A R59W mutation in human protoporphyrinogen oxidase results in decreased enzyme activity and is prevalent in South Africans with variegate porphyria.

Variegate porphyria (VP), a low-penetrant autosomal dominant inherited disorder of haem metabolism, is characterised by photosensitivity (Fig. 1) and a propensity to develop acute neuropsychiatric attacks with abdominal pain, vomiting, constipation, tachycardia, hypertension, psychiatric symptoms and, in the worst cases, quadriplegia. Acute attacks, often precipitated by inappropriate drug therapy, are potentially fatal. While earlier workers thought the distal haem biosynthetic enzyme ferrochelatase may be involved in the genesis of VP, it was shown in the early 1980's, and is now accepted, that VP is associated with decreased protoporphyrinogen oxidase activity (PPO) (E.C.1.3.3.4). VP prevalence is much higher in South Africa than elsewhere; probably due to a founder effect with patients descending from a 17th century Dutch immigrant. PPO cDNAs from Bacillus subtilis, Myxococcus xanthus, human placenta and mouse liver have been cloned, sequenced and expressed. Human and mouse cDNAs consist of open reading frames 1431 nucleotides long, encoding a 477 amino acid protein. The human PPO gene contains thirteen exons, spanning approximately 4.5 kb. We have identified a C to T transition in codon 59 (in exon 3) resulting in an arginine to tryptophan substitution (R59W). A protein expressed from an in vitro-mutagenized PPO construct exhibits substantially less activity than the wild type. The R59W mutation was present in 43 of 45 patients with VP from 26 of 27 South African families investigated, but not in 34 unaffected relatives or 9 unrelated British patients with PPO deficiency. Since at least one of these families is descended from the founder of South African VP, this defect may represent the founder gene defect associated causally with VP in South Africa.

The expression of protoporphyrinogen oxidase in human tissues.

Protoporphyrinogen oxidase is the penultimate enzyme in the haem biosynthetic pathway. In this study, the expression of protoporphyrinogen oxidase in a variety of human organs has been documented by immunohistochemical means at the light microscopy level in order to shed light on its inter- and intra-organ distribution. The expression varied amongst organs and the various cell types within an organ. The pattern of staining generally reflected presumed metabolic functionality and haem demand. Strongest staining was noted in hepatocytes, proximal convoluted tubules of the kidney, serous cells of the peribronchial gland in the lung, parietal cells of the stomach, tips of the villi in the small intestine and interstitial cells of the testis. Our results suggest that there are some significant sites of haem synthesis in addition to the liver and bone marrow, and should be borne in mind in studies related to haem or porphyrin dynamics and flux.

Molecular characterization of erythropoietic protoporphyria in South Africa.

BACKGROUND: Erythropoietic protoporphyria (EPP) results from a partial deficiency of ferrochelatase (FECH). Clinical expression normally requires coinheritance of a common hypomorphic FECH allele (IVS3-48C) in trans to a deleterious (primary) FECH mutation. OBJECTIVES: To characterize South African subjects with EPP, by identification and assessment of FECH sequence variations, including the IVS3-48C polymorphism. METHODS: Polymerase chain reaction amplification, single-strand conformational polymorphism analysis and restriction endonuclease analysis were employed to identify and determine the frequencies of FECH sequence variations, including the IVS3-48C polymorphism, in a study cohort of symptomatic and asymptomatic South African EPP family members, and a matched control cohort. RESULTS: We identified 29 patients from 18 families. With the exception of one family, who may represent a phenocopy of EPP, the presentation of EPP was typical. All were of European immigrant stock, and we have not identified EPP in other ethnic groups. Ten sequence variations were identified, including four apparent disease-causing mutations, the IVS3-48T/C polymorphism and five further polymorphisms. The molecular basis of EPP was established for 15 of the 17 families. A 5-bp deletion in exon 7 (757_761delAGAAG) was present in 12 of these families and haplotype studies in these families suggested a single mutational event and thus a local founder effect for this deletion. The other mutations were family specific and included two previously described splice-site mutations (IVS3+2T>G and IVS7+1G>A) and a novel 7-bp deletion in exon 4 (356_362delTTCAAGA). CONCLUSIONS: The IVS3-48C allele appears to modulate the phenotypic expression of EPP in the South African EPP cohort as observed in other populations.

