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Porphyria
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{{short description|A group of inherited metabolic disorders}}{{about|the medical condition||Porphyry (disambiguation)}}{{distinguish|Porphyra}}{{Use dmy dates|date=April 2014}}







factoids
or {{IPAc-enɔːrfrə}}| symptoms = Depending on subtype–abdominal pain, chest pain, vomiting, confusion, constipation, fever, seizures, blisters with sunlight| complications = | onset = Recurrent attacks that last days to weeks| duration = genetics>genetic| risks = | diagnosis = Blood, urine, and stool tests, genetic testingLead poisoning, alcoholic liver diseaseDANCYGIERTITLE=CLINICAL HEPATOLOGY: PRINCIPLES AND PRACTICE OF HEPATOBILIARY DISEASESPUBLISHER=SPRINGER SCIENCE & BUSINESS MEDIAPAGE=1088LANGUAGE=ENARCHIVEURL=HTTPS://WEB.ARCHIVE.ORG/WEB/20170908185104/HTTPS://BOOKS.GOOGLE.COM/BOOKS?ID=LRPX8C4P90QC&PG=PA1088DF=DMY-ALL, | prevention = | treatment = Depends on type and symptoms| medication = | prognosis = | frequency = 1 to 100 in 50,000 people| deaths = }}Porphyria is a group of diseases in which substances called porphyrins build up, negatively affecting the skin or nervous system. The types that affect the nervous system are also known as acute porphyria, as symptoms are rapid in onset and last a short time. Symptoms of an attack include abdominal pain, chest pain, vomiting, confusion, constipation, fever, high blood pressure, and high heart rate. The attacks usually last for days to weeks. Complications may include paralysis, low blood sodium levels, and seizures.JOURNAL, Stein, PE, Badminton, MN, Rees, DC, Update review of the acute porphyrias, British Journal of Haematology, February 2017, 176, 4, 527–538, 10.1111/bjh.14459, 27982422, Attacks may be triggered by alcohol, smoking, hormonal changes, fasting, stress, or certain medications. If the skin is affected, blisters or itching may occur with sunlight exposure.Most types of porphyria are inherited from one or both of a person's parents, and are due to a mutation in one of the genes that make heme.WEB, Porphyria,weblink NIDDK, 25 October 2016, February 2014, no,weblink 26 October 2016, dmy-all, They may be inherited in an autosomal dominant, autosomal recessive, or X-linked dominant manner. One type, porphyria cutanea tarda, may also be due to increased iron in the liver, hepatitis C, alcohol, or HIV/AIDS. The underlying mechanism results in a decrease in the amount of heme produced and a build-up of substances involved in making heme. Porphyrias may also be classified by whether the liver or the bone marrow is affected. Diagnosis is typically made by blood, urine, and stool tests. Genetic testing may be done to determine the specific mutation.Treatment depends on the type of porphyria and a person's symptoms. The treatment of porphyria of the skin generally involves the avoidance of sunlight. The treatment for acute porphyria may involve giving intravenous heme or a glucose solution. Rarely a liver transplant may be carried out.The precise frequency of porphyria is unclear: it is estimated that it affects somewhere between 1 and 100 per 50,000 people. Rates vary around the world. Porphyria cutanea tarda is believed to be the most common type.WEB, porphyria,weblink GHR, 26 October 2016, July 2009, no,weblink 26 October 2016, dmy-all, The disease was described as early as 370 BC by Hippocrates. The underlying mechanism was first described by Felix Hoppe-Seyler in 1871. The name porphyria is from the Greek πορφύρα, porphyra, meaning "purple", a reference to the color of the urine that may occur during an attack.BOOK, McManus, Linda, Pathobiology of Human Disease: A Dynamic Encyclopedia of Disease Mechanisms, 2014, Elsevier, 9780123864574, 1488,weblink no,weblink 8 September 2017, dmy-all, {{TOC limit|3}}

Signs and symptoms

{{Refimprove section|date = January 2016}}(File:Prfr1.jpg|thumb|A skin rash in a person with porphyria)

Acute porphyrias

The acute porphyrias are acute intermittent porphyria (AIP), variegate porphyria (VP), aminolevulinic acid dehydratase deficiency porphyria (ALAD) and hereditary coproporphyria (HCP). These diseases primarily affect the nervous system, resulting in episodic crises known as acute attacks. The major symptom of an acute attack is abdominal pain, often accompanied by vomiting, hypertension (elevated blood pressure), and tachycardia (an abnormally rapid heart rate). The most severe episodes may involve neurological complications: typically motor neuropathy (severe dysfunction of the peripheral nerves that innervate muscle), which leads to muscle weakness and potentially to quadriplegia (paralysis of all four limbs) and central nervous system symptoms such as seizures and coma. Occasionally, there may be short-lived psychiatric symptoms such as anxiety, confusion, hallucinations, and, very rarely, overt psychosis. All these symptoms resolve once the acute attack passes. Given the many presentations and the relatively low occurrence of porphyria, patients may initially be suspected to have other, unrelated conditions. For instance, the polyneuropathy of acute porphyria may be mistaken for Guillain–Barré syndrome, and porphyria testing is commonly recommended in those situations.JOURNAL, Albers JW, Fink JK, Porphyric neuropathy, Muscle Nerve, 30, 4, 410–422, 2004, 15372536, 10.1002/mus.20137, 2027.42/34640,

