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Protoporphyria

  • Author: Maureen B Poh-Fitzpatrick, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 11, 2016
 

Background

The term protoporphyria now encompasses 2 clinically similar but distinct disorders that most often result from hereditary mutations in 2 different genes. The more common of these is erythropoietic protoporphyria, (EPP, OMIM 177000), which is caused by impaired activity of ferrochelatase (FECH), the ultimate enzyme of heme biosynthesis.[1, 2] . The resultant accumulated excess of its substrate, metal-free protoporphyrin, causes 2 principal manifestations: (1) an acute cutaneous photosensitivity typically first appearing during childhood and (2) hepatobiliary disease.[1, 3, 4, 5]

The predominant genotype associated with phenotypic expression of EPP is one mutant ferrochelatase allele (FECH) encoding a defective enzyme protein with little or no function, coupled with a relatively common polymorphic allele with low gene expression that reduces, but does not abrogate, the activity of its encoded enzyme.[6, 7] This complex form of inheritance has been termed pseudodominant[8, 9] or semidominant.[10] Others refer to this genotype as autosomal recessive,[11] because anomalies in both paired alleles are required for disease expression; however, one alteration is far more deleterious than the other. Infrequently, 2 deleterious FECH mutations are present; this recessively inherited form of EPP appears to impart a higher risk for hepatic dysfunction in some cases.[12, 13]

Rarely, acquired somatic mutation or deletion of a ferrochelatase gene secondary to myelodysplastic or myeloproliferative disorders leads to an adult-onset protoporphyric disorder.[14