Porphyria: Difference between revisions
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The porphyrias are a "diverse group of metabolic diseases characterized by errors in the biosynthetic pathway of heme in the [[liver]], the [[bone marrow]], or both. They are classified by the deficiency of specific enzymes, the tissue site of enzyme defect, or the clinical features that include neurological (acute) or cutaneous (skin lesions). Porphyrias can be hereditary or acquired as a result of toxicity to the hepatic or erythropoietic marrow tissues."<ref>{{MeSH}}</ref><ref name="pmid15767622">{{cite journal |author=Anderson KE, Bloomer JR, Bonkovsky HL, ''et al'' |title=Recommendations for the diagnosis and treatment of the acute porphyrias |journal=Ann. Intern. Med. |volume=142 |issue=6 |pages=439–50 |year=2005 |month=March |pmid=15767622 |doi= |url=http://www.annals.org/cgi/content/full/142/6/439 |issn=}}</ref><ref name="pmid18579817">{{cite journal |author=Bonkovsky HL, Siao P, Roig Z, Hedley-Whyte ET, Flotte TJ |title=Case records of the Massachusetts General Hospital. Case 20-2008. A 57-year-old woman with abdominal pain and weakness after gastric bypass surgery |journal=N. Engl. J. Med. |volume=358 |issue=26 |pages=2813–25 |year=2008 |month=June |pmid=18579817 |doi=10.1056/NEJMcpc0803190 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18579817&promo=ONFLNS19 |issn=}}</ref> | The porphyrias are a "diverse group of metabolic diseases characterized by errors in the biosynthetic pathway of heme in the [[liver]], the [[bone marrow]], or both. They are classified by the deficiency of specific enzymes, the tissue site of enzyme defect, or the clinical features that include neurological (acute) or cutaneous (skin lesions). Porphyrias can be hereditary or acquired as a result of toxicity to the hepatic or erythropoietic marrow tissues."<ref>{{MeSH}}</ref><ref name="pmid15767622">{{cite journal |author=Anderson KE, Bloomer JR, Bonkovsky HL, ''et al'' |title=Recommendations for the diagnosis and treatment of the acute porphyrias |journal=Ann. Intern. Med. |volume=142 |issue=6 |pages=439–50 |year=2005 |month=March |pmid=15767622 |doi= |url=http://www.annals.org/cgi/content/full/142/6/439 |issn=}}[http://www.annals.org/cgi/content/full/142/6/439/T2 Table that quantifies frequency of symptoms]</ref><ref name="pmid18579817">{{cite journal |author=Bonkovsky HL, Siao P, Roig Z, Hedley-Whyte ET, Flotte TJ |title=Case records of the Massachusetts General Hospital. Case 20-2008. A 57-year-old woman with abdominal pain and weakness after gastric bypass surgery |journal=N. Engl. J. Med. |volume=358 |issue=26 |pages=2813–25 |year=2008 |month=June |pmid=18579817 |doi=10.1056/NEJMcpc0803190 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18579817&promo=ONFLNS19 |issn=}}</ref> | ||
==Classification== | ==Classification== | ||
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===Historical patients | ==Diagnosis== | ||
Patients may have pink or red urine from the porphyrins. | |||
===Neurovisceral attacks=== | |||
The best laboratory tests during an acute neurovisceral attack are the 5-aminolevulinic acid (ALA) and porphobilinogen in urine or serum. An alternative, rapid test is the urine Hoesch or Watson–Schwartz test for porphobilinogen. | |||
When considering adult patients with neurovisceral symptoms, all three of the relevant porphyrias (AIP, HCP, VP) have elevated urinary porphobilinogen level is elevated (20 to 200 mg/L; 220 to 880 µmol/d).<ref name="pmid15767622">{{cite journal |author=Anderson KE, Bloomer JR, Bonkovsky HL, ''et al'' |title=Recommendations for the diagnosis and treatment of the acute porphyrias |journal=Ann. Intern. Med. |volume=142 |issue=6 |pages=439–50 |year=2005 |month=March |pmid=15767622 |doi= |url=http://www.annals.org/cgi/content/full/142/6/439 |issn=}}</ref> This level may be | |||
==Historical patients== | |||
The insanity exhibited by [[George III of the United Kingdom|King George III]] evidenced in the regency crisis of 1788 has inspired several attempts at retrospective diagnosis. The first, written in 1855, thirty-five years after his death, concluded he suffered from acute mania. M. Guttbacker, in 1941, suggested manic-depressive psychosis as a more likely diagnosis, The first suggestion that a physical illness was the cause of King George's mental derangements came in 1966, in a paper "The Insanity of King George III: A Classic Case of Porphyria"<ref>Ida Macalpine & Richard Hunger, "The Insanity of King George III: A Classic Case of Porphyria", ''British Medical Journal'', 1966, pp. 65-71.