Chronic porphyrias

The non-acute porphyrias are X-linked dominant protoporphyria (XLDPP), congenital erythropoietic porphyria (CEP), porphyria cutanea tarda (PCT), and erythropoietic protoporphyria (EPP). None of these are associated with acute attacks; their primary manifestation is with skin disease. For this reason, these four porphyrias—along with two acute porphyrias, VP and HCP, that may also involve skin manifestations—are sometimes called cutaneous porphyrias.Skin disease is encountered where excess porphyrins accumulate in the skin. Porphyrins are photoactive molecules, and exposure to light results in promotion of electrons to higher energy levels. When these return to the resting energy level or ground state, energy is released. This accounts for the property of fluorescence typical of the porphyrins. This causes local skin damage.Two distinct patterns of skin disease are seen in porphyria:
  • Immediate photosensitivity. This is typical of XLDPP and EPP. Following a variable period of sun exposure—typically about 30 minutes—patients complain of severe pain, burning, and discomfort in exposed areas. Typically, the effects are not visible, though occasionally there may be some redness and swelling of the skin.
  • Vesiculo-erosive skin disease. This—a reference to the characteristic blistering (vesicles) and open sores (erosions) noted in patients—is the pattern seen in CEP, PCT, VP, and HCP. The changes are noted only in sun-exposed areas such as the face and back of the hands. Milder skin disease, such as that seen in VP and HCP, consists of increased skin fragility in exposed areas with a tendency to form blisters and erosions, particularly after minor knocks or scrapes. These heal slowly, often leaving small scars that may be lighter or darker than normal skin. More severe skin disease is sometimes seen in PCT, with prominent lesions, darkening of exposed skin such as the face, and hypertrichosis: abnormal hair growth on the face, particularly the cheeks. The most severe disease is seen in CEP and a rare variant of PCT known as hepatoerythropoietic porphyria (HEP); symptoms include severe shortening of digits, loss of skin appendages such as hair and nails, and severe scarring of the skin with progressive disappearance of ears, lips, and nose. Patients may also show deformed, discolored teeth or gum and eye abnormalities.

Cause

The porphyrias are generally considered genetic in nature.

