The Hepatic Porphyrias: Revealing the Complexities of a Rare Disease.

The porphyrias are a group of metabolic disorders that are caused by defects in heme biosynthesis pathway enzymes. The result is accumulation of heme precursors, which can cause neurovisceral and/or cutaneous photosensitivity. Liver is commonly either a source or target of excess porphyrins, and porphyria-associated hepatic dysfunction ranges from minor abnormalities to liver failure. In this review, the first of a three-part series, we describe the defects commonly found in each of the eight enzymes involved in heme biosynthesis. We also discuss the pathophysiology of the hepatic porphyrias in detail, covering epidemiology, histopathology, diagnosis, and complications. Cellular consequences of porphyrin accumulation are discussed, with an emphasis on oxidative stress, protein aggregation, hepatocellular cancer, and endothelial dysfunction. Finally, we review current therapies to treat and manage symptoms of hepatic porphyria.

Single-incision laparoscopic partial cecectomy for appendiceal mucocele in a patient with porphyria photosensitivity.

Erythropoietic protoporphyria (EPP) is a rare hereditary subtype of cutaneous porphyria characterized by photosensitivity. Increased exposure to light irradiation may precipitate acute liver failure, and surgical light-induced intestinal burns and perforations are known to occur. We report a case of EPP in a patient who underwent laparoscopic partial cecectomy for appendiceal mucocele. A 55-year-old man with EPP was presented for treatment of appendiceal mucocele. A light test using two types of laparoscopes (Companies O and S) was performed preoperatively. Light from the laparoscope manufactured by Company O caused photosensitivity; this effect was not observed with light from the laparoscope manufactured by Company S. Therefore, we performed laparoscopic partial cecectomy through a single umbilical incision using the laparoscope from Company S. Except for the incision site, the patient's skin was completely covered using surgical drapes. No intra- or postoperative complications were observed. Histopathological examination of the resected specimen revealed a low-grade appendiceal mucinous neoplasm.

Photodermatoses: what's new.

PURPOSE OF REVIEW: The purpose of this review is to summarize and highlight the recent literature in photodermatoses. In the past year, there have been many developments in this heterogeneous group of conditions. RECENT FINDINGS: This review is divided by photodermatoses type, which include idiopathic photodermatoses, photodermatoses secondary to exogenous agents, photodermatoses secondary to endogenous agents (the porphyrias), and genodermatoses. The idiopathic photodermatoses section focuses on case series and reports highlighting new disease presentations or further disease characterization and new treatment strategies for these disorders. The second section discusses a unique case and has a brief update on photoallergens. Clinical, diagnostic, and treatment updates for porphyrias are discussed in Section 3. For genodermatoses, we discuss complications and neoplastic risk of xeroderma pigmentosum and a few highlights from other rare disorders. Finally, we conclude with a brief overview of photoprotection updates, from assessing sun-damaged skin to the most effective photoprotective agents. SUMMARY: Up-to-date information will help providers identify and manage this rare group of disorders.

Loss of hepatocyte ß-catenin protects mice from experimental porphyria-associated liver injury.

