Inherited Neuropathies.

The inherited neuropathies are a common and heterogeneous group of slowly progressive disorders affecting motor, sensory, and autonomic nerves. These hereditary conditions can be confined to the peripheral nervous system, termed the primary hereditary neuropathies, or can occur as part of a multisystem disease. Identification of systemic involvement is necessary to distinguish the primary and secondary hereditary neuropathies to prevent the misdiagnosis of potentially treatable entities. Recent genetic and technological advances have dramatically improved our understanding of the underlying pathophysiology of these inherited neuropathies and hence provide the correct milieu for the future development of disease-modifying therapies. This review provides clinical, neurophysiological, genetic, pathophysiological, and treatment insights into the primary inherited neuropathies, and those associated with multisystem diseases, including porphyria and mitochondrial disorders.

Porphyria: A Rare, Complicated, and Misdiagnosed Disease.

Diagnosis of porphyria is often difficult due to the range of symptoms, which are common in many other disorders, hence frequently leading to misdiagnosis. Attacks can be triggered through sunlight and contact with diverse substances, including medications. Signs are severe, appear quickly, and tend to last from days to weeks, affecting the skin, mentation, the digestive, cardiovascular, nervous, and muscular system. Neuropathy signifies a severe and potentially life-threatening attack. Porphyria is mainly an inherited disorder, but can be acquired, and emerges in adults and children. The exact rates of porphyria are unknown and vary around the world. Diagnosis, clinical presentation, treatment, and disease management are introduced.

wALADin benzimidazoles differentially modulate the function of porphobilinogen synthase orthologs.

The heme biosynthesis enzyme porphobilinogen synthase (PBGS) is a potential drug target in several human pathogens. wALADin1 benzimidazoles have emerged as species-selective PBGS inhibitors against Wolbachia endobacteria of filarial worms. In the present study, we have systematically tested wALADins against PBGS orthologs from bacteria, protozoa, metazoa, and plants to elucidate the inhibitory spectrum. However, the effect of wALADin1 on different PBGS orthologs was not limited to inhibition: several orthologs were stimulated by wALADin1; others remained unaffected. We demonstrate that wALADins allosterically modulate the PBGS homooligomeric equilibrium with inhibition mediated by favoring low-activity oligomers, while 5-aminolevulinic acid, Mg(2+), or K(+) stabilized high-activity oligomers. Pseudomonas aeruginosa PBGS could be inhibited or stimulated by wALADin1 depending on these factors and pH. We have defined the wALADin chemotypes responsible for either inhibition or stimulation, facilitating the design of tailored PBGS modulators for potential application as antimicrobial agents, herbicides, or drugs for porphyric disorders.

Lon peptidase 1 (LONP1)-dependent breakdown of mitochondrial 5-aminolevulinic acid synthase protein by heme in human liver cells.

5-Aminolevulinic acid synthase (ALAS-1) is the first rate controlling enzyme that controls cellular heme biosynthesis. Negative feedback regulation of ALAS-1 by the end product heme is well documented and provides the foundation for heme treatment of acute porphyrias, a group of diseases caused by genetic defects in the heme biosynthesis pathway and exacerbated by controlled up-regulation of ALAS-1. Heme is known to affect ALAS-1 activity by repressing gene transcription, accelerating mRNA degradation, and impeding pre-ALAS-1 mitochondrial translocation. In the current study, we examined the effect of heme on the rate of mature ALAS-1 protein turnover in human cells and tissues and explored the mediator involved in this new regulatory mechanism. We found that heme and other metalloporphyrins such as CoPP and CrPP decreased mitochondrial ALAS-1 protein through proteolysis. This degradative effect cannot be emulated by iron or free protoporphyrin, two major chemical components of the heme ring, and is independent of oxidative stress. Down-regulating the activity of mitochondrial LONP1, an ATP-dependent protease that controls the selective turnover of mitochondrial matrix proteins, with potent inhibitors and specific siRNA diminished the negative effect of heme on mitochondrial ALAS-1. Therefore, our data support the existence of a conserved heme feedback regulatory mechanism that functions on the mature form of ALAS-1 protein through the activity of a mitochondrial proteolytic system.

Pseudoporphyria induced by dialysis treated with oral N-acetylcysteine.

Pseudoporphyria is a rare bullous dermatosis that clinically and histopathologically is similar to porphyria cutanea tarda. It mainly affects patients with chronic renal failure on peritoneal dialysis or hemodialysis. Medications can also be involved in the etiology. Diagnosis and management of this condition is a challenge for dermatologists. The authors report a case of pseudoporphyria related to dialysis with favorable outcome after the use of oral N-acetylcysteine.

Pseudoporfiria induzida pela diálise tratada com N-acetilcisteína oral / Pseudoporphyria induced by dialysis treated with oral N-acetylcysteine

Pseudoporfiria é dermatose bolhosa rara, semelhante clínica e histopatologicamente à porfiria cutânea tardia. Acomete, principalmente, pacientes renais crônicos em diálise peritoneal ou hemodiálise. Medicamentos também podem ser envolvidos na etiologia. O diagnóstico e o manejo desta entidade é um desafio para os dermatologistas. Os autores demonstram um caso de pseudoporfiria, relacionada à diálise, com evolução favorável após o uso de N-acetilcisteína oral.