</ref>, with a follow-up in 1968, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia"<ref>Ida Macalpine, Richard Hunger, & Claude Rimington, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia: A Followup Study of George III's Illness", ''British Medical Journal'', 1968, pp. 7-18.</ref>. The papers, by a mother/son psychiatrist team, were written as though the case for porphyria had been proven, but the response demonstrated that many, including those more intimately familiar with actual manifestations of porphyria, were unconvinced. The theory is treated in ''Purple Secret''<ref>Röhl, John C.G., Warren Martin,& David Hunt, ''Purple Secret'', Bantam Press, London, 1998 ISBN 0-593-04148-8</ref>, which documents the ultimately unsuccessful search for genetic evidence of porphyria in the remains of royals suspected to suffer from it.<ref>The authors demonstrated a single point mutation in the PPOX gene, but not one which has been associated with disease.</ref> In 2005 it was suggested that [[arsenic]] (which is known to be porphyrogenic) given to George III with antimony may have caused his porphyria.<ref>Cox TM, Jack N, Lofthouse S, Watling J, Haines J, Warren MJ. King George III and porphyria: an elemental hypothesis and investigation. ''Lancet'' 2005;366(9482):332-5. PMID 16039338.</ref> Despite the lack of direct evidence, the notion that George III (and other members of the royal family) suffered from porphyria has achieved such popularity that many forget that it is merely a hypothesis. | The insanity exhibited by [[George III of the United Kingdom|King George III]] evidenced in the regency crisis of 1788 has inspired several attempts at retrospective diagnosis. The first, written in 1855, thirty-five years after his death, concluded he suffered from acute mania. M. Guttbacker, in 1941, suggested manic-depressive psychosis as a more likely diagnosis, The first suggestion that a physical illness was the cause of King George's mental derangements came in 1966, in a paper "The Insanity of King George III: A Classic Case of Porphyria"<ref>Ida Macalpine & Richard Hunger, "The Insanity of King George III: A Classic Case of Porphyria", ''British Medical Journal'', 1966, pp. 65-71.</ref>, with a follow-up in 1968, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia"<ref>Ida Macalpine, Richard Hunger, & Claude Rimington, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia: A Followup Study of George III's Illness", ''British Medical Journal'', 1968, pp. 7-18.</ref>. The papers, by a mother/son psychiatrist team, were written as though the case for porphyria had been proven, but the response demonstrated that many, including those more intimately familiar with actual manifestations of porphyria, were unconvinced. The theory is treated in ''Purple Secret''<ref>Röhl, John C.G., Warren Martin,& David Hunt, ''Purple Secret'', Bantam Press, London, 1998 ISBN 0-593-04148-8</ref>, which documents the ultimately unsuccessful search for genetic evidence of porphyria in the remains of royals suspected to suffer from it.<ref>The authors demonstrated a single point mutation in the PPOX gene, but not one which has been associated with disease.</ref> In 2005 it was suggested that [[arsenic]] (which is known to be porphyrogenic) given to George III with antimony may have caused his porphyria.<ref>Cox TM, Jack N, Lofthouse S, Watling J, Haines J, Warren MJ. King George III and porphyria: an elemental hypothesis and investigation. ''Lancet'' 2005;366(9482):332-5. PMID 16039338.</ref> Despite the lack of direct evidence, the notion that George III (and other members of the royal family) suffered from porphyria has achieved such popularity that many forget that it is merely a hypothesis. | ||
Revision as of 23:15, 9 September 2008
The porphyrias are a "diverse group of metabolic diseases characterized by errors in the biosynthetic pathway of heme in the liver, the bone marrow, or both. They are classified by the deficiency of specific enzymes, the tissue site of enzyme defect, or the clinical features that include neurological (acute) or cutaneous (skin lesions). Porphyrias can be hereditary or acquired as a result of toxicity to the hepatic or erythropoietic marrow tissues."[1][2][3]
Classification
| Name | Onset |
|---|---|
| Cutaneous involvement | |
| Congenital erythropoietic porphyria | Infancy |
| Erythropoietic protoporphyria | Infancy |
| Hepatoerythropoietic porphyria | Infancy |
| Porphyria cutanea tarda | Adulthood |
| Neurovisceral involvement | |
| ALA-dehydratase deficient porphyria (ADP) OMIM 125270 |
Childhood |
| Acute intermittent porphyria (AIP) OMIM 176000 |
Adulthood |
| Hereditary coproporphyria (HCP) OMIM 121300 |
Adulthood |
| Variegate porphyria (VP) OMIM 176200 |
Adulthood |
Diagnosis
Patients may have pink or red urine from the porphyrins.
