The clinical management of porphyria cutanea tarda: An update.

Porphyria cutanea tarda (PCT) is the commonest of the porphyrias (Semin Liver Dis 1998;18:67). It often occurs secondary to an underlying internal disorder, has significant impacts on liver health and longevity, and is a treatable disease. Thus, for the clinician, recognising the disease to make the correct diagnosis, identifying causative underlying diseases, and treating the porphyria and its complications, are crucial. Although reviews on the management of PCT have been written, there have recently been significant advances in the understanding of the factors predisposing to the disease, and of its wider health impacts. This review aims to help the clinician to diagnose and manage patients with PCT, with an emphasis on the impact of recent advances on clinical management.

Hepatoerythropoietic porphyria due to a novel mutation in the uroporphyrinogen decarboxylase gene.

BACKGROUND: Hepatoerythropoietic porphyria (HEP) is a rare form of porphyria that results from a deficiency of uroporphyrinogen decarboxylase (UROD). The disease is caused by homoallelism or heteroallelism for mutations in the UROD gene. OBJECTIVE: To study a 19-year-old woman from Equatorial Guinea, one of the few cases of HEP of African descent and to characterize a new mutation causing HEP. METHODS: Excretion of porphyrins and residual UROD activity in erythrocytes were measured and compared with those of other patients with HEP. The UROD gene of the proband was sequenced and a new mutation identified. The recombinant UROD protein was purified and assayed for enzymatic activity. The change of amino acid mapped to the UROD protein and the functional consequences were predicted. RESULTS: The patient presented a novel homozygous G170D missense mutation. Porphyrin excretion showed an atypical pattern in stool with a high pentaporphyrin III to isocoproporphyrin ratio. Erythrocyte UROD activity was 42% of normal and higher than the activity found in patients with HEP with a G281E mutation. The recombinant UROD protein showed a relative activity of 17% and 60% of wild-type to uroporphyrinogen I and III respectively. Molecular modelling showed that glycine 170 is located on the dimer interface of UROD, in a loop containing residues 167-172 that are critical for optimal enzymatic activity and that the carboxyl side chain from aspartic acid is predicted to cause negative interactions between the protein and the substrate. CONCLUSIONS: The results emphasize the complex relationship between the genetic defects and the biochemical phenotype in homozygous porphyria.

Identification and characterization of novel uroporphyrinogen decarboxylase gene mutations in a large series of porphyria cutanea tarda patients and relatives.

Porphyria cutanea tarda (PCT) arises from decreased hepatic activity of uroporphyrinogen decarboxylase (UROD). Both genetic and environmental factors interplay in the precipitation of clinically overt PCT, but these factors may vary between different geographic areas. Decreased activity of UROD in erythrocytes was used to identify patients with UROD mutations among a group of 130 Spanish PCT patients. Nineteen patients (14.6%) were found to harbor a mutation in the UROD gene. Eight mutations were novel: M1I, 5del10, A22V, D79N, F84I, Q116X, T141I and Y182C. Five others were previously described: F46L, V134Q, R142Q, P150L and E218G. The new missense mutations and P150L were expressed in Escherichia coli. D79N and P150L resulted in proteins that were localized to inclusion bodies. The other mutations produced recombinant proteins that were purified and showed reduced activity (range: 2.3-73.2% of wild type). These single amino acid changes were predicted to produce complex structural alterations and/or reduced stability of the enzyme. Screening of relatives of the probands showed that 37.5% of mutation carriers demonstrated increased urinary porphyrins. This study emphasizes the role of UROD mutations as a strong risk factor for PCT even in areas where environmental factors (hepatitis C virus) have been shown to be highly associated with the disease.

Magnetic Anomalies over the Mid-Atlantic Ridge near 27{degrees}N.