Genetics

Subtypes of porphyrias depend on which enzyme is deficient.{| class="wikitable"!Porphyria type!Deficient enzyme!Type of porphyria!Inheritance!Symptoms!Prevalence| X-linked dominant protoporphyria (XLDPP)ALA synthase>5-aminolevulinate (ALA) synthase (ALAS)| ErythropoieticSex linkage#Types of links>X-linked dominant|Photosensitivity, cirrhosisgrh.nlm.nih.gov/condition/x-linked sideroblastic anemiaweblink{{dead link>date=September 2017 fix-attempted=yes }}| Aminolevulinate dehydratase deficiency porphyria (ALADP)| 5-aminolevulinate dehydratase (ALAD)| HepaticAutosomal recessiveTable 18-1 in: MARKS, DAWN B. AUTHOR3=SANDRA I KIM TITLE=BIOCHEMISTRY AND MOLECULAR BIOLOGY LOCATION=PHILADELPHIA PAGES= OCLC= ACCESSDATE=, | Abdominal pain, neuropathyOverview of the Porphyrias {{webarchive>url=https://web.archive.org/web/20110722233132weblink |date=22 July 2011 }} at The Porphyrias Consortium (a part of NIH Rare Diseases Clinical Research Network (RDCRN)) Retrieved June 2011| Acute intermittent porphyria (AIP)| Hydroxymethylbilane synthase (HMBS) formerly porphobilinogen deaminase (PBGD)| Hepatic| Autosomal dominant| Periodic abdominal pain, peripheral neuropathy, psychiatric disorders, tachycardiaMedscape - Diseases of Tetrapyrrole Metabolism - Refsum Disease and the Hepatic Porphyrias {{webarchive>url=https://web.archive.org/web/20110604065657weblink |date=4 June 2011 }} Author: Norman C Reynolds. Chief Editor: Stephen A Berman. Updated: 23 March 2009| Congenital erythropoietic porphyria (CEP)Uroporphyrinogen III synthase>uroporphyrinogen synthase (UROS)| Erythropoietic| Autosomal recessive| Severe photosensitivity with erythema, swelling and blistering. Hemolytic anemia, splenomegaly| 1 in 1,000,000 or less.| Porphyria cutanea tarda (PCT)Uroporphyrinogen III decarboxylase>uroporphyrinogen decarboxylase (UROD)| Hepatic| Approximately 80% sporadicweblink 20% Autosomal dominantVesicle (dermatology)>vesicles and bullae| 1 in 10,000| Hereditary coproporphyria (HCP)Coproporphyrinogen III oxidase>coproporphyrinogen oxidase (CPOX)| Hepatic| Autosomal dominant| Photosensitivity, neurologic symptoms, colic| 1 in 500,000| HarderoporphyriaCoproporphyrinogen III oxidase>coproporphyrinogen oxidase (CPOX)| Erythropoietic| Autosomal recessive| Jaundice, anemia, enlarged liver and spleen, often neonatal. Photosensitivity later.| Extremely rare; fewer than 10 cases ever reported.| Variegate porphyria (VP)Protoporphyrinogen oxidase>protoporphyrinogen oxidase (PPOX)| HepaticAutosomal dominantSINGALLAST2=ANDERSONLAST3=PAGONLAST4=ADAMLAST5=ARDINGERLAST6=WALLACELAST7=AMEMIYALAST8=BEANLAST9=BIRDLAST10=DOLANLAST11=FONGLAST12=SMITHLAST13=STEPHENSTITLE=VARIEGATE PORPHYRIADATE=2013URL=HTTPS://WWW.NCBI.NLM.NIH.GOV/BOOKS/NBK121283/PUBLISHER=UNIVERSITY OF WASHINGTONDEADURL=NOARCHIVEDATE=18 JANUARY 2017, dmy-all, | Photosensitivity, neurologic symptoms, developmental delay JOURNAL = THE QUARTERLY JOURNAL OF MEDICINE ISSUE = 194 YEAR = 1980, 7433635, | Erythropoietic protoporphyria (EPP)| Ferrochelatase (FECH)| Erythropoietic| Autosomal dominant| Photosensitivity with skin lesions. Gallstones, mild liver dysfunction LAST2 = HANN LAST3 = SMITH TITLE = PEDIATRIC HEMATOLOG PUBLISHER = BLACKWELL PUB. ISBN = 978-1-4051-3400-2, –200,000

Triggers

Acute porphyria can be triggered by a number of drugs, most of which are believed to trigger it by interacting with enzymes in the liver which are made with heme. Such drugs include:WEB, About Porphyria: Safety database, Porphyria Drug Safety Database, American Porphyria Foundation, 27 August 2017, Tishler, PV,weblink no,weblink" title="web.archive.org/web/20170712121843weblink">weblink 12 July 2017, dmy-all, WEB, napos, The Drug Database for Acute Porphyria, European Porphyria Network, 27 August 2017, Brun, A,weblink no,weblink" title="web.archive.org/web/20170823070041weblink">weblink 23 August 2017, dmy-all, BOOK, Joint Formulary Committee, British National Formulary (BNF), 2013, 978-0-85711-084-8, 65, London, UK, Pharmaceutical Press, 663,

Pathogenesis

File:Heme synthesis.svg|thumb|right|350px|Heme synthesis—note that some reactions occur in the cytoplasm and some in the mitochondrionmitochondrionIn humans, porphyrins are the main precursors of heme, an essential constituent of hemoglobin, myoglobin, catalase, peroxidase, and P450 liver cytochromes.The body requires porphyrins to produce heme, which is used to carry oxygen in the blood among other things, but in the porphyrias there is a deficiency (inherited or acquired) of the enzymes that transform the various porphyrins into others, leading to abnormally high levels of one or more of these substances. Porphyrias are classified in two ways, by symptoms and by pathophysiology. Physiologically, porphyrias are classified as liver or erythropoietic based on the sites of accumulation of heme precursors, either in the liver or in the bone marrow and red blood cells.BOOK, Lourenço, Charles Marquez, Lee, Chul, Anderson, Karl E., Jean-Marie, Saudubray, Georges, van den Berghe, John H., Walter, Inborn Metabolic Diseases: Diagnosis and Treatment, 5th, 2012, Springer, New York, 978-3-642-15719-6, 521–532, Disorders of Haem Biosynthesis, Deficiency in the enzymes of the porphyrin pathway leads to insufficient production of heme. Heme function plays a central role in cellular metabolism. This is not the main problem in the porphyrias; most heme synthesis enzymes—even dysfunctional enzymes—have enough residual activity to assist in heme biosynthesis. The principal problem in these deficiencies is the accumulation of porphyrins, the heme precursors, which are toxic to tissue in high concentrations. The chemical properties of these intermediates determine the location of accumulation, whether they induce photosensitivity, and whether the intermediate is excreted (in the urine or feces).There are eight enzymes in the heme biosynthetic pathway, four of which—the first one and the last three—are in the mitochondria, while the other four are in the cytosol. Defects in any of these can lead to some form of porphyria.The hepatic porphyrias are characterized by acute neurological attacks (seizures, psychosis, extreme back and abdominal pain, and an acute polyneuropathy), while the erythropoietic forms present with skin problems, usually a light-sensitive blistering rash and increased hair growth.Variegate porphyria (also porphyria variegata or mixed porphyria), which results from a partial deficiency in PROTO oxidase, manifests itself with skin lesions similar to those of porphyria cutanea tarda combined with acute neurologic attacks. Hereditary coproporphyria, which is characterized by a deficiency in coproporphyrinogen oxidase, coded for by the CPOX gene, may also present with both acute neurologic attacks and cutaneous lesions. All other porphyrias are either skin- or nerve-predominant.