BACKGROUND & AIMS: Porphyrias result from anomalies of heme biosynthetic enzymes and can lead to cirrhosis and hepatocellular cancer. In mice, these diseases can be modeled by administration of a diet containing 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC), which causes accumulation of porphyrin intermediates, resulting in hepatobiliary injury. Wnt/ß-catenin signaling has been shown to be a modulatable target in models of biliary injury; thus, we investigated its role in DDC-driven injury. METHODS: ß-Catenin (Ctnnb1) knockout (KO) mice, Wnt co-receptor KO mice, and littermate controls were fed a DDC diet for 2 weeks. ß-Catenin was exogenously inhibited in hepatocytes by administering ß-catenin dicer-substrate RNA (DsiRNA), conjugated to a lipid nanoparticle, to mice after DDC diet and then weekly for 4 weeks. In all experiments, serum and livers were collected; livers were analyzed by histology, western blotting, and real-time PCR. Porphyrin was measured by fluorescence, quantification of polarized light images, and liquid chromatography-mass spectrometry. RESULTS: DDC-fed mice lacking ß-catenin or Wnt signaling had decreased liver injury compared to controls. Exogenous mice that underwent ß-catenin suppression by DsiRNA during DDC feeding also showed less injury compared to control mice receiving lipid nanoparticles. Control livers contained extensive porphyrin deposits which were largely absent in mice lacking ß-catenin signaling. Notably, we identified a network of key heme biosynthesis enzymes that are suppressed in the absence of ß-catenin, preventing accumulation of toxic protoporphyrins. Additionally, mice lacking ß-catenin exhibited fewer protein aggregates, improved proteasomal activity, and reduced induction of autophagy, all contributing to protection from injury. CONCLUSIONS: ß-Catenin inhibition, through its pleiotropic effects on metabolism, cell stress, and autophagy, represents a novel therapeutic approach for patients with porphyria. LAY SUMMARY: Porphyrias are disorders resulting from abnormalities in the steps that lead to heme production, which cause build-up of toxic by-products called porphyrins. Liver is commonly either a source or a target of excess porphyrins, and complications can range from minor abnormalities to liver failure. In this report, we inhibited Wnt/ß-catenin signaling in an experimental model of porphyria, which resulted in decreased liver injury. Targeting ß-catenin affected multiple components of the heme biosynthesis pathway, thus preventing build-up of porphyrin intermediates. Our study suggests that drugs inhibiting ß-catenin activity could reduce the amount of porphyrin accumulation and help alleviate symptoms in patients with porphyria.

The eye and the skin in nonendocrine metabolic disorders.

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

El uso de placebo en ensayos clínicos de fase III en Brasil / The use of placebos in phase III clinical trials in Brazil

El Consejo Federal de Medicina de Brasil (CFM) -órgano normativo y fiscalizador del ejercicio ético de la medicina- prohibió, en 2008, la participación de médicos brasileños en investigaciones que utilizaran placebo para enfermedades con tratamiento eficaz y efectivo, en contraposición a la Declaración de Helsinki, que permite su uso en condiciones metodológicamente justificadas. Con el objetivo de verificar si la normativa ética del CFM modificó el uso de placebo en ensayos clínicos de fase III en Brasil, se analizaron varias características de sus registros en el ClinicalTrials.gov, en los períodos de 2003 a 2007 y de 2009 a 2013. Se concluye que: a) la normativa promulgada por el CFM en 2008 fue ineficaz y prevaleció la posición adoptada por la Declaración de Helsinki; b) el patrocinio de ensayos con placebo por parte de la industria farmacéutica multinacional fue significativo; c) predominaron las investigaciones de fármacos para enfermedades crónicas, y fueron poco significativas para las enfermedades postergadas, de importancia para Brasil.

In 2008, Brazil's Federal Council of Medicine [Conselho Federal de Medicina] (CFM) - regulatory and supervisory agency on the ethical practice of medicine - banned the participation of Brazilian doctors in studies using placebos for diseases with efficient and effective treatment. This position differs with the Helsinki Declaration, which allows the use of placebos in methodologically justified conditions. To ascertain whether the CMF's ethical regulation modified the use of placebos in phase III clinical trials in Brazil, characteristics of the records in ClinicalTrials.gov were researched in the periods from 2003 to 2007 and from 2009 to 2013. The conclusions reached were: a) the regulations issued by the CFM in 2008 were ineffective and the position adopted by the Helsinki Declaration prevails; b) there was significant sponsorship by the multinational pharmaceutical industry of trials with placebos; c) the research was predominantly on new drugs for chronic diseases, with little study done of the neglected diseases which are of great importance to Brazil.

[Skin and chronic kidney disease]. / Il coinvolgimento cutaneo nelle patologie metaboliche associate a malattia renale cronica.

