiency is common in patients with Crohn's disease (CD), especially in those with skin lesions and growth retardation. Patients with fistulas have been considered to be another group with zinc deficiency. We therefore determined serum zinc concentrations of 50 patients with CD. Zinc deficiency was diagnosed in 17 out of 50 patients (34%). Serum zinc concentrations of patients with fistulas were significantly lower than those of patients without fistulas, and zinc deficiency was found in 11/17 (65%) patients. Zinc deficiency may play a role in the formation and clinical course of fistulas. Therefore, in view of possible therapeutic implications, determination of serum zinc concentration in patients with CD and fistulas appears to be of value.

Urinary porphyrins in liver disease

By use of quantitative thin-layer chromatography, urinary porphyrins were examined in 40 healthy volunteers, 38 patients with prophyria cutanea tarda (PCT), and 139 patients with various liver diseases. Significant elevations not only of coproporphyrin but also of some other porphyrins were found in many patients with liver disease. However, there was no evident relationship between porphyrin disturbances and functional or clinical findings, and all of these non-PCT patients who initially demonstrated intense uroporphyrinuria, when re-studied apparently had more normal porphyrin excretion. It seems, therefore, that whereas porphyrin estimations are useful in porphyrias, no clinically important conclusions can be drawn from urinary findings in patients with liver disease. The origin of defective haem biosynthesis in liver disease remains obscure. It can only be speculated that transient and reversible urocoproporphyrinuria may occur in patients with defective hepatic uroporphyrinogen decarboxylase activity who clinically and biochemically are not porphyric.

Porphyria cutanea tarda and pregnancy

A female patient with porphyria cutanea tarda (PCT) clinically cured by a low-dose chloroquine treatment showed neither exacerbation of the disease nor an increased excretion of urinary porphyrins during pregnancy. The role of estrogens and gestagens as clinical manifestation factors of PCT is discussed. According to our observation the porphyrogenic effect of the estrogens seems to have been overestimated.

Liquid-chromatographic profiles of urinary porphyrins

Information on changes in the urinary excretion pattern of porphyrins can be especially useful in the diagnosis of disorders of porphyrin metabolism. Most clinical laboratory procedures are designed for assay of uroporphyrin and coproporphyrin only, and in many cases even these are not cleanly separated. Hence, we developed a "high-performance" liquid-chromatographic procedure to separate and quantify all five urinary porphyrins--that is, those with four through eight carboxyl groups. Before chromatography, the porphyrins are isolated from other urinary components by two simple, rapid pretreatment steps, then injected into the chromatograph in nonesterified form. They are separated and eluted with a step gradient of methanol/phosphate buffer, pH 3.0, in which the methanol content is first 650, then 850 mL/L. As little as 1 ng of eluted porphyrins can be measured fluorometrically. Analytical recovery of coproporphyrin is virtually 100% and of uroporphyrin 75-80%. CVs are about 10% for coproporphyrin at 70 micrograms/L and 20-40% for uroporphyrin at 8 micrograms/L.

Effects of phlebotomy on urinary porphyrin pattern and liver histology in patients with porphyria cutanea tarda

Urinary porphyrin profiles and liver histology have been investigated in a group of adult alcoholics with porphyria cutanea tarda (PCT) before and after one year phlebotomy. Both parameters were evaluated during the same period in a group of patients who did not undergo specific therapy for PCT. All patients were advised to abstain from alcohol. At the end of the one year observation period there was a significant fall of urinary total porphyrins and in the uro/coproporphyrin ratio in treated patients compared to basal values whereas no changes were found in controls. Liver biopsy findings revealed a significant reduction of hepatic fatty degeneration and siderosis with no changes in inflammatory infiltrates and fibrosis in treated patients, so the progression of liver disease was similar to controls. These results show that clinical and biochemical remission of PCT can occur independently of the evolution of the concomitant liver disease.

Porphyrinogens in urine in various types of porphyrias

Porphyrinogens were determined in very fresh, diluted morning urine in two types of hepatic porphyria, using a simple and very quick spectrophotometric method. It was shown that acidification by itself is insufficient for the complete conversion of colourless porphyrinogens into porphyrins in photometric determination of porphyrins in diluted urine. A correlation was shown between percentual content of porphyrinogens and the sum of pentacarboxyporphyrins and coprophyrin. A difference was found between the excretion of porphyrinogens in morning fresh urine in porphyria cutanea tarda (average porphyrinogen fraction 22.5%, SD 10.3% of total porphyrins) and in acute intermittent porphyria (average porphyrinogen fraction 77.1%, SD 9.3% of total porphyrins). The method is at the same time suitable for the detection of urobilinoids in urine. Oxidation of the urine in acute intermittent porphyria is recommended before absorption on talc and subsequent thin-layer chromatography, because porphyrinogens are not adsorbed on talc.

Patterns of porphyrin-excretion in female estrogen-induced porphyria cutanea tarda

It has been suggested that the urinary profile of porphyrins excreted by female patients with estrogen-induced porphyria cutanea tarda is peculiar in that heptacarboxylic porphyrin equals or exceeds uroporphyrin. The chromatographic pattern of urinary porphyrin excretion was studied in nine females with porphyria cutanea tarda precipitated by estrogens, 129 porphyric males, and nine females, whose porphyria was not hormone-induced. Both female porphyric groups showed absolutely the same urinary chromatographic pattern and looked quite similar to the pattern observed in male patients. None of our female porphyric patients, whether treated with estrogens or not, showed percentage values for the heptacarboxylic porphyrin higher or equal to the uroporphyrin values. Our results do not support the hypothesis that the profile of urinary porphyrin excretion found in estrogen-induced porphyria cutanea tarda is atypical.

Liquid-chromatographic analysis for urinary porphyrins

Urinary porphyrins are separated, according to number of carboxyl groups, in a system consisting of a mu-Bondapak C18 stationary phase and a mobile phase of methanol and aqueous sodium phosphate (pH 3.5) in a linear gradient. The specimen is prepared simply by adjusting the pH of a 5-mL sample to 2.0 and removing solids by centrifugation. The eluted porphyrins are measured fluorometrically. Naturally occurring non-porphyrin fluorescent substances are eluted ahead of the porphyrins. Chromatography requires about 20 min, and a re-establishment of initial conditions requires an additional 15 min.

Hydroxychloroquine treatment of porphyria cutanea tarda

Six patients with skin changes and urinary porphyrin excretion patterns characteristic for porphyria cutanea tarda were treated with hydroxychloroquine sulfate therapy. During treatment periods ranging from five to 13 months, cutaneous symptoms disappeared and urinary porphyrin excretion abnormalities were completely or almost completely reversed. In three subjects, hydroxychloroquine therapy was accompanied by changes in the urinary excretion of iron. The first four patients, followed up for nine to 24 months after treatment, all had relapse, and substantial porphyrinuria developed once more; cutaneous symptoms recurred in two of these. Three of the four patients were re-treated, and their conditions again improved or went into remission with hydroxychloroquine therapy. In two patients, treatment responses were slower than those initially seen, despite the use of higher drug doses; in the third patient, the response to re-treatment was more rapid than that seen during the first treatment course.