Diagnosis

Porphyrin studies

Porphyria is diagnosed through biochemical analysis of blood, urine, and stool.JOURNAL, Thadani H, Deacon A, Peters T, Diagnosis and management of porphyria, BMJ, 320, 7250, 1647–1651, 2000, 10856069, 1127427, 10.1136/bmj.320.7250.1647, WEB, Tests for Porphyria diagnosis,weblink American Porphyria Foundation, 17 May 2014, yes,weblink" title="web.archive.org/web/20140320095019weblink">weblink 20 March 2014, dmy-all, In general, urine estimation of porphobilinogen (PBG) is the first step if acute porphyria is suspected. As a result of feedback, the decreased production of heme leads to increased production of precursors, PBG being one of the first substances in the porphyrin synthesis pathway.JOURNAL, Anderson KE, Bloomer JR, Bonkovsky HL, Kushner JP, Pierach CA, Pimstone NR, Desnick RJ, Recommendations for the diagnosis and treatment of the acute porphyrias, Ann. Intern. Med., 142, 6, 439–50, 2005, 15767622, 10.7326/0003-4819-142-6-200503150-00010, In nearly all cases of acute porphyria syndromes, urinary PBG is markedly elevated except for the very rare ALA dehydratase deficiency or in patients with symptoms due to hereditary tyrosinemia type I.JOURNAL, Berkó G, Durkó I, [Modification of the Mauzerall-Granick method for the determination of urinary aminolevulinic acid]., Hungarian, Orvosi Hetilap, 112, 51, 3085–6, 19 December 1971, 5136653, In cases ofmercury- or arsenic poisoning-induced porphyria, other changes in porphyrin profiles appear, most notably elevations of uroporphyrins I & III, coproporphyrins I & III, and pre-coproporphyrin.BOOK, Woods, J.S., Porphyrin metabolism as indicator of metal exposure and toxicity, Goyer, R.A. & Cherian, M.G., Toxicology of metals, biochemical aspects, 115, 19–52, Chapter 2, Springer, Berlin, 1995, 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. The urine screening test has been known to fail in the initial stages of a severe, life-threatening attack of acute intermittent porphyria.{{Citation needed|date=February 2007}}Up to 90% of the genetic carriers of the more common, dominantly inherited acute hepatic porphyrias (acute intermittent porphyria, hereditary coproporphyria, variegate porphyria) have been noted in DNA tests to be latent for classic symptoms and may require DNA or enzyme testing. The exception to this may be latent post-puberty genetic carriers of hereditary coproporphyria.{{Citation needed|date=February 2007}}As most porphyrias are rare conditions, general hospital labs typically do not have the expertise, technology, or staff time to perform porphyria testing. In general, testing involves sending samples of blood, stool, and urine to a reference laboratory. All samples to detect porphyrins must be handled properly. Samples should be taken during an acute attack; otherwise a false negative result may occur. Samples must be protected from light and either refrigerated or preserved.If all the porphyrin studies are negative, one must consider pseudoporphyria. A careful medication review often will find the cause of pseudoporphyria.

Additional tests

Further diagnostic tests of affected organs may be required, such as nerve conduction studies for neuropathy or an ultrasound of the liver. Basic biochemical tests may assist in identifying liver disease, hepatocellular carcinoma, and other organ problems.

Management

Acute porphyria

Carbohydrate administration

Often, empirical treatment is required if the diagnostic suspicion of a porphyria is high since acute attacks can be fatal. A high-carbohydrate diet is typically recommended; in severe attacks, a dextrose 10% infusion is commenced, which may aid in recovery by suppressing heme synthesis, which in turn reduces the rate of porphyrin accumulation. However, this can worsen hyponatraemia and should be done with extreme caution as it can prove fatal.WEB,weblink Porphyrias - immediate management, patient.co.uk, 19 October 2016, no,weblink" title="web.archive.org/web/20161020045301weblink">weblink 20 October 2016, dmy-all,