Ten magnetic profiles across the mid-Atlantic ridge near 27 degrees N show trends that are parallel to the ridge axis and symmetrical about the ridge axis. The configuration of magnetic bodies that could account for the pattern supports the Vine and Matthews hypothesis for the origin of magnetic anomalies over oceanic ridges. A polarity-reversal time scale inferred from models for sea-floor spreading in the Pacific-Antarctic ridge and radiometrically dated reversals of the geomagnetic field indicates a spreading rate of 1.25 centimeters per year during the last 6 million years and a rate of 1.65 centimeters per year between 6 and 10 million years ago. A similar analysis of more limited data over the mid-Atlantic ridge near 22 degrees N also indicates a change in the spreading rate. Here a rate of 1.4 centimeters per year appears to have been in effect during the last 5 million years; between 5 and 9 million years ago, an increased rate of 1.7 centimeters per year is indicated. The time of occurrence and relative magnitude of these changes in the spreading rate, about 5 to 6 million years ago and 18 to 27 percent, respectively, accords with the spreading rate change implied for the Juan de Fuca ridge in the northeast Pacific.

Central North Atlantic Plate Motions over the Last 40 Million Years.

The relative motion vector for the North American and African plates has been determined from detailed charting of the trend of the Atlantis fracture zone for over 1000 kilometers in the central North Atlantic near 30 degrees N and from identification of marine magnetic anomalies and deep-sea drilling results. The vector (pole) is located at 52.5 degrees N, 34 degrees W and has a magnitude (opening rate) of 5.7 x 10(-7) degree per year. Major changes in either the pole location or the opening rate are not evident for the last 40 million years.

Structural and kinetic characterization of mutant human uroporphyrinogen decarboxylases.

Porphyria cutanea tarda (PCT) is caused by inhibition of uroporphyrinogen decarboxylase (URO-D) activity in hepatocytes. Subnormal URO-D activity results in accumulation and urinary excretion of uroporphyrin and heptacarboxyl porphyrin. Heterozygosity for mutations in the URO-D gene is found in the familial form of PCT (F-PCT). Over 70 mutations of URO-D have been described but very few have been characterized structurally. Here we characterize 3 mutations in the URO-D gene found in patients with F-PCT, G318R, K297N, and D306Y. Expression of the D306Y mutation results in an insoluble recombinant protein. G318R and K297N have little effect on the structure or activity of recombinant URO-D, but the proteins display reduced stability in vitro.

Longitudinal study of a mouse model of familial porphyria cutanea tarda.

Most rodent models of porphyria cutanea tarda (PCT) share in common the administration of iron and agents that induce transcription of cytochrome P450s. Dissection of changes related to porphyrin accumulation required generation of a genetic model free from exogenous precipitants. Mice heterozygous for a null Urod mutation and homozygous for null Hfe alleles spontaneously develop major increases in hepatic and urinary porphyrins several months after weaning but the high % uroporphyrin signature of PCT is established earlier, before total hepatic and urinary porphyrins rise. Total porphyrin levels eventually plateau at higher levels in females than in males. Porphyrinogens were the dominant tetrapyrroles accumulating in hepatocytes. Hepatic Urod activity is markedly reduced but total hepatic heme content does not diminish. Microsomal heme, however, is reduced and in vitro metabolism of prototype substrates showed that some but not all cytochrome P450 activities are reduced. High hepatic levels of uroporphyrinogen are also associated with increased glutathione S-transferase activity and elevated mRNA of 2 transporters, Abcc1 and Abcc4. This murine model of familial PCT affords the opportunity to study changes in porphyrinogen and porphyrin accumulation and transport in the absence of exogenous factors that alter P450 activity and transmembrane transporters.

Harderoporphyria: Case of lifelong photosensitivity associated with compound heterozygous coproporphyrinogen oxidase (CPOX) mutations.

A 78-year-old man with a history of neonatal anemia and jaundice and life-long photosensitivity was found to have harderoporphyria, as evidenced by increased porphyrins in urine, plasma, erythrocytes and feces including large amounts of harderoporphyrin in feces and erythrocytes. Two previously undescribed coproporphyrinogen oxidase (CPOX) mutations were identified, including a deletion of four amino acids in a region of the enzyme mutated in 7 of the 8 previously reported cases. This case increases the molecular heterogeneity of this rare porphyria, and illustrates that it should be considered as a cause of chronic photosensitivity and porphyrin elevation at any age.

Mutational analysis of human uroporphyrinogen decarboxylase.