Neurovisceral attacks
The best laboratory tests during an acute neurovisceral attack are the 5-aminolevulinic acid (ALA) and porphobilinogen in urine or serum. An alternative, rapid test is the urine Hoesch or Watson–Schwartz test for porphobilinogen.
When considering adult patients with neurovisceral symptoms, all three of the relevant porphyrias (AIP, HCP, VP) have elevated urinary porphobilinogen level is elevated (20 to 200 mg/L; 220 to 880 µmol/d).[2] This level may be
Historical patients
The insanity exhibited by King George III evidenced in the regency crisis of 1788 has inspired several attempts at retrospective diagnosis. The first, written in 1855, thirty-five years after his death, concluded he suffered from acute mania. M. Guttbacker, in 1941, suggested manic-depressive psychosis as a more likely diagnosis, The first suggestion that a physical illness was the cause of King George's mental derangements came in 1966, in a paper "The Insanity of King George III: A Classic Case of Porphyria"[4], with a follow-up in 1968, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia"[5]. The papers, by a mother/son psychiatrist team, were written as though the case for porphyria had been proven, but the response demonstrated that many, including those more intimately familiar with actual manifestations of porphyria, were unconvinced. The theory is treated in Purple Secret[6], which documents the ultimately unsuccessful search for genetic evidence of porphyria in the remains of royals suspected to suffer from it.[7] In 2005 it was suggested that arsenic (which is known to be porphyrogenic) given to George III with antimony may have caused his porphyria.[8] Despite the lack of direct evidence, the notion that George III (and other members of the royal family) suffered from porphyria has achieved such popularity that many forget that it is merely a hypothesis.
It is also suspected that Mary Queen of Scots--George III's grandmother six times removed--also suffered from acute intermittent porphyria, although this is subject to much debate.
Other commentators have suggested that Vincent van Gogh may have suffered from acute intermittent porphyria.[9]
References
- ↑ Anonymous (2024), Porphyria (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ 2.0 2.1 Anderson KE, Bloomer JR, Bonkovsky HL, et al (March 2005). "Recommendations for the diagnosis and treatment of the acute porphyrias". Ann. Intern. Med. 142 (6): 439–50. PMID 15767622. [e]
Table that quantifies frequency of symptoms Cite error: Invalid
<ref>tag; name "pmid15767622" defined multiple times with different content - ↑ Bonkovsky HL, Siao P, Roig Z, Hedley-Whyte ET, Flotte TJ (June 2008). "Case records of the Massachusetts General Hospital. Case 20-2008. A 57-year-old woman with abdominal pain and weakness after gastric bypass surgery". N. Engl. J. Med. 358 (26): 2813–25. DOI:10.1056/NEJMcpc0803190. PMID 18579817. Research Blogging.
- ↑ Ida Macalpine & Richard Hunger, "The Insanity of King George III: A Classic Case of Porphyria", British Medical Journal, 1966, pp. 65-71.
- ↑ Ida Macalpine, Richard Hunger, & Claude Rimington, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia: A Followup Study of George III's Illness", British Medical Journal, 1968, pp. 7-18.
- ↑ Röhl, John C.G., Warren Martin,& David Hunt, Purple Secret, Bantam Press, London, 1998 ISBN 0-593-04148-8
- ↑ The authors demonstrated a single point mutation in the PPOX gene, but not one which has been associated with disease.
- ↑ Cox TM, Jack N, Lofthouse S, Watling J, Haines J, Warren MJ. King George III and porphyria: an elemental hypothesis and investigation. Lancet 2005;366(9482):332-5. PMID 16039338.
- ↑ Loftus LS, Arnold WN. Vincent van Gogh's illness: acute intermittent porphyria? BMJ 1991;303:1589-91. PMID 1773180.