Heme analogs

Hematin (trade name Panhematin) and heme arginate (trade name NormoSang) are the drugs of choice in acute porphyria, in the United States and the United Kingdom, respectively. These drugs need to be given very early in an attack to be effective; effectiveness varies amongst individuals. They are not curative drugs but can shorten attacks and reduce the intensity of an attack. Side effects are rare but can be serious. These heme-like substances theoretically inhibit ALA synthase and hence the accumulation of toxic precursors. In the United Kingdom, supplies of NormoSang are kept at two national centers; emergency supply is available from St Thomas's Hospital, London.BOOK, British National Formulary (BNF 57), March 2009, BMJ Group and RPS Publishing, United Kingdom, 978-0-85369-845-6, 549, 9.8.2: Acute porphyrias, British Medical Association, Royal Pharmaceutical Society of Great Britain, In the United States, Lundbeck manufactures and supplies Panhematin for infusion.WEB,weblink Panhematin for Acute Porphyria, 2010, American Porphyria Foundation, 5 August 2010, yes,weblink" title="web.archive.org/web/20100825015445weblink">weblink 25 August 2010, dmy-all, Heme arginate (NormoSang) is used during crises but also in preventive treatment to avoid crises, one treatment every 10 days.{{citation needed|date=December 2014}}Any sign of low blood sodium (hyponatremia) or weakness should be treated with the addition of hematin, heme arginate, or even tin mesoporphyrin, as these are signs of impending syndrome of inappropriate antidiuretic hormone (SIADH) or peripheral nervous system involvement that may be localized or severe, progressing to bulbar paresis and respiratory paralysis.{{Citation needed|date=February 2007}}

Cimetidine

Cimetidine has also been reported to be effective for acute porphyric crisis and possibly effective for long-term prophylaxis.JOURNAL, Cherem JH, Malagon J, Nellen H, Cimetidine and acute intermittent porphyria, Ann. Intern. Med., 143, 9, 694–5, 2005, 16263899, 10.7326/0003-4819-143-9-200511010-00023,

Symptom control

Pain is severe, frequently out of proportion to physical signs, and often requires the use of opiates to reduce it to tolerable levels. Pain should be treated as early as medically possible. Nausea can be severe; it may respond to phenothiazine drugs but is sometimes intractable. Hot baths and showers may lessen nausea temporarily, though caution should be used to avoid burns or falls.

Early identification

It is recommended that patients with a history of acute porphyria, and even genetic carriers, wear an alert bracelet or other identification at all times. This is in case they develop severe symptoms, or in case of accidents where there is a potential for drug exposure, and as a result they are unable to explain their condition to healthcare professionals. Some drugs are absolutely contraindicated for patients with any form of porphyria.WEB,weblink Porphyria - Diagnosis and treatment - Mayo Clinic, www.mayoclinic.org, 2018-12-06,

Neurologic and psychiatric disorders

Patients who experience frequent attacks can develop chronic neuropathic pain in extremities as well as chronic pain in the abdomen.JOURNAL, Birgisdottir BT, Asgeirsson H, Arnardottir S, Jonsson JJ, Vidarsson B, [Acute abdominal pain caused by acute intermittent porphyria - case report and review of the literature], Icelandic, Laeknabladid, 96, 6, 413–18, 2010, 20519771, Intestinal pseudo-obstruction, ileus, intussusception, hypoganglionosis, and encopresis in children have been associated with porphyrias. This is thought to be due to axonal nerve deterioration in affected areas of the nervous system and vagal nerve dysfunction. Pain treatment with long-acting opioids, such as morphine, is often indicated, and, in cases where seizure or neuropathy is present, Gabapentin is known to improve outcome.JOURNAL, Tsao YC, Niu DM, Chen JT, Lin CY, Lin YY, Liao KK, Gabapentin reduces neurovisceral pain of porphyria, Acta Neurol Taiwan, 19, 2, 112–5, 2010, 20714961, Seizures often accompany this disease. Most seizure medications exacerbate this condition. Treatment can be problematic: barbiturates especially must be avoided. Some benzodiazepines are safe and, when used in conjunction with newer anti-seizure medications such as gabapentin, offer a possible regimen for seizure control. Gabapentin has the additional feature of aiding in the treatment of some kinds of neuropathic pain. Magnesium sulfate and bromides have also been used in porphyria seizures; however, development of status epilepticus in porphyria may not respond to magnesium alone. The addition of hematin or heme arginate has been used during status epilepticus.JOURNAL, Cherian A, Thomas SV, Status epilepticus, Ann Indian Acad Neurol, 12, 3, 140–53, 2009, 20174493, 2824929, 10.4103/0972-2327.56312, Depression often accompanies the disease and is best dealt with by treating the offending symptoms and if needed the judicious use of antidepressants. Some psychotropic drugs are porphyrinogenic, limiting the therapeutic scope. Other psychiatric symptoms such as anxiety, restlessness, insomnia, depression, mania, hallucinations, delusions, confusion, catatonia, and psychosis may occur.Murray ED, Buttner N, Price BH. (2012) Depression and Psychosis in Neurological Practice. In: Neurology in Clinical Practice, 6th Edition. Bradley WG, Daroff RB, Fenichel GM, Jankovic J (eds.) Butterworth Heinemann. 12 April 2012. {{ISBN|978-1437704341}}