Kidneys and skin are seldom considered associated, but their relationship is more closer than generally believed. In some immunological diseases (SLE...) and genetic syndromes (tuberous sclerosis, Fabrys disease...) the cutaneous manifestations are integral parts of the clinical picture. In advanced uremia, besides the well-known itching skin lesions, calciphylaxis may appear, a typical example of cutaneous involvement secondary to the metabolic complications (calcium-phosphate imbalance) of the renal disease. Nephrogenic systemic fibrosis appears only in patients with renal failure and it has a very severe prognosis due to the systemic organ involvement. Moreover, there is a heterogeneous group of metabolic diseases, with renal involvement, that may be accompanied by skin lesions, either related to the disease itself or to its complications (diabetes mellitus, porphyrias). In systemic amyloidosis, fibrils may deposit even in dermis leading to different skin lesions. In some heroin abusers, in the presence of suppurative lesions in the sites of needle insertion, renal amyloidosis should be suspected, secondary to the chronic inflammation. Atheroembolic disease is nowadays frequently observed, as a consequence of the increasing number of invasive intravascular manoeuvres. Skin manifestations like livedo reticularis or the blue toe syndrome are the most typical signs, but often renal dysfunction is also present. In all these conditions, the skin lesion may be a first sign, a warning, that should arouse the suspicion of a more complex pathology, even with renal involvement. Being aware of this relationship is fundamental to accelerate the diagnostic process.

Medical conditions with neuropsychiatric manifestations.

Medical disease sometimes affects patients through neuropsychiatric manifestations. When neuropsychiatric symptoms are predominant, identifying medical disease early in the illness course is imperative because many of these conditions are reversible with appropriate treatment. A high index of suspicion is required on the part of clinicians, particularly when patients also present with physical signs or unexplained symptoms that might suggest a broader, systemic process. The processes that most commonly cause neuropsychiatric symptoms include infectious, autoimmune, endocrinologic, metabolic, and neoplastic diseases. This article focuses on the most common of these conditions, and conditions for which early diagnosis and treatment are particularly important.

Acute non-cancer mortality excess after polychlorinated biphenyls and polychlorinated dibenzofurans mixed exposure from contaminated rice oil: Yusho.

In Japan in 1968, rice-oil contaminated by polychlorinated biphenyls and polychlorinated dibenzofurans caused severe food poisoning, termed "Yusho" (oil disease). Several previous studies attempted to evaluate the effects targeting officially-certified Yusho patients. However, these studies have several limitations such as the left-truncated nature of the registry or residual confounding arising from the referent population selection. We thus conducted an area-based standardized mortality ratios (SMRs) study using vital statistics. A severely affected area (Tamanoura area) was adopted as the exposure group, with a reference population from Nagasaki prefecture in Kyushu, which included the Tamanoura. A large number of residents in Tamanoura were exposed to the rice-oil (28% of all the certified cases as of 2009). We estimated SMRs of non-cancer and cancer diseases for the years 1968-2002. Shortly after the exposure, SMRs of all causes, diabetes mellitus, cardiovascular disease, pneumonia/bronchitis, and bronchus/lung cancer were elevated. In particular, SMRs of heart disease were 1.97 [95% confidence intervals (CI): 1.09-3.56] in 1968, 2.05 (95% CI: 1.16-3.60) in 1969, and 1.89 (95% CI: 1.05-3.41) in 1975. However, we did not observe clear increase in SMRs more than 10 years after the exposure. This study provides further evidence in Yusho, especially on acute effects on non-cancer mortality.