Uroporphyrinogen decarboxylase (URO-D), a heme biosynthetic enzyme, catalyzes the multi-step decarboxylation reaction converting uroporphyrinogen I or III to coproporphyrinogen I or III. The URO-D protein has been purified from several sources and its gene has been cloned from many organisms. In spite of this, little is known about the active site(s) of the enzyme. Inhibitor studies suggest that cysteine and histidine residues are important for enzyme activity. We employed the Kunkel method of site-directed mutagenesis to convert each of the six cysteines in human URO-D to serine and each of the three conserved histidines to asparagine. Recombinant mutant URO-D's were expressed in Escherichia coli, partially purified, and their kinetic properties compared to recombinant wild-type URO-D. All cysteine mutants retained approx. 40% wild-type enzyme activity, indicating that no single cysteine is absolutely critical for the integrity of the catalytic site. The three histidine mutants also retained significant enzyme activity and one, (H339N), displayed unique properties. The H339N mutation resulted in an enzyme with high residual activity but decarboxylation of intermediate reaction products of the I isomer series was markedly abnormal. The histidine at residue 339 is likely important in imparting isomer specificity.

Characterization and crystallization of human uroporphyrinogen decarboxylase.

The cytosolic enzyme uroporphyrinogen decarboxylase (URO-D) catalyzes the fifth step in the heme biosynthetic pathway, converting uroporphyrinogen to coproporphyrinogen by decarboxylating the four acetate side chains of the substrate. Recombinant human URO-D has been expressed in Escherichia coli with a histidine tag and has been purified to homogeneity. Purified protein was determined to be a monodisperse dimer by dynamic light scattering. Equilibrium sedimentation analysis confirmed that the protein is dimeric, with a dissociation constant of 0.1 microM. URO-D containing an amino-terminal histidine tag was crystallized in space group P3(1)21 or its enantiomer P3(2)21 with unit cell dimensions a = b = 103.6 A, c = 75.2 A. There is one molecule in the asymmetric unit, consistent with generation of the dimer by the twofold axis of this crystallographic operator. Native data have been collected to 3.0 a resolution.

Deletion of subunit 9 of the Saccharomyces cerevisiae cytochrome bc1 complex specifically impairs electron transfer at the ubiquinol oxidase site (center P) in the bc1 complex.

Deletion of QCR9, the nuclear gene encoding subunit 9 of the mitochondrial cytochrome bc1 complex in Saccharomyces cerevisiae, results in inactivation of the bc1 complex and inability of the yeast to grow on non-fermentable carbon sources. The loss of bc1 complex activity is due to loss of electron transfer activity at the ubiquinol oxidase site (center P) in the complex. Electron transfer at the ubiquinone reductase site (center N), is unaffected by the loss of subunit 9, but the extent of cytochrome b reduction is diminished. This is the first instance in which a supernumerary polypeptide, lacking a redox prosthetic group, has been shown to be required for an electron transfer reaction within the cytochrome bc1 complex.

CYP3A-inducing agents and the attenuation of uroporphyrin accumulation and excretion in a rat model of porphyria cutanea tarda.

An experimental model of porphyria cutanea tarda (PCT) can be achieved in 3 weeks by a single injection of a mixture of polychlorinated biphenyls (Aroclor 1254) into iron-loaded female Fischer 344 rats maintained continuously on delta-aminolevulinic acid-supplemented drinking water. In this model, daily treatment with 5-pregnen-3 beta-ol-20-one-16 alpha-carbonitrile (pregnenolone 16 alpha-carbonitrile) attenuated uroporphyrin and heptacarboxylporphyrin accumulation and excretion by 75%. Pregnenolone 16 alpha-carbonitrile treatment had only a minor effect on hepatic iron stores, and it had no effect on the induction of CYP1A activities by Aroclor 1254. In the absence of Aroclor 1254, pregnenolone 16 alpha-carbonitrile had no effect on the accumulation and excretion of highly carboxylated porphyrins. Attenuation of porphyrin accumulation could also be demonstrated with daily troleandomycin treatment. Troleandomycin increased CYP3A-dependent erythromycin demethylase activity, but to a lesser extent than pregnenolone 16 alpha-carbonitrile. Much of the CYP3A induced by troleandomycin was sequestered as a catalytically inactive metabolic-intermediate complex. In the absence of Aroclor 1254, troleandomycin had no effect on the accumulation and excretion of highly carboxylated porphyrins, nor did troleandomycin alter the induction of CYP1A by Aroclor 1254. The results suggest that the major attenuation of hepatic accumulation and urinary excretion of uro- and heptacarboxylporphyrins in the rat PCT model by pregnenolone 16 alpha-carbonitrile and troleandomycin is due to an enhancement of CYP3A catalytic activity.