Underlying liver disease

Some liver diseases may cause porphyria even in the absence of genetic predisposition. These include hemochromatosis and hepatitis C. Treatment of iron overload may be required.WEB,weblink Porphyria {{!, NIDDK|website=National Institute of Diabetes and Digestive and Kidney Diseases|language=en-US|access-date=2018-12-06}}Patients with the acute porphyrias (AIP, HCP, VP) are at increased risk over their life for hepatocellular carcinoma (primary liver cancer) and may require monitoring. Other typical risk factors for liver cancer need not be present.WEB,weblink Porphyria {{!, NIDDK|website=National Institute of Diabetes and Digestive and Kidney Diseases|language=en-US|access-date=2018-12-06}}

Hormone treatment

Hormonal fluctuations that contribute to cyclical attacks in women have been treated with oral contraceptives and luteinizing hormones to shut down menstrual cycles. However, oral contraceptives have also triggered photosensitivity and withdrawal of oral contraceptives has triggered attacks. Androgens and fertility hormones have also triggered attacks.{{citation needed|date=December 2014}}

Erythropoietic porphyria

These are associated with accumulation of porphyrins in erythrocytes and are rare.The pain, burning, swelling, and itching that occur in erythropoietic porphyrias generally require avoidance of bright sunlight. Most kinds of sunscreen are not effective, but SPF-rated long-sleeve shirts, hats, bandanas, and gloves can help. Chloroquine may be used to increase porphyrin secretion in some EPs. Blood transfusion is occasionally used to suppress innate heme production.The rarest is congenital erythropoietic porphyria (C.E.P.), otherwise known as Gunther's disease. The signs may present from birth and include severe photosensitivity, brown teeth that fluoresce in ultraviolet light due to deposition of Type 1 porphyrins, and later hypertrichosis. Hemolytic anemia usually develops. Pharmaceutical-grade beta carotene may be used in its treatment.Martin A Crook.2006. Clinical chemistry and Metabolic Medicine. seventh edition. Hodder Arnold. {{ISBN|0-340-90616-2}} A bone marrow transplant has also been successful in curing CEP in a few cases, although long-term results are not yet available.JOURNAL, Faraci M, Morreale G, Boeri E, Lanino E, Dallorso S, Dini G, Scuderi F, Cohen A, Cappelli B, Unrelated HSCT in an adolescent affected by congenital erythropoietic porphyria, Pediatr Transplant, 12, 1, 117–120, 2008, 18186900, 10.1111/j.1399-3046.2007.00842.x, In December 2014, afamelanotide received authorization from the European Commission as a treatment for the prevention of phototoxicity in adult patients with EPP.WEB, Community register of medicinal products for human use,weblink ec.europa.eu, European Commission, 24 December 2014, no,weblink" title="web.archive.org/web/20141224180750weblink">weblink 24 December 2014, dmy-all,

Epidemiology

Rates of all types of porphyria taken together have been estimated to be approximately one in 25,000 in the United States.eMedicine > Porphyria, Cutaneous {{webarchive|url=https://web.archive.org/web/20101205041014weblink |date=5 December 2010 }} Authors: Vikramjit S Kanwar, Thomas G DeLoughery, Richard E Frye and Darius J Adams. Updated: 27 July 2010. The worldwide prevalence has been estimated to be between one in 500 and one in 50,000 people.Genetics Home Reference > Porphyria {{webarchive|url=https://web.archive.org/web/20100805111912weblink |date=5 August 2010 }} Reviewed July 2009Porphyrias have been detected in all races and in multiple ethnic groups on every continent. There are high incidence reports of AIP in areas of India and Scandinavia. More than 200 genetic variants of AIP are known, some of which are specific to families, although some strains have proven to be repeated mutations.

History

The underlying mechanism was first described by Felix Hoppe-Seyler in 1871,JOURNAL, Hoppe-Seyler F, Das Hämatin, Tubinger Med-Chem Untersuch, 1871, 4, 523–33, and acute porphyrias were described by the Dutch physician Barend Stokvis in 1889.WEB, Nick Lane, Born to the purple: the story of porphyria, Scientific American,weblink 2002-12-16, 5 August 2008, no,weblink" title="web.archive.org/web/20071011105238weblink">weblink 11 October 2007, dmy-all, JOURNAL, Stokvis BJ, Over twee zeldzame kleurstoffen in urine van zieken, Nederl Tijdschr Geneeskd, 2, 409–417, Dutch, Reprinted in JOURNAL, Stokvis BJ, Over twee zeldzame kleurstoffen in urine van zieken, Dutch, Ned Tijdschr Geneeskd, 133, 51, 2562–70, December 1989, 2689889, The links between porphyrias and mental illness have been noted for decades. In the early 1950s, patients with porphyrias (occasionally referred to as "porphyric hemophilia"Denver, Joness. "An Encyclopaedia of Obscure Medicine". Published by University Books, Inc., 1959.) and severe symptoms of depression or catatonia were treated with electroshock therapy.

