Porphyrias: a review and case report

Anemia MCV=HCT/RBC 80-100 >100 <80 Microcytic Sudden massive blood lose Marrow failure hemolysis Megaloblastic anemia Spurious macrocytic anemia

Microcytic anemia Defect in hemoglobin synthesis 3-dimensional structure of hemoglobin. The four subunits are shown in red and yellow, and the heme groups in green.

Microcytic anemia Defect in hemoglobin sythesis Low or normal Iron binding capacity High High Iron Low or normal Defect in: Porphyrin synthesis Heme synthesis Globin synthesis Iron deficiency

Defect in: Porphyrin synthesis Heme synthesis Globin synthesis Hemoglobin electrophoresis Abnormal Normal Defect in: Porphyrin synthesis Heme synthesis Defect in: Globin synthesis Quantitative Both Qualitative Thalassemia Sickle-thal S,C,F,ect

Heme Non-erythroid Erythroid Haemoglobin Haemoproteins Electron transfer and energy trapping myoglobin Cytochromes Others

Porphyrins synthesis Mitochondrion Cytosol Spontaneous URO I COPRO I

ALA synthase + Water-soluble D-ALA Excreted in urine ALA dehydrase Glycine ALA synthase + NH2-CH2-COOH Water-soluble Excreted in urine D-ALA ALA dehydrase PBG deaminase Water-soluble Excreted in urine PBG Hydroxymethylbilane

Hydroxymethylbilane URO III synthase Spontaneous URO I COPRO I URO III decarboxylase Uroporphyrinogen III Water-soluble Excreted in urine Less water-soluble Excreted in urine/feces Coproporphyrinogen III

CORPO III COPRO oxidase Protoporphyrinogen IX Poor water-solubility Excreted in feces PROTO oxidase Protoporphyrin IX Ferrochelatase Heme

Main Types of Porphyria Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria ALA (Neurological Porphyrias) Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane (Unstable) Non-acute Porphyrias URO III synthase Spontaneous Porphyria Cutanea Tarda URO III URO I Erythropoietic Protoporphyria URO III decarboxylase (Cutaneous Porphyrias) Congenital Erythropietic Porphyria COPRO I COPRO III COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Main Types of Porphyria Tissue expression Inheritance Acute Porphyrias ALAD Deficiency Porphyria Liver Autosomal recessive Acute Intermittent Porphyria Liver Autosomal dominant (Neurological Porphyrias) Hereditary Coproporphyria Liver Autosomal dominant Variegate Porphyria Liver Autosomal dominant Non-acute Porphyrias Autosomal dominant Porphyria Cutanea Tarda Liver (Cutaneous Porphyrias) Erythropoietic Protoporphyria E , L Autosomal dominant Congenital Erythropietic Porphyria Erythroid cells Autosomal recessive Secondary Porphyrias Lead Poisoning Iron Deficiency Coproporphyrinuria

Acute Porphyrias urine Non-acute Porphyrias Secondary Porphyrias Heme Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria urine ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Porphyria Cutanea Tarda URO III URO I Erythropoietic Protoporphyria URO III decarboxylase Congenital Erythropietic Porphyria COPRO I COPRO III COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias urine urine Non-acute Porphyrias urine Secondary Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria urine ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria urine PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Porphyria Cutanea Tarda URO III URO I urine Erythropoietic Protoporphyria URO III decarboxylase Congenital Erythropietic Porphyria COPRO I COPRO III COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias urine urine Non-acute Porphyrias urine urine Urine Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria urine ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria urine PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Porphyria Cutanea Tarda urine URO III URO I urine Erythropoietic Protoporphyria URO III decarboxylase Congenital Erythropietic Porphyria COPRO I Urine feces COPRO III COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias urine urine Non-acute Porphyrias urine urine Urine Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria urine ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria urine PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Porphyria Cutanea Tarda urine URO III URO I urine Erythropoietic Protoporphyria URO III decarboxylase Congenital Erythropietic Porphyria COPRO I Urine feces COPRO III COPRO oxidase Secondary Porphyrias Lead Poisoning feces PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias Non-acute Porphyrias Urine Urine Feces Secondary Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Congenital Erythropietic Porphyria URO III URO I Urine Porphyria Cutanea Tarda URO III decarboxylase Erythropoietic Protoporphyria COPRO I COPRO III Urine Feces COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias Non-acute Porphyrias urine Urine Urine Feces Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Congenital Erythropietic Porphyria urine URO III URO I Urine Porphyria Cutanea Tarda URO III decarboxylase Erythropoietic Protoporphyria COPRO I COPRO III Urine Feces COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias Non-acute Porphyrias Feces Secondary Porphyrias Feces Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Congenital Erythropietic Porphyria URO III URO I Porphyria Cutanea Tarda URO III decarboxylase Erythropoietic Protoporphyria COPRO I COPRO III COPRO oxidase Feces Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Feces Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme

Acute Porphyrias urine Non-acute Porphyrias Urine Feces Feces Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria urine ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Congenital Erythropietic Porphyria URO III URO I Porphyria Cutanea Tarda URO III decarboxylase Erythropoietic Protoporphyria COPRO I Urine Feces COPRO III COPRO oxidase Feces Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Feces Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme Zn-protoporphyrin

Acute Porphyrias Non-acute Porphyrias Secondary Porphyrias Heme Glycine +Succinyl CoA Acute Porphyrias ALAD Deficiency Porphyria ALA synthase Acute Intermittent Porphyria ALA Hereditary Coproporphyria ALA dehydrase Variegate Porphyria PBG PBG deaminase Hydroxymethylbilane URO III synthase Spontaneous Non-acute Porphyrias Congenital Erythropietic Porphyria URO III URO I Porphyria Cutanea Tarda URO III decarboxylase Erythropoietic Protoporphyria COPRO I COPRO III COPRO oxidase Secondary Porphyrias Lead Poisoning PROTO IX PROTO oxidase Iron Deficiency Protoporphyrin IX Coproporphyrinuria Ferrochelatase Heme Zn-protoporphyrin

Sunnybrook Health Sciences Center Sampling Guide Hepatic Porphyrias (normal RBC Porphyrins) Erythropoietic Porphyrias ( RBC Porphyrins) Acute Intermittent Porphyria (AIP) Congenital Erythropoietic Porphyria (CEP) Variegate porphyria (VP) Erythropoietic Protoporphyria (EP) Hereditary Coproporphyria (HCP) Porphyria Cutanea Tarda (PCT) Presentation: Porphyrias Tests to order Sample Acute symptoms AIP 1. Urine Porphyrin Precursors Screen & Quantitation Random (50 ml) or 24-h with Tartaric acid Acute symptoms + skin lesions (may occur independently) VP HCP 2. Feces Porphyrins Screen & Quantitation Random Skin lesions PCT CEP EP 3. Urine Porphyrins Screen & Quantitation 4. RBC Porphyrins Screen & Quantitation Random (50 ml) or 24-h with Na2CO3 Lavender-top (EDTA) blood; need Hct Notes: At time of acute attack: 1. Collect a random urine sample first (50 ml with no preservatives), before attempting to collect a 24-h sample. 2. Request "Porphyrin Precursors" (ALA & PBG) instead of "Porphyrins" screen and quantitation. The Laboratory will have to adjust pH to 4-6 for "Porphyrin Precursors", but pH 8-10 for "Porphyrins". - The commonest problem causing confusion! 3. All sample containers should be covered with tin foil to shield off from light.

Porphyrin assays provided through HICL Test Name Specimen Type Search / Alternate Name  Porphyrin Precursors (ALA & PBG)    Urine (24h) ALA,Aminolevulinic Acid,PBG,Porphobilinogen, -ALA, -aminolevulinic Acid  Porphyrin Precursors (ALA & PBG)   Urine (Random) ALA,Aminolevulinic Acid,PBG, -ALA,Porphobilinogen  Porphyrins: Quantitation    Uroporphyrin,Heptacarboxylic Acid,Hexacarboxylic Acid,Pentacarboxylic Acid,Coproporphyrin Whole blood (EDTA) Free Protoporphyrin,Protoporphyrin - Free Feces (Random) Coproporphyrin,Uroporphyrin,Heptacarboxylic Acid,Hexacarboxylic Acid,Pentacarboxylic Acid,Deuteroporphyrin,Mesoporphyrin,Protoporphyrin Plasma (EDTA or Heparin) Bio-Rad Column HPLC

Enzymatic Spectrophometric Screening ICP-MS Isocoproporphyrin Not Available - See Note.  Porphobilinogen Deaminase    Whole blood (Heparin) Uroporphyrinogen 1 Synthetase,HMB,Hydroxymethylbilane Synthase  Porphyrins: Screen    Urine (24h) Feces (Random) Urine (Random)  Zinc Protoporphyrin    ZPP,Metal Enzymatic Spectrophometric Screening ICP-MS Lead    Whole blood (heparin) Pb,Zinc Protoporphyrin,ZPP,Metal