Pergolide mesylate treatment of cocaine withdrawal.

Side effects occasionally limit the use of bromocriptine for cocaine withdrawal. The recently released medication pergolide shares some pharmacologic properties with bromocriptine but differs in potency and dopamine receptor subtype specificity. The authors tested pergolide in the treatment of 21 patients experiencing cocaine withdrawal. Sixteen patients reported rapid improvement in sleep and decreased cocaine craving. Side effects were limited primarily to gastrointestinal complaints.

A new coagulation defect associated with a case of melanomatosis.

A marked abnormality of the intrinsic coagulation system was observed in a patient with melanomatosis and frank melanuria. With successful treatment of the tumour there was a parallel improvement in the clotting abnormality. This defect was shown to be a deficiency of factor XI together with a previously unrecognised factor. This is distinct from either Fletcher or Fitzgerald factors and appears to act between factors XI and X in the coagulation sequence.

Acute ileus from steroid withdrawal simulating intestinal obstruction after surgery for ulcerative colitis.

Sixty of 127 prednisone-dependent patients with ulcerative colitis who underwent colectomy and endorectal ileal pull-through with ileal reservoir and subsequent laparotomy with ileostomy closure (254 operations) during a 4-year period developed 95 episodes of intestinal obstruction during the early post-operative period. Acute ileus due to steroid withdrawal caused symptoms of intestinal obstruction in 43 patients (76 episodes), whereas true mechanical small-bowel obstruction occurred in only 17 patients (19 episodes). Symptoms of both conditions were similar; however, hypoactive bowel sounds, acute onset of emotional depression, no evidence of obstruction on radiologic contrast stomatogram or enema, and prompt relief of symptoms within 4 hours after intravenous administration of hydrocortisone acetate distinguished acute steroid withdrawal. Since ileus from acute steroid withdrawal occurred four times as frequently as mechanical small-bowel obstruction, prompt recognition and treatment should appreciably reduce postoperative morbidity and hospital costs.

Adaptive changes in ileal mucosal nutrient transport following colectomy and endorectal ileal pull-through with ileal reservoir.

To study ileal mucosal function when used in an ileal reservoir or ileostomy, eight dogs underwent colectomy and endorectal ileal pull-through with creation of a lateral ileal reservoir. Ileal mucosal biopsy specimens were obtained at the initial operation, from the ileostomy and dormant ileal reservoir at the time of ileostomy closure, and from the reservoir 3 months later. Rates of uptake for four different substrates were determined by radioactive absorption techniques. Absorption of carbohydrates, amino acids, and bile acids was markedly decreased and of short-chain fatty acid mildly reduced in ileal reservoir mucosa compared with normal ileum, largely owing to a decrease in reservoir absorptive surface area from flattened villi. Reservoir uptake of the substrates evaluated within 3 months after operation was similar to that for normal colonic mucosa. Uptake of all measured substrates from ileostomy mucosa approximated that of normal ileum. The use of short ileal reservoirs and the avoidance of stasis may favor reduced bacterial growth and increased nutrient absorption.

Extracorporeal membrane oxygenation in the treatment of neonatal respiratory failure.