Dor neuropática em paciente com porfiria: relato de caso / Neuropathic pain in a patient with porphyria: case report / Dolor neuropático en paciente con porfiria: relato de caso

JUSTIFICATIVA E OBJETIVOS: As porfirias são um grupo de distúrbios herdados ou adquiridos que envolvem enzimas participantes do processo de síntese do heme. As manifestações agudas afetam o sistema nervoso, resultando em dor abdominal, vômitos, neuropatia aguda, convulsões e distúrbios mentais. A fisiopatogenia resulta do efeito tóxico dos precursores de porfirina, podendo ser desencadeada por fármacos usados de rotina na prática médica, restrição intensa de carboidratos e estresse metabólico. O objetivo deste trabalho foi apresentar um caso de porfiria de diagnóstico tardio, evoluindo para dor crônica. RELATO DO CASO: Paciente do sexo feminino, 27 anos, internada há 5 meses com dor abdominal intensa sem diagnóstico clínico. Foi indicada laparotomia exploradora, a qual não evidenciou causa para o quadro. A paciente, exposta a trauma cirúrgico e medicamentos que desencadeiam crise de porfiria, como cetoprofeno, metoclopramina e antibióticos, evoluiu com hiponatremia importante, elevação de enzimas hepáticas, convulsão e perda dos movimentos, sendo internada em Unidade de Terapia Intensiva. Após diagnóstico de porfiria, manteve dor em membros inferiores, sendo encaminhada para tratamento no Serviço de Dor da Santa Casa de Misericórdia de São Paulo. Iniciou tratamento com amitriptilina, gabapentina, opioide e analgésicos simples, mas continuou apresentando crises recorrentes da porfiria e, insegura quanto à condução do caso, abandonou o acompanhamento. CONCLUSÕES: A porfiria é um dos raros grupos de distúrbios enzimáticos que permanecem desconhecidos por grande parte dos profissionais de saúde. O paciente, ao perceber esse desconhecimento sobre a doença, tem seu nível de estresse e insegurança com o tratamento aumentado, dificultando a adesão e a continuidade ao mesmo.

BACKGROUND AND OBJECTIVES: Porphyrias represent a group of inherited or acquired disorders that involve enzymes that participate in heme synthesis. Acute manifestations affect the nervous system resulting in abdominal pain, vomiting, acute neuropathy, seizures, and mental disorders. The physiopathogeny results from the toxic effects of porphyrin precursors, and it can be triggered by drugs used routinely in medical practice, severe carbohydrate restriction, and metabolic stress. The objective of this report was to present the case of a late onset porphyria evolving to chronic pain. CASE REPORT: This is a 27 years old female who was admitted 5 months prior to her clinic appointment with severe abdominal pain without diagnosis. An exploratory laparotomy was indicated, which failed to demonstrate a cause for her pain. The patient was exposed to surgical trauma and drugs that can trigger porphyria, such as ketoprophen, metoclopramide, and antibiotics, and she evolved with significant hyponatremia, increased liver enzymes, seizures, and loss of movements that led to be admitted to the Intensive Care Unit. After the diagnosis of porphyria was made, the patient remained with pain in the lower limbs, being referred to the Pain Department of Santa Casa de Misericórdia de São Paulo. Treatment with amitriptyline, gabapentin, opioid, and simple analgesics was instituted; however, the patient continued to present recurring episodes of porphyria and, feeling insecure with the conduction of the case, she stopped the treatment. CONCLUSIONS: Porphyria is one of the rare groups of enzymatic disorders that remain unknown by the great majority of health professionals. Upon recognizing this lack of knowledge about the disease, the level of stress and insecurity of the patient increases hindering adhesion to and continuity of the treatment.

