3. TISSUES :- ALL TISSUES BUT PREDOMINANTLY IN THE LIVER AND BONE-MARROW SUBCELLULAR SITE :- PARTLY IN MITOCHONDRION ( FIRST STEP AND THE LAST THREE STEPS ) AND PARTLY CYTOSOLIC. (REMAINING STEPS) STARTING MATERIALS :- 1)Succinyl CoA( FROM TCA CYCLE) 2)AA - GLYCINE

4. MITOCHONDRIA Lead Inhibits 1 2 MITOCHONDRIA COMMITTED STEP & RATE –LIMITING

5. 3 HYDROXYMETHYLBILANE (LINEAR TETRAPYRROLE) FOUR MOLECUES OF PRORPHOBILINOGEN TYPE III UROPORPHYRINOGENTYPE I UROPORPHYRINOGEN 4 Also called PBG deaminase

6. 5 ACETYL TO METHYL ( A  M )

7. Coporporphyrinogen oxidase Protoporphyrinogen oxidase Ferrochelatase COPROPORPHYRINOGEN III PROTOPORPHYRINOGEN III PROTOPORPHYRIN III Fe +2 HEME M I T O C H O N D R I A 6 7 8 PROPIONYL TO VINYL (P  V ) 2CO 2

8. Iron is coordinately linked with 5N (4 Pyrrole and 1 N 2 of a His residue of Globin) Lead inhibits

9. Uroporphyrinogen I synthase Uroporphyrinogen III synthase Uroporphyrinogen decarboxylase Coporporphyrinogen oxidase Protoporphyrinogen oxidase Ferrochelatase 6 7 8 MITOCHONDRIA CYTOSOL

10. REMEMBER :- – 2/3 rd of TOTAL HEME SYNTHESIZED GOES FOR SYNTHESIS OF cytP450. – cytP450 is involved in metabolism of drugs and xenobiotics.

12. FEEDBACKINHIBITIONFEEDBACKINHIBITION

13. MANY DRUGS CAN CAUSE MARKEDLY INCREASE ALA SYNTHASE. -WHY ? Several factors can cause DEREPRESSION OF ALAS- 1 IN LIVER eg. – Glucose administration – Administration of HEMATIN. ALAS-2 DOESNOT UNDERGO FEEDBACK REGULATION BY HEME. ALAS-2 IS NOT INDUCED BY DRUGS THAT INDUCE ALAS-1.

14. The Porphyrinogens are colourless, whereas the various Porphyrins and are coloured. There is a characteristic absorption curve for each porphyrin. For eg.( in 5%HCl ) Peak absorption of hematoporphyrins at 400nm SORET BAND

15. The porphyrias are a group of genetic disorders due to abnormalities in the pathway of biosynthesis of heme. The symptoms produced depend on the type of defect. Autosomal dominant porphyrias include acute intermittent porphyria, most cases of erythropoietic protoporphyria, hereditary coproporphyria, and variegate porphyria. Most common is PORPHYRIA is AIP

17. If the lesion occurs early in the pathway prior to the formation of porphyrinogens ALA and PBG will accumulate in body tissues and fluids. – Clinically they will complain of abdominal pain and neuropsychiatric symptoms.

18. If the enzyme is blocked later in the pathway it will lead to accumulation of porphyrinogens. Porphyrinogens 2H Porphyrin derivatives PHOTOSENSITIVITY – The porphyrins when exposed to light of 400nm become excited and then react with molecular oxygen to produce oxygen radicals. – These radicals injure lysosomes and other cellular organelle. The lysosomes release degradative enzymes which cause various damage to skin, resulting in SCARRING and damage to organs like the Liver.

19. Summary of Major Findings in the Porphyrias Enzyme InvolvedType and ClassMajor Signs and Symptoms Results of Laboratory Tests 1. ALA synthase (erythroid form) X-linked sideroblastic anemia (erythropoietic) Anemia ONLY.Red cell counts and hemoglobin decreased 2. ALA dehydratase ALA dehydratase deficiency (hepatic) Abdominal pain, neuropsychiatric symptoms (A-N ) Urinary ALA 3. Uroporphyrinogen I synthase Acute intermittent porphyria (hepatic) Abdominal pain, neuropsychiatric symptoms (A-N) Urinary ALA and PBG increased

20. Enzyme InvolvedType and ClassMajor Signs and Symptoms Results of Laboratory Tests 4.Uroporphyrinogen III synthase Congenital erythropoietic (erythropoietic) Photosensitivity (P) ALA, PBG ++ 5. Uroporphyrinogen decarboxylase Porphyria cutanea tarda (hepatic) Photosensitivity (P) Urinary uroporphyrin I increased 6. Coproporphyrinogen oxidase Hereditary coproporphyria (hepatic) Photosensitivity, abdominal pain, neuropsychiatric symptoms (P-A-N) Urinary ALA, PBG, and coproporphyrin III and fecal coproporphyrin III increased 7. Protoporphyrinogen oxidase Variegate porphyria (hepatic) Photosensitivity, abdominal pain, neuropsychiatric symptoms (P-A-N) Urinary ALA, PBG, and coproporphyrin III and fecal protoporphyrin IX increased 8. FerrochelataseProtoporphyria (erythropoietic) Photosensitivity (P) Fecal and red cell protoporphyrin IX increased

22. – Photosensitivity and skin lesions

23. Disorder Enzyme defect Neuroviscer al crises Skin lesions Inheritanc e OMIM# Acute porphyrias ALA dehydratase deficiency porphyria (ADP) ALAD+-AR125270 Acute intermittent porphyria (AIP) PBGD+-AD176000 Hereditary coproporphyria (HCP) CPO++ 1,2 AD121300 Variegate porphyria (VP) PPOX++ 1,2 AD600923 Non-acute porphyrias Congenital erythropoietic porphyria (CEP) UROS-+2+2 AR263700 Porphyria cutanea tarda (PCT) UROD-+2+2 Complex176090176090, 176100 176100 Erythropoietic protoporphyria (EPP) FECH-+3+3 AD177000 1 Skin lesions and neurovisceral crises may occur alone or together; 2 fragile skin, blisters; 3 acute photosensitivity without fragile skin, blisters.