Vampires and werewolves

Porphyria has been suggested as an explanation for the origin of vampire and werewolf legends, based upon certain perceived similarities between the condition and the folklore.In January 1964, L. Illis's 1963 paper, "On Porphyria and the Aetiology of Werwolves," was published in Proceedings of the Royal Society of Medicine. Later, Nancy Garden argued for a connection between porphyria and the vampire belief in her 1973 book, Vampires. In 1985, biochemist David Dolphin's paper for the American Association for the Advancement of Science, "Porphyria, Vampires, and Werewolves: The Aetiology of European Metamorphosis Legends," gained widespread media coverage, popularizing the idea.{{fact|date=August 2019}}The theory has been rejected by a few folklorists and researchers as not accurately describing the characteristics of the original werewolf and vampire legends or the disease, and as potentially stigmatizing people with porphyria.American Vampires: Fans, Victims, Practitioners, Norine Dresser, W. W. Norton & Company, 1989."Did vampires suffer from the disease porphyria — or not?" {{webarchive|url=https://web.archive.org/web/20130205152541weblink |date=5 February 2013 }} The Straight Dope, 7 May 1999.A 1995 article from the Postgraduate Medical Journal (via NIH) explains:As it was believed that the folkloric vampire could move about freely in daylight hours, as opposed to the 20th century variant, congenital erythropoietic porphyria cannot readily explain the folkloric vampire but may be an explanation of the vampire as we know it in the 20th century. In addition, the folkloric vampire, when unearthed, was always described as looking quite healthy ("as they were in life"), while due to disfiguring aspects of the disease, sufferers would not have passed the exhumation test. Individuals with congenital erythropoietic porphyria do not crave blood. The enzyme (hematin) necessary to alleviate symptoms is not absorbed intact on oral ingestion, and drinking blood would have no beneficial effect on the sufferer. Finally, and most important, the fact that vampire reports were literally rampant in the 18th century, and that congenital erythropoietic porphyria is an extremely rare manifestation of a rare disease, makes it an unlikely explanation of the folkloric vampire.JOURNAL, Cox, Ann M., 1995, Porphyria and vampirism: another myth in the making, Postgraduate Medical Journal, 71, 841, 643–644, 10.1136/pgmj.71.841.643-a, 7494765, 2398345,