Pseudoporphyria is a rare bullous dermatosis that clinically and histopathologically is similar to porphyria cutanea tarda. It mainly affects patients with chronic renal failure on peritoneal dialysis or hemodialysis. Medications can also be involved in the etiology. Diagnosis and management of this condition is a challenge for dermatologists. The authors report a case of pseudoporphyria related to dialysis with favorable outcome after the use of oral N-acetylcysteine.

Hemodialysis-associated pseudoporphyria resistant to N-acetylcysteine.

We report a 33-year-old female patient who had hemodialysis-associated pseudoporphyria which did not respond to treatment with oral N-acetylcysteine. She responded favorably to treatment with the anti-malarial drug, chloroquine. The case is being reported to highlight the difficulty in interpreting the urinary porphyrin assays in patients on hemodialysis. Additionally, the current literature on pseudoporphyria disorders in patients with end-stage renal disease is briefly discussed.

Porphyrias at a glance: diagnosis and treatment.

Porphyrias are a group of eight rare inherited metabolic disorders of heme biosynthesis pathway. Porphyrias are still underdiagnosed, although examinations of urine and plasma are first-line tests for detecting excess of porphyrins or heme precursors in suspected patients. Diagnosis, particularly for the acute forms, is essential to avoid precipitating factors and the use of triggering drugs. Mutation screening of family members is recommended to identify presymptomatic carriers and to prevent acute attacks. The therapeutic approach should be appropriate regarding specific forms of porphyria and treatment should be started promptly.

[Neurological complications of acute intermittent porphyria precipitated by porphyrinogenic drugs and efficiency of heme-arginate treatment]. / Complications neurologiques de la porphyrie aiguë intermittente précipitées par les médicaments porphyrinogéniques et efficacité du traitement par l'hème-arginate.

BACKGROUND: Acute intermittent porphyria (AIP) is a rare metabolic disorder of heme biosynthesis characterized by enzymatic defect of porphobiligen desaminase with accumulation and increased excretion of porphyrins and their precursors. Clinical picture is characterized by attacks with a triad of abdominal pain, psychiatric disorder and neurological involvement (central and peripheral). Peripheral nervous system manifestations, often precipitated by porphyrinogenic medications are of poor outcome. AIM: We report a new cases A 13-year-old girl who presented several attacks of AIP and developed acute severe axonal motor neuropathy, three weeks after porphyrinogenic medications (Famotidin, Phenobarbital and Nifedipine). CONCLUSION: We stress on the importance of early diagnosis of AIP to prevent serious neurological complications often precipitated by medications and the efficiency of heme arginate treatment when administrated early during the attacks.

Las Porfirias / The Porphyrias

Las porfirias son un conjunto de enfermedades –genéticas (monogenicas) o adquiridas debidas a disminución de la actividad de al menos una de las enzimas que participan en la vía de síntesis del grupo hem. Según sea la o las enzimas defectuosas, se genera una enfermedad con un patrón típico de alteraciones en la circulación, excreción y acumulación tisular de porfirinas o sus precursores, produciendo manifestaciones clínicas características para cada variedad. Se han diagnosticado en animales y en hombres de todas las razas y áreas geográficas. Se reconocen diversas variedades: la aguda intermitente particularmente frecuente en Suecia, la variegata común en la población blanca de Sudáfrica, la coproporfiria, la porfiria de Dõss de la que se han descrito unos pocos casos en el mundo, la eritropoyética congénita de muy baja prevalencia, la cutánea tarda que es lo mas frecuente de todas y que puede ser hereditaria o adquirida, en cuyo caso se relaciona con la hepatitis por virus C o B y VIH, por último la protoporfiria que suele expresarse muy tempranamente y ser causa de enfermedad hepática aguda grave que requiere trasplante hepático. En Chile hemos identificado la mayor parte de las variedades, existiendo tanto casos de origen europeo como de pueblos originarios. Los portadores de mutaciones genéticas pueden presentar una enfermedad clínicamente evidente o una asintomática o latente, en la que incluso puede no haber alteraciones metabólicas detectables. Los periodos sintomáticos y de latencia pueden alternarse, pero la mayoría de los enfermos tiene la enfermedad latente a lo largo de toda su vida. Las manifestaciones clínicas que se pueden observar en las porfirias son: crisis agudas, alteraciones cutáneas y diversas complicaciones tales como hepatopatias. Las primeras consisten en episodios, dramáticos por su gravedad, de alteraciones neurológicas, psíquicas, cardiovasculares, digestivas, urinarias y de compromiso del estado general que incluye hiponatremia.

A case of haemodialysis-associated pseudoporphyria successfully treated with oral N-acetylcysteine.