24. PORPHYRIA CUTANEA TARDA

25. GUNTHER’S DISEASE(Congenital Erythropoietic porphyria )

26. Gingival recession

27. GUNTHER’S DISEASE (Congenital Erythropoietic porphyria ) Erythrodontia

28. ALA and PBG are Neurotoxic Vasoconstriction of CNS and abdominal blood vessels. Decreased Heme containing proteins - Decreased cellular energy. Elevation of stress hormones – Anxiety, Increase in BP etc.

29. DRUGS :- Certain medicines, such as BARBITURATES(SEDATIVE ), GRISEOFULVIN (ANTI- FUNGAL)birth control pills, antibiotics, and medicines for treating seizures. Why ? THEY ARE METABOLISED BY CYT P450, hence UTILIZATION of HEME in CYTOCHROME P450 IS INCREASED.This DECREASES THE INTRACELLULAR CONCENTRATION. Dehydration (loss of too much water and salt) too much sun exposure.

30. Cigarette smoking and alcohol consumption. Hormone changes,during menses, menarche and menopause. Physical or mental stress, such as with an infection, depression, emotional problem, or after surgery. Starvation due to fasting or crash dieting.

31. Why accumulation PBG and ALA lead to complications: ALA and PBG are Neurotoxic Vasoconstriction of CNS and abdominal blood vessels. Decreased Heme containing proteins - Decreased cellular energy. Elevation of stress hormones – Anxiety, Increase in BP etc.

32. Porphyria is diagnosed through spectroscopy and biochemical analysis of blood, urine, and stool.spectroscopybloodurinestool In general, urine estimation of porphobilinogen (PBG) is the first step if acute porphyria is suspected.porphobilinogen In nearly all cases of acute porphyria syndromes, urinary PBG is markedly elevated except for the very rare ALA dehydratase deficiency.

33. Urinary ALA and PBG are always markedly increased in symptomatic patients with AIP and even in some asymptomatic individuals with the inherited enzyme deficiency. PBG in urine is oxidized to porphobilin upon standing, which gives a dark-brown color to urine, and often referred to as ‘port-wine reddish urine’.

34. Lab diagnosis: Urinary PBG excretion during an attack : – usually 50–200 mg/24 h [normal, 0–4mg/24 h] Urinary ALA excretion : – 20–100 mg/24 h [normal, 1–7 mg/24 h] Portwine color of urine on prolonged standing

35. Repeat testing during an attack and subsequent attacks may be necessary in order to detect a porphyria, as levels may be normal or near-normal between attacks. UV fluorescence :- Presence of porphyrins in urine is detected by Ehrlich’s reagent. If urine is observed under UV light it emits strong red-fluorescence if porphyrins are present. DNA analysis to identify the causative mutation in the appropriate gene (AIP:HMBS; VP: PPOX; HCP: CPO ) is the method of choice. Enzyme measurements are not as specific or sensitive as DNA analysis. – Erythrocyte PBG deaminase assay is still used for detection of latent AIP when DNA analysis is not available or a mutation cannot be detected. – Measurement of protoporphyrinogen and coproporphyringen oxidases is complex and requires nucleated cells.

36. USG of LIVER AND LIVER ENZYMES :- predisposed to Hepatocellular Carcinoma NERVE CONDUCTION STUDIES :- PERIPHERAL NEUROPATHY due to axonal degeneration affects proximal muscles esp. shoulders and arms and may lead to Bulbar paralysis  DEATH if affected.

37. Acute phase :- I.V GLUCOSE- GLUCOSE REPRESSES ALA SYNTHASE I.V HEMATIN –HEME REPRESSES ALA SYNTHASE PAIN MANAGEMENT :- Narcotics NAUSEA AND VOMITING :- PHENOTHIAZINES SEDATION MANAGEMENT OF SEIZURES :- Clonazepam

38. SUSCEPTIBLE PATIENTS MUST AVOID DIRECT EXPOSURE TO SUNLIGHT –sunscreens may help.

39. Porphyrinuria can occur in Lead Poisoning due to inhibition of ferrochelatase also. Rem :- Lead also inhibits ALA dehydratase

40. MCQ AIP is the major autosomal-dominant acute hepatic porphyria. This disease is caused by a deficiency in porphobilinogen (PBG) deaminase, an enzyme of heme biosynthesis. Patients afflicted with this disease would be expected to excrete excess amounts of which of the following? (A) Delta-aminolevulinic acid (ALA) (B) Coproporphyrinogen III (C) Hydroxymethylbilane (D) Protoporphyrin IX (E) Type III uroporphyrinogen

41. Uroporphyrinogen decarboxylase

42. ALA DEHYDRATASE

43. MCQ 1 A 25-year-old man has experienced chronic blistering and scarring of his skin when exposed to sunlight. This man is a smoker and drinks heavily, both of which exacerbate his responses to sunlight. Analysis of his urine and plasma indicates a high accumulation of complex porphyrins, predominantly uroporphyrin.The symptoms and clinical signs displayed by this patient indicate he is suffering from which of the following disorders? (A) Acute intermittent porphyria (AIP) (B) Hereditary coproporphyria (HCP) (C) Porphyria cutanea tarda (PCT) (D) Variegate porphyria (E) X-linked sideroblastic anemia