We report 18 consecutive neonates with severe respiratory failure due to pulmonary hypertension treated with extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation was begun at 52 +/- 36 hours of age with an arterial partial pressure of oxygen (PO2) of 36 +/- 14 mm Hg despite maximal pharmacologic and ventilator support (inspired fraction of oxygen [FiO2], 0.99 +/- 0.03; respiratory rate, 98 +/- 31/min; and positive inspiratory pressure, 54 +/- 11 cm of water). With initial flows of 130 +/- 17 mL/kg per minute, ventilator settings were reduced to the following: FiO2, 0.30; respiratory rates, 15/min; and positive inspiratory pressure, 24 cm of water. Support using extracorporeal membrane oxygenation was gradually reduced to 22% of initial flows and arterial blood samples showed pH 7.48 +/- .05, PO2 of 106 +/- 27 mm Hg, and PCO2 of 36 +/- 5 mm Hg just prior to decannulation. After 107 +/- 45 hours, extracorporeal membrane oxygenation was stopped and infants were extubated 61 +/- 53 hours (median, 46 hours) afterward. There was one death (94.4% survival rate); all survivors were discharged and underwent a follow-up examination at 1 to 27 months of age. Complications included two intracranial hemorrhages (one death and one asymptomatic), one patent ductus arteriosus requiring ligation on extracorporeal membrane oxygenation, and chronic lung disease in one patient. In selected neonates, extracorporeal membrane oxygenation allows for resolution of pulmonary hypertension, results in improved survival, and is associated with a low incidence of chronic lung disease. Extracorporeal membrane oxygenation should be considered in the treatment of severe respiratory failure.

Short-term treatment with novel ribonucleotide reductase inhibitors Trimidox and Didox reverses late-stage murine retrovirus-induced lymphoproliferative disease with less bone marrow toxicity than hydroxyurea.

We evaluated the ability of a short course of treatment with the ribonucleotide reductase (RR) inhibitor hydroxyurea (HU) and two novel RR inhibitors Trimidox (TX) and Didox (DX) to influence late-stage murine retrovirus-induced lymphoproliferative disease. LPBM5 murine leukaemia virus retrovirus-infected mice were treated daily with HU, TX or DX for 4 weeks, beginning 9 weeks post-infection, after development of immunodeficiency and lymphoproliferative disease. Drug effects on disease progression were determined by evaluating spleen weight and histology. Effects on haematopoiesis were determined by measuring peripheral blood indices (white blood cells and haematocrit) and assay of femur cellularity and femoral and splenic content of colony-forming units granulocyte-macrophage (CFU-GM) and burst-forming units-erythroid (BFU-E). HU, TX and DX partially reversed late-stage retrovirus-induced disease, resulting in spleen weights significantly below pre-treatment values. Spleen histology was also improved by RR inhibitor treatment (DX>TX>HU). However, as expected, HU was significantly myelosuppressive, inducing a reduction in peripheral indices associated with depletion of femoral CFU-GM and BFU-E. In contrast, although TX and DX were moderately myelosuppressive, both drugs were significantly better tolerated than HU. In summary, short-term treatment in late-stage murine retroviral disease with HU, TX or DX induced dramatic reversal of disease pathophysiology. However, the novel RR inhibitors TX and DX had more effective activity and significantly less bone marrow toxicity than HU.

Reconstruction of malfunctioning ileoanal pouch procedures as an alternative to permanent ileostomy.

During the past 13 years, 261 patients with ulcerative colitis and 29 with colonic polyposis underwent endorectal pullthrough (ERP) at UCLA Medical Center. Of the first 111 consecutive patients to undergo ERP, 5 returned to a permanent ileostomy because of persistent symptoms related to reservoir stasis. Transabdominal shortening of the reservoir was performed in 38 of the 111 patients; 24 experienced marked clinical improvement. Fourteen of the 38 patients had persistent stasis and required shortening of the ileal spout either transanally (5 patients) or via an abdominoperineal approach (9 patients). Eighteen of the initial 111 patients underwent one-stage abdominoperineal reservoir reconstruction. During the past 4 years, 8 of 149 consecutive patients with a primary lateral isoperistaltic reservoir underwent subsequent abdominoperineal reservoir reconstruction. Fourteen of 18 patients with a straight pullthrough with reservoir underwent reconstruction to a lateral isoperistaltic reservoir. An aggressive operative approach to the management of pouchitis and reservoir stasis (diarrhea, frequency, urgency, incomplete emptying) has resulted in only 4 of the last 246 consecutive patients returning to a permanent ileostomy. Several changes in the operative technique have evolved during the 13-year period. Important features for optimal pouch function appear to include: (1) a short rectal muscle cuff, (2) a small ileal reservoir, (3) a short ileal spout, (4) removal of all rectal mucosa, and (5) aggressive correction of rectal strictures.