We report a 33-year-old woman with haemodialysis-associated pseudoporphyria successfully responding to treatment with oral N-acetylcysteine. We briefly review the current literature on bullous skin disorders in end-stage renal disease, and compare and contrast the pathogenesis of pseudoporphyria and porphyria cutanea tarda in this context. We also discuss the antioxidant properties and clinical applications of N-acetylcysteine, including the treatment of haemodialysis-associated pseudoporphyria.

[Laboratory tests and therapeutic strategies for the porphyrias]. / Labordiagnostik und Therapie der Porphyrien.

The porphyrias are a heterogeneous group of predominantly hereditary metabolic diseases resulting from a dysfunction of heme biosynthesis. Most of the porphyrias can manifest with a broad range of cutaneous symptoms on the sun-exposed areas of the body, whereas other variants reveal life-threatening acute neurological attacks. Further, mixed types of porphyrias exist. Besides the skin, other organs can be affected, such as the liver and the central nervous system. Therefore, interdisciplinary supervision of these patients is mandatory. In this review we will first present the clinical picture and diagnosis of the porphyrias, including the specific biochemical laboratory tests and a diagnostic algorithm. Thereafter, the current therapeutic concepts will be briefly addressed. Finally, we introduce the European Porphyria Initiative (EPI), an association of various European porphyria centers that is aiming at gathering the broad experience of internationally renowned porphyria experts for the development of European consensus guidelines for diagnosis and treatment of these metabolic disorders.

Aminolevulinic acid: from its unique biological function to its star role in photodynamic therapy.

Porphyrins are molecules essential for life. They are involved in the key processes of photosynthesis and respiration. The biosynthesis of tetrapyrroles in all living cells occurs through several steps where the formation of aminolevulinic acid (ALA) is the first committed intermediate. Two alternative routes for the formation of ALA have been proposed: one involves the condensation of Succinyl CoA and glycine catalyzed by ALA synthetase taking place in the mitochondria, and the second one is the so called 5-carbon route, occurring in the stroma of plastids. Eight molecules of ALA are used in the formation of protoporphyrin IX. Specific deficiencies in one of the enzymes of the heme pathway produce the porphyrias. In the acute porphyrias, the pathogenesis of the neurological dysfunction is attributed to the accumulation of ALA. Fluorescent and photosensitizing properties of protoporphyrin accumulated after the exogenous administration of ALA, can be used to visualize and destroy malignant cells in the so-called photodynamic diagnosis (PDD) and photodynamic therapy (PDT) of cancer. Many clinical ALA-PDT applications to malignant and non-malignant pathologies are currently in use. Different approaches to enhance ALA penetration in cells are under investigation, including the use of more lipophilic ALA derivatives and studies of the transport mechanisms of ALA. ALA has also been proposed to be used as a biodegradable herbicide, as an insecticide and as a plant growth regulator.

Pseudoporfiria en paciente dializada / Pseudoporphyria in a dialyzed patient

Se presenta el caso de una paciente de 34 años de edad con insuficiencia renal crónica de varios años de evolución. A los 6 meses de empezar el tratamiento con hemodiálisis presentó lesiones clínica e histológicamente características de pseudoporfiria. A su vez presentaba niveles normales de porfirinas en sangre. Se inició el tratamiento con N-acetilcisteína a razón de 600 mg dos veces al día (AU)

Volatile anaesthetics induce biochemical alterations in the heme pathway in a B-lymphocyte cell line established from hepatoerythropoietic porphyria patients (LBHEP) and in mice inoculated with LBHEP cells.

Hepatoerythropoietic porphyria (HEP) is the homozygous form of Porphyria Cutanea Tarda (PCT), characterized by an accumulation of porphyrins due to uroporphyrinogen decarboxylase deficiency. Fluorinated volatile anaesthetics are often used to produce general anaesthesia. Anaesthesia has certainly been implicated in the triggering of acute porphyria crisis. The effects of volatile anaesthetics in a B-lymphocyte cell line established from HEP patients (LBHEP) on heme metabolism have been investigated.LBHEP cells were exposed to sodium phosphate buffer containing dissolved Enflurane, Isoflurane or Sevoflurane (10mM) during 20min. Aminolevulinate synthase (ALA-S) activity, the regulatory enzyme of heme synthesis, was 300% induced by the anaesthetics. A 25-30% diminution of porphobilinogenase (PBG-ase) activity was found when Isoflurane or Sevoflurane were added to the cells, while no significant changes were detected after Enflurane treatment. Although some oxidative stress has been induced by the anaesthetics, reflected by the 35% diminution of glutathione (GSH), no alteration in heme oxygenase (HO) activity, the enzyme involved in heme breakdown and frequently induced as a response to stress stimuli, was observed. Studies using animals inoculated with LBHEP cells were also performed. Findings here described mimic biochemical alterations in the heme pathway, which are characteristic of another hepatic porphyria, similar to those previously reported when these anaesthetics were administered to animals, and they also advertise about the possible unsafe use of these drugs in the case of hepatic non-acute porphyrias.