Notable cases

File:Allan Ramsay - King George III in coronation robes - Google Art Project.jpg|thumb|right|George III in his coronation robes]]File:Mary, Queen of Scots after Nicholas Hilliard.jpg|thumb|right|Mary, Queen of ScotsMary, Queen of Scots
  • King George III. The mental illness exhibited by George III 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 that he had acute mania. M. Guttmacher, 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 derangement came in 1966, in a paper called "The Insanity of King George III: A Classic Case of Porphyria",JOURNAL, Macalpine I, Hunter R, The "insanity" of King George 3d: a classic case of porphyria, Br Med J, 1, 5479, 65–71, January 1966, 5323262, 1843211, 10.1136/bmj.1.5479.65, with a follow-up in 1968, "Porphyria in the Royal Houses of Stuart, Hanover and Prussia".JOURNAL, Macalpine I, Hunter R, Rimington C, Porphyria in the royal houses of Stuart, Hanover, and Prussia. A follow-up study of George 3d's illness, Br Med J, 1, 5583, 7–18, January 1968, 4866084, 1984936, 10.1136/bmj.1.5583.7, 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 experts, including those more intimately familiar with the manifestations of porphyria, were unconvinced. Many psychiatrists disagreed with the diagnosis, suggesting bipolar disorder as far more probable. The theory is treated in Purple Secret,BOOK, Warren, Martin, Rh̲l, John C. G., Hunt, David C., Purple secret: genes, "madness" and the Royal houses of Europe, Bantam Books, London, 1998, 978-0-593-04148-2, which documents the ultimately unsuccessful search for genetic evidence of porphyria in the remains of royals suspected to have had it.The authors demonstrated a single point mutation in the PPOX gene but not one that has been associated with disease. In 2005, it was suggested that arsenic (which is known to be porphyrogenic) given to George III with antimony may have caused his porphyria.JOURNAL, Cox TM, Jack N, Lofthouse S, Watling J, Haines J, Warren MJ, King George III and porphyria: an elemental hypothesis and investigation, The Lancet, 366, 9482, 332–335, 2005, 16039338, 10.1016/S0140-6736(05)66991-7, This study found high levels of arsenic in King George's hair. In 2010, one analysis of historical records argued that the porphyria claim was based on spurious and selective interpretation of contemporary medical and historical sources.JOURNAL, Peters TJ, Wilkinson D, King George III and porphyria: a clinical re-examination of the historical evidence, History of Psychiatry, 21, 81 Pt 1, 3–19, 2010, 21877427, 10.1177/0957154X09102616, The mental illness of George III is the basis of the plot in The Madness of King George, a 1994 British film based upon the 1991 Alan Bennett play, The Madness of George III. The closing credits of the film include the comment that the illness that King George had has been attributed to porphyria and that it is hereditary.
  • Descendants of George III. Among other descendants of George III theorized by the authors of Purple Secret to have had porphyria (based on analysis of their extensive and detailed medical correspondence) were his great-great-granddaughter Princess Charlotte of Prussia (Emperor William II's eldest sister) and her daughter Princess Feodora of Saxe-Meiningen. They uncovered better evidence that George III's great-great-great-grandson Prince William of Gloucester was reliably diagnosed with variegate porphyria.BOOK,weblink Tetrapyrroles: Birth, Life and Death, 9780387785189, Smith, Martin, Smith, Alison, 2009-12-21, no, 9 April 2014,weblink" title="web.archive.org/web/20140704171216weblink">weblink 4 July 2014, dmy-all,
  • Mary, Queen of Scots. It is believed that Mary, Queen of Scots, King George III's ancestor, also had acute intermittent porphyria,WEB,weblink bulletin: The University of Sussex NewsletterThe Royal Family's Toxic Time-Bomb Friday 25th June 1999, no,weblink" title="web.archive.org/web/20130915114324weblink">weblink 15 September 2013, dmy-all, although this is subject to much debate. It is assumed she inherited the disorder, if indeed she had it, from her father, James V of Scotland. Both father and daughter endured well-documented attacks that could fall within the constellation of symptoms of porphyria.
File:Maria I, Queen of Portugal - Giuseppe Troni, atribuído (Turim, 1739-Lisboa, 1810) - Google Cultural Institute.jpg|thumb|right|200px|Maria I of Portugal in a c. 1790s portrait attributed to Giuseppe Troni or Thomas Hickey.]]
  • Maria I of Portugal. Maria I—known as "Maria the Pious" or "Maria the Mad" because of both her religious fervor and her acute mental illness, which made her incapable of handling state affairs after 1792 – is also thought to have had porphyria. Francis Willis, the same physician who treated George III, was even summoned by the Portuguese court but returned to England after the court limited the treatments he could oversee. Contemporary sources, such as Secretary of State for Foreign Affairs Luís Pinto, noted that the queen had ever-worsening stomach pains and abdominal spasms: hallmarks of porphyria.BOOK, Roberts, Jenifer, 2009, The Madness of Queen Maria, The Remarkable Life of Maria I of Portugal, Templeton Press, 978-0954558918,
  • Vlad III. Vlad III was also said to have had acute porphyria, which may have started the notion that vampires were allergic to sunlight.WEB,weblink BBC News - UK - Charles visits 'relative' Dracula's home, no,weblink" title="web.archive.org/web/20130824073651weblink">weblink 24 August 2013, dmy-all,
  • Vincent van Gogh. Other commentators have suggested that Vincent van Gogh may have had acute intermittent porphyria.JOURNAL, Loftus LS, Arnold WN, Vincent van Gogh's illness: acute intermittent porphyria?, BMJ, 303, 6817, 1589–1591, 1991, 1773180, 1676250, 10.1136/bmj.303.6817.1589,
  • King Nebuchadnezzar of Babylon. The description of this king in Daniel 4 suggests to some that he had porphyria.JOURNAL, Beveridge A, The madness of politics, J R Soc Med, 96, 12, 602–604, 2003, 14645615, 539664, 10.1258/jrsm.96.12.602,
  • Physician Archie Cochrane. He was born with porphyria, which caused health problems throughout his life.BOOK, Cochrane, Archibald L, Blythe, Max, 2009, 1989, One Man's Medicine: An Autobiography of Professor Archie Cochrane, Cardiff, Cardiff University, 978-0-9540884-3-9,
  • Paula Frías Allende. The daughter of the Chilean novelist Isabel Allende, she fell into a porphyria-induced coma in 1991,BOOK, Allende, Isabel, Paula, HarperCollins, New York, NY, 1995, 978-0-06-017253-4, which inspired Isabel to write the memoir Paula, dedicated to her.
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References

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External links

{{Medical condition classification and resources|DiseasesDB = E070}}-{{ICD1080e|70}}277.1}}|ICDO = |OMIM = |MedlinePlus = 001208|eMedicineSubj = |eMedicineTopic = |MeshName = Porphyrias|MeshNumber = C17.800.849.617|Orphanet = 738}{{Heme metabolism disorders}}

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