Hepatoerythropoietic porphyria precipitated by viral hepatitis.

Porphyria cutanea tarda (PCT), the condition resulting from a deficiency of hepatic uroporphyrinogen decarboxylase activity, is the commonest form of porphyria. Both acquired and familial form exist and are commonly associated in adults with liver disease and hepatic iron overload. The condition is extremely rare in children; most cases of childhood PCT are familial and some particularly severe cases have been shown to have a hepatoerythropoietic porphyria or homozygous uroporphyrinogen decarboxylase deficiency. A case is described of hepatoerythropoietic porphyria in which the disease was first precipitated at the age of two by a coincidental hepatitis A infection and improved as the hepatitis cleared. This paper reviews the evidence that viral hepatitis may precipitate overt PCT in children in a manner analogous to the precipitation of PCT in adults by alcohol associated liver disease.

Purification of human erythrocyte porphobilinogen deaminase.

Human erythrocyte porphobilinogen deaminase was isolated using ammonium sulphate fractionation and heat treatment, Sephadex G-25 and G-100 chromatography, di-ethylamino-ethyl anion-exchange chromatography, chromatofocusing over a pH gradient of 7-4 and, finally, hydrophobic interaction chromatography on a phenyl-Sepharose column. The enzyme appeared pure as judged by sodium-dodecylsulphate-polyacrylamide gel electrophoresis with silver staining, and yielded a 7 115-fold purification.

Propofol as an i.v. anaesthetic induction agent in variegate porphyria.

The choice of an i.v. anaesthetic induction poses problems for the anaesthetist confronted with a patient with one of the acute porphyrias. We undertook a prospective clinical trial in 13 variegate porphyric subjects using propofol as an anaesthetic induction agent. Urinary porphyrin precursors and porphyrins were measured before operation and 1-5 days after operation. Stool and plasma porphyrin concentrations were measured over the same period. Comparison of these data in the porphyric patients and in 21 control subjects over the trial period revealed no significant change in porphyrin or porphyrin precursor output after operation. Urinary porphyrin precursor concentrations did not exceed the limits established for variegate porphyric patients in remission, and there were no changes in the stool and plasma porphyrin profiles or any symptoms of an acute porphyric attack. We conclude that propofol did not appear to be porphyrinogenic when used for the induction of anaesthesia in 13 patients with variegate porphyria.

The effect of oral activated charcoal on the course of congenital erythropoietic porphyria.

The administration of oral activated charcoal to two patients with congenital erythropoietic porphyria has previously been reported to result in a marked reduction in plasma and urinary porphyrin concentrations and in one case, clinical remission. We describe an additional case in which the use of charcoal was associated with an apparent exacerbation of the biochemical activity of the disease following an initial period of remission. This result is unexpected, and currently unexplained. We conclude that charcoal therapy in porphyria may not be without risk, and should be used with caution.

A systematic study of the clinical and biochemical expression of variegate porphyria in a large South African family.