JUSTIFICATIVA Y OBJETIVOS: Las porfirias son un grupo de disturbios heredados o adquiridos que involucran las enzimas participantes en el proceso de síntesis del grupo hemo. Las manifestaciones agudas afectan el sistema nervioso, trayendo como resultando el dolor abdominal, vómitos, neuropatía aguda, convulsiones y disturbios mentales. La fisiopatogenia es el resultado del efecto tóxico de los precursores de la porfirina, pudiendo ser desencadenada por fármacos usados como rutina en la práctica médica, la restricción intensa de carbohidratos y por el estrés metabólico. El objetivo de este trabajo fue presentar un caso de porfiria de diagnóstico tardío, que evolucionó para dolor crónico. RELATO DEL CASO: Paciente del sexo femenino, 27 años, ingresada hace 5 meses, con dolor abdominal intenso sin diagnóstico clínico. Fue indicada la laparotomía exploradora, que no mostró la causa para el cuadro. La paciente, expuesta al trauma quirúrgico y a los medicamentos que desencadenan crisis de porfiria, como el ceprofeno, la metoclopramina y los antibióticos, evolucionó con importante hiponatremia, elevación de enzimas hepáticas, convulsión y pérdida de los movimientos, y tuvo que ser ingresada en una Unidad de Cuidados Intensivos. Después del diagnóstico de porfiria, continuó con el dolor en los miembros inferiores y tuvo que ser derivada al Servicio de Dolor de la Santa Casa de Misericordia de São Paulo para tratamiento. Empezó el tratamiento con amitriptilina, gabapentina, opioide y analgésicos sencillos, pero continuó presentando crisis recurrentes de porfiria y como estaba insegura en cuanto a la conducción del caso, abandonó el acompañamiento. CONCLUSIONES: La porfiria es uno de los raros grupos de disturbios enzimáticos que permanecen sin conocerse por una gran parte de los profesionales de la salud. El paciente, al darse cuenta que no conoce la enfermedad, se estresa mucho más y se siente muy inseguro con respecto al tratamiento, dificultando su aplicación y continuidad.

Entre la locura y el poder: La vida de Jorge III de Inglaterra / Between madness and power: The life of George III of England

En tiempo de las Invasiones Inglesas reinaba en Gran Bretaña Jorge III (1738-1820), singular personaje afectado por crisis demenciales temporarias que lo inhabilitaban para gobernar. El soberano padecía de porfiria, enfermedad metabólica que cursa con brotes de esquizofrenia. Debió superar muchos cambios políticos, la Guerra de los Siete Años y la Guerra de la Independencia de Gales, luego de haber designado primer ministro a Williams Pitt. Después de un ataque muy severo sufrido por el monarca en 1788, el doctor Richard Warren emitió un veredicto decisivo: Rex noster insanita (nuestro rey está loco), refiriéndose a su paciente regio, que murió ciego, sordo y en estado de demencia senil. La dimensión patológica de Jorge III ha sido evaluada por el historiador Vivian Green, profesor de Oxford, quien determinó que más que una tragedia pública, la locura del rey inglés fue una desgracia personal.

At the time of the English Invasions, George III (1738-1820) reigned in Great Britain; a singular character affected by temporary dementia crisis that inhibit him to reign. The King suffered of porphyria, a metabolic disease with frequent outbreaks of schizophrenia. He had to overcome many political changes, the Seven Years' War and the Welsh Independence's War, after appointing Williams Pitt as prime minister. After a very severe attack undergone by the monarch in 1788, doctor Richard Warren issued a decisive verdict: Rex noster insanita (our king is crazy), referring to his regal patient, who died blind, deaf and in a state of senile dementia. The pathological dimension of George III has been evaluated by the historian Vivian Green, an Oxford professor, who determined that more than a public tragedy, the madness of the British king was a personal misfortune.

Precautions to be taken by radiologists and radiographers when prescribing hyoscine-N-butylbromide.

Hyoscine-N-butylbromide (Buscopan, Boehringer Ingelheim) is a widely used antispasmodic in radiological practice. There seems to be no consensus as to best practice within radiology regarding the precautions that need to be taken when prescribing Buscopan. We have performed a thorough review of the available literature and make the following recommendations to those administering Buscopan: (1) enquire whether there is an allergic history; (2) ensure patient literature warns that "in the rare event that following the examination you develop painful, blurred vision in one or both eyes, you must attend hospital immediately for assessment"; (3) warn patients to expect blurred vision and not to drive until this has worn off; (4) remind clinicians that special consideration needs to be given as to the method of investigating patients with cardiac instability, such as those recently admitted with acute coronary syndrome, recurrent cardiac pain at rest, uncontrolled left ventricular failure and recent ventricular arrhythmias.