CASE A boy, average hematologic parameters over the subsequent 3 years were as follows: Mean corpuscular volume (MCV), 67 fL → microcytic Iron studies were unremarkable → Defect in: Porphyrin synthesis Heme synthesis Globin synthesis Hemoglobin (Hb) level, 70.0 g/L; Mean corpuscular hemoglobin level, consistently < 20 pg; Reticulocyte counts ranged from 3.6% to 6.7%;

A physical examination revealed scars on the face, hands, and forearms photosensitive bullous dermatosis The diapers exhibited brilliant pink fluorescence when illuminated with long-range ultraviolet light. → Photosensitive porphyrin rings Fluorescent red cells were detected using a microscope fitted with a 405 nm light source. → CEP or EP A 50-mL urine sample contained 2003 ug uroporphyrin (normal, trace); 92% of this was uro-I. → CEP Erythrocyte UROS activity was 21% of the normal mean. Collectively, these findings confirmed the diagnosis of CEP.

Erythrocyte UROS activity was normal in both parents, an unexpected finding as obligate carriers (heterozygotes) for UROS mutations generally have half-normal enzymatic activity. UROS was sequenced, and no mutations or deletions were found in the child or the parents. A GATA1 point mutation was found in the child at codon 216, changing arginine to tryptophan (R216W), as well as on 1 of the 2 GATA1 alleles of his mother and maternal grandmother. GATA1 gene, at Xp11.23, encodes a transcription factor, GATA binding factor 1 (GATA-1), that is critical for normal erythropoiesis, globin gene expression, and megakaryocyte development. GATA-1 also regulates expression of UROS in developing erythrocytes.

General Symptomology: __Abdominal pain ___Abdominal tenderness ___Loss of appetite ___Nausea ___Vomiting ___Constipation ___Carbohydrate craving ___Breast secretions ___Diarrhea ___Partial ileus [Intestinal blockage] ___Abdominal distention ___Dysuria [Painful Urination] ___Bladder Dysfunction ___Urinary Retention ___Amenorrhea [Lack of menses] Physical Findings of Acute Attack __Red or dark urine ___Tachycardia [Pulse] >100 ___Labile hypertension >90 diastolic [blood pressure] ___Fever [Pyrexia] ___Profused sweating ___Edema [Retention of fluids] [Swelling] ___Postural Hypotension [Low Blood Pressure] ___Hypertrichosis [excessive body hair growth] ___Hyperpigmentation [skin coloring]

Neurological Symptoms of Acute Attack [Peripheral manifestations] ___Peripheral neuropathy ___Muscle weakness ___Paresis . paralysis ___Sensory disorde ___Respiratory paralysis ___Foot drop ___Wrist drop ___Abnormal Gait ___Pain:  Arms, legs, hips and/or lower back ___Loss of sensation ___Dyesthesia                 ___Numbness                 ___Tingling                ___Burning Sensation ___Bulbar paresis                 ___Tongue paralization                 ___Mouth paralization                 ___Throat paralization [Cerebral manifestations] ___Behavorial change ___Anxiety ___Irritability ___Delirium ___Depression ___Confusion ___Hallucination ___Insomnia ___ANS [altered neurological state] ___Restlessness ___Sensory loss ___Seizure ___Depressed or absent tendon reflexes ___Cranial nerve involvement

Hematology/Blood Chemistry ___Hyponatremia [Below normal sodium level] <130 ___Increased Bun [Urea Nitrogen] ___Increased AST [Aspartate Aminotransferase] ___Elevated Alkaline Phosphatase [Liver panel test] ___Increased ALT [Aspartate Aminotransferase] ___Hypokalemia [Below normal potassium level] ___Leukocytosis [Abnormal increase in WBC] > 10,000 ___Increased ESR >22 ___Hypochloremia < 90 [A decrease in the chloride level] ___Anemia [Iron deficiency] Cutaneous manifestations ___Skin photosensitivity ___Blistering ___Severe Tissue Scarring ___Increased Hair growth ___Pigmentation Darkening ___Thickening of skin ___Severe Itching Special lab studies ___Decreased blood volume ___EEG abnormalities ___Electromyographic abnormalities ___Muscle denervation ___Decreased nerve conduction velocity ___Abnormal CSF ___Increased fibrillation potential