BACKGROUND: Variegate porphyria (VP) is an autosomal dominant disorder associated with deficient haem synthesis. Recent reports indicate that the clinical penetrance of VP may have been overestimated in studies which predated the availability of DNA-based testing for VP. OBJECTIVES: To undertake a study specifically designed to assess the clinical and biochemical penetrance of VP in a kindred characterized by gene status. METHODS: We studied a large family carrying the South African founder mutation which is known to result in almost complete haplodeficiency. All informative members were tested for the R59W mutation. Biochemical evidence of porphyria was sought by porphyrin analysis and by plasma fluorescence scanning. The presence of clinically expressed porphyria was assessed using a structured questionnaire and telephone or personal interview. RESULTS: Of 62 informative subjects, 33 had inherited the mutation. Of 28 adults, one subject had experienced a single acute attack. She and a further 10 subjects had experienced photosensitivity. The frequency of acute attacks in this family is therefore 4% (95% confidence interval, CI 1-18%), and of photosensitivity is 39.3% (95% CI 24-58%). The sensitivity and specificity of porphyrin analysis in this family were 0.46 (95% CI 0.30-0.64) and 1.00 (95% CI 0.85-1.00), respectively, and for plasma scanning the values were 0.85 (95% CI 0.58-0.96) and 1.00 (95% CI 0.72-1.00), respectively. CONCLUSIONS: The clinical penetrance of VP in our family is approximately 40%. Many more subjects with VP are diagnosed in an asymptomatic phase than previously, and the acute attack is now an uncommon manifestation of VP. Plasma scanning is more sensitive than faecal porphyrin analysis, but neither is sufficiently sensitive for the detection of carrier status.

Variegate porphyria.

Variegate porphyria is an autosomal dominant inherited trait resulting in decreased activity of protoporphyrinogen oxidase. It is characterized clinically by photosensitive skin disease and a propensity to acute neurovisceral crises. The disease is found worldwide but has an exceptionally high frequency in South Africa. The gene for human protoporphyrinogen oxidase has been identified and sequenced, and several mutations in the protoporphyrinogen oxidase gene sequence have been identified. In South Africa, fewer patients now present with acute attacks, leaving a greater proportion with skin disease or asymptomatic disease. Acute attacks of variegate porphyria appear to be less easily provoked and to be milder than those associated with acute intermittent porphyria.

Safety of vancomycin in acute porphyria.

A 27-year-old female with acute intermittent porphyria presented in a life-threatening acute attack. She developed a Staphylococcus aureus septicaemia and was treated with intravenous vancomycin for 4 weeks. Porphyrins and their precursors were monitored and declined during the course of therapy. The safety of vancomycin in people with the acute porphyrias has not previously been documented, and we conclude that, in this case, the use of vancomycin was without ill-effect.

Porphyrinogenicity of etomidate and ketamine as continuous infusions. Screening in the DDC-primed rat model.

The porphyrinogenicity of etomidate and ketamine administered as continuous i.v. infusions was screened in the DDC-primed rat model of latent variegate porphyria. Ketamine produced no change from control in 5-aminolaevulinate synthase (ALAs) activity and haem intermediate production in either untreated or DDC-primed rats, and would appear to be safe for use in the patient with genetic porphyria. Etomidate, while producing no significant changes in these parameters in untreated rats, caused a statistically significant 47% increase in hepatic ALAs activity with a corroborative 85% increase in coproporphyrin and a 40% increase in protoporphyrin content, in DDC-primed rats. On these grounds, etomidate must be regarded as potentially porphyrinogenic when administered as a continuous infusion for total i.v. anaesthesia.

Protoporphyrinogen oxidase and porphobilinogen deaminase in variegate porphyria.

Two enzymes of the haem biosynthetic pathway were investigated in patients with variegate porphyria. Protoporphyrinogen oxidase in cultures of Epstein-Barr virus transformed lymphoblasts from twenty-seven patients showed a mean maximal velocity (Vmax) of 0.39 +/- 0.08+ nmol of protoporphyrin mg protein-1 h-1, a 52% reduction (P less than 0.001) from a non-porphyric control group (0.82 +/- 0.10). Km values (1.00 +/- 0.27 microM) did not differ significantly (P greater than 0.05) from control values in any of the patients. The mean Vmax of porphobilinogen deaminase in the cultures was 1.50 +/- 0.18 nmol of uroporphyrin mg protein-1 min-1, a 24% reduction (P less than 0.001) from controls (1.94 +/- 0.14). Mean porphobilinogen deaminase activity in the erythrocytes of twenty-one patients with variegate porphyria was 8.37 +/- 1.99 nmol of uroporphyrin 1 erythrocytes-1 s-1, a 28% reduction (P less than 0.001) from normal (11.98 +/- 2.11). The reduced activities of these two enzymes comply with the expression of variegate porphyria during its quiescent and acute phases.

Porphyria--the UCT experience.

Several forms of porphyria are commonly seen in South Africa. Much of the knowledge accumulated in this field has been due to the meticulous research of Professor Lennox Eales and his colleagues at the University of Cape Town. Professor Eales headed the Porphyria Research Group, founded by the CSIR in 1957 and upgraded to a Unit by the MRC in 1979, until he retired in 1983. Since then porphyria research at UCT has continued within the MRC Liver Research Centre. We present here a description of those forms of porphyria commonly seen in South Africa, based in part on recent work carried out at UCT and in part on the work of Lennox Eales, to whom we dedicate this article.

Uroporphyrinogen decarboxylase and protoporphyrinogen oxidase in dual porphyria.

The urinary and faecal porphyrin excretory profiles of dual porphyria are said to represent the superimposition of those found in porphyria cutanea tarda on those seen in variegate porphyria. To test this hypothesis the enzymes responsible for these conditions, protoporphyrinogen oxidase (variegate porphyria) and uroporphyrinogen decarboxylase (porphyria cutanea tarda) were measured in vitro in haemolysates and lymphoblasts of 10 subjects with dual porphyria in order to clarify the enzymatic defects. Mean protoporphyrinogen oxidase activity in lymphoblasts from subjects with dual porphyria was decreased by 45% from 0.82 +/- 0.10 to 0.45 +/- 0.09 nmol protoporphyrin/mg protein/h (P less than 0.001). Uroporphyrinogen decarboxylase activity was also significantly reduced from 0.12 +/- 0.05 nmol 7-, 6-, 5- and 4-carboxyl porphyrin/mg protein/h in lymphoblasts from normal subjects to 0.08 +/- 0.02 nmol in lymphoblasts of subjects with dual porphyria (P less than 0.01). There was a similar 27% decrease in mean uroporphyrinogen decarboxylase activity of haemolysates from the same dual porphyria group (P less than 0.01). Mean activity of this enzyme in 5 patients with variegate porphyria did not differ significantly from that in normal subjects. These findings may well provide a rational basis for the abnormal porphyrin excretory profiles found in subjects with dual porphyria.

Administration of oral activated charcoal in variegate porphyria results in a paradoxical clinical and biochemical deterioration.

BACKGROUND: Porphyrinogens are the obligate intracellular precursors of haem. These compounds are, however, unstable and are easily oxidized to the corresponding porphyrins, which are the form in which they are usually measured in the laboratory. A substantial enterohepatic cycling of porphyrins has been shown. Administration of oral activated charcoal, by interrupting this cycle, may reduce plasma and urine porphyrin levels in patients with some forms of porphyria. The effect of charcoal in subjects with variegate porphyria (VP) has not been reported. OBJECTIVES: To determine the clinical and biochemical effects of the administration of oral activated charcoal in patients with VP. METHODS: Oral activated charcoal was administered to eight subjects with VP. Clinical activity was assessed by skin lesion counts fortnightly for 6 weeks, 6 weeks after cessation of therapy, and during a subsequent 6-week control period during which no charcoal was taken. Urine and plasma porphyrins and urine precursors were measured by standard techniques. RESULTS: Treatment resulted in a significant increase in skin disease, urine and plasma porphyrins. CONCLUSIONS: Oral charcoal administration results in a paradoxical aggravation of VP, suggesting a complex and as yet undefined interaction of hepatic porphyrin metabolism and bowel porphyrin reabsorption. Oral sorbents should not be prescribed to subjects with VP.

Identification and characterisation of a deletion (537delAT) in the protoporphyrinogen oxidase gene in a South African variegate porphyria family.