Manifestaciones anatomoclínicas de las enfermedades cutáneas metabólicas y sistémicas misceláneas: Parte II / Anatomoclinical manifestations of metabolic and systemic diseases: Part II

Numerosas enfermedades sistémicas y metabólicas tienen manifestaciones cutáneas, muchas de estas manifestaciones pueden favorecer su diagnóstico. Dado el gran número de estas patologías, esta revisión no pretende ser un análisis exhaustivo de todas ellas, sino que presenta un análisis clínico-patológico de algunas enfermedades metabólicas y sistémicas seleccionadas.

Numerous systemic and metabolic diseases have coetaneous manifestations, many of these manifestations can favor diagnosis Due to the great number of these conditions, this review does not try to be a comprehensive analysis of all of them, but present a clinicopathological analysis of some selected metabolic and systemic diseases.

[Iron overload and chronic liver diseases]. / Surcharges en fer et maladies chroniques du foie.

Several liver diseases can be associated with liver iron overload: alcohol liver disease, non alcoholic fatty liver disease, chronic viral hepatitis and porphyria cutanea tarda. These diseases are frequently associated with abnormal iron tests but iron overload is infrequent. Hyperferritinemia in these patients can be explained by cellular necrosis, synthesis increase, inflammation and iron overload. Research of C282Y mutation should be performed in patients who stopped alcohol for at least 1 or 2 weeks and transferrin saturation > 45%. Several studies are conducted to explore the mechanisms of iron overload and the role of iron in hepatic fibrogenesis and carcinogenesis. These studies will help to better define the role of venesection and iron chelators in patients with chronic liver diseases.

Heme deficiency suppresses the expression of key neuronal genes and causes neuronal cell death.

Defective heme synthesis may cause acute porphyrias, which are associated with a wide array of neurological disturbances involving both the central and peripheral nervous systems. Thus, the understanding of the roles of heme in neuronal cell function may provide insights into the molecular events underlying the pathogenesis of neuropathies associated with defective heme synthesis. In this report, we use rat pheochromocytoma (PC12) clonal cells as a model system for studying the role of heme in neuronal cell survival. We examined the effects of inhibition of heme synthesis on signaling pathways and gene expression in nerve growth factor (NGF)-induced PC12 cells. We found that succinyl acetone-induced heme deficiency selectively caused apoptosis in NGF-induced PC12 cells. Further, we found that in succinyl acetone-treated, NGF-induced cells, the pro-survival Ras-ERK1/2 signaling pathway was inactivated and the pro-apoptotic JNK signaling pathway was activated. In these cells, the activation of caspase and the cleavage of nuclear poly (ADP-ribose) polymerase (PARP) were also evident. Importantly, microarray gene expression analysis showed that more than 20 key neuronal genes that were induced by NGF were suppressed by succinyl acetone. These genes include those encoding survival motor neuron protein, synaptic vesicle protein SVOP, and neural cell adhesion molecule NCAM. These results indicate that heme is important for neuronal cell signaling and the proper functioning of neuronal cells.

[Acute abdomen]. / Akutes Abdomen.

Acute abdomen is not a disease entity on its own but describes a critical state of the patient which can be caused by numerous diseases. The surgeon and internist have to apply an interdisciplinary approach to enable a rapid decision on whether immediate laparotomy is mandatory. Few appropriate diagnostic procedures support decision making. In many cases there is an indication for immediate surgery, such as perforated gastric or duodenal ulcer, acute appendicitis, diverticulitis, ruptured aortic aneurysm, mechanic ileus, infarction of the mesenteric artery. This review is mainly focused on diseases which may present as acute abdomen but for which surgery is usually not indicated, such as acute pancreatitis. Furthermore, one also has to consider rare diseases in which laparotomy would clearly be a mistake, such as acute intermittent porphyria or intestinal pseudo-obstruction.