Variegate porphyria is an autosomal dominant disorder of haem metabolism resulting from a partial decrease in protoporphyrinogen oxidase activity. Variegate porphyria is highly prevalent in South Africa, the result of a founder effect now confirmed genetically as a single point mutation (R59W) which has been described in nearly all South African variegate porphyria patients studied. Only two other mutations (H20P, R168C) have been reported in South Africa. We utilised simultaneous, single-stranded conformational polymorphism and heteroduplex analysis, and direct sequencing to identify a further mutation; a 2 bp deletion in exon 6 which results in a premature stop codon 11 codons downstream from the mutation and is the first reported deletion in the protoporphyrinogen oxidase gene in a South African family. The familial segregation of this mutation strongly suggests that it is the disease causing mutation for variegate porphyria in this family. This further evidence for allelic heterogeneity limits the utility of tests for the R59W mutation in the diagnosis of variegate porphyria in South Africa.

Mapping of the variegate porphyria (VP) gene: contradictory evidence for linkage between VP and microsatellite markers at chromosome 14q32.

The gene for variegate porphyria (VP), an autosomal dominant disease with a high prevalance in South Africa, evidently due to a founder effect, was previously mapped to chromosome 14q32. In the current study this localization was evaluated by linkage and haplotype analyses using microsatellite markers spanning a region of more than 20 cM on chromosome 14q32. In many recent studies linkage disequilibrium between disease and marker loci has been utilized to map genes in founder populations, but we could not find any association between VP and the markers used in this study. Our data suggest that the allocation of VP to chromosome 14q32 may be incorrect.

Porphyria cutanea tarda: the etiological importance of mutations in the HFE gene and viral infection is population-dependent.

A number of factors, including increased iron stores and alcohol consumption, are known to be associated with the development of porphyria cutanea tarda (PCT) in susceptible individuals. Recent reports have described a significant association between inheritance of the C282Y and H63D mutations in the HFE gene, associated with genetic hemochromatosis (GH) and PCT. A strong association between hepatitis C virus infection and PCT has also been demonstrated, while case reports record a link between human immunodeficiency virus (HIV) and PCT. We have investigated the frequency of these factors in a racially-mixed population of patients with PCT in Cape Town, South Africa. 57 patients with PCT drawn from three ethnic groups were screened for the presence of the C282Y and H63D mutations linked to GH, and the prevalences were compared with corresponding healthy control populations. The seroprevalence of markers for HCV, hepatitis B (HBV) and HIV infection were examined in 28 of these. In the control populations, we found that both the C282Y and H63D mutations are highly prevalent in South Africans of European origin. In a population of mixed or Asian origin, the C282Y mutation is very rare whereas the H63D mutation is common. Neither mutation was encountered in any African subject. Both mutations are associated with PCT, but the association is dependent on the ethnic origins of the population to which the patient belongs. In contrast to other studies, HCV infection is numerically unimportant in PCT in our patients. HIV infection is increasingly encountered in our patients with PCT, but the strength of the association cannot be determined in view of the high background prevalence of HIV infection in some sectors of the South African population. The contribution of specific risk factors may be heavily dependent on the population from which patients are drawn, and care should be taken in extrapolating from observations in one racial or geographic population to any other.

Homozygous variegate porphyria: an evolving clinical syndrome.

Variegate porphyria is one of the most frequently encountered genetic conditions in South Africa. It is inherited as an autosomal dominant disease and in excess of 300 heterozygous cases have been studied by the Cape Town unit. Despite this, the homozygous condition has not previously been encountered in South Africa. We report two cases of homozygous variegate porphyria, one of whom represents the first South African case. We delineate a syndrome principally characterized by growth retardation, developmental delay, epileptic seizures, photosensitivity and an abnormal porphyrin excretion pattern. In addition we describe, in one case, two features not previously reported: skin disease in areas unexposed to light and a severe sensory neuropathy which may account at least in part for the hand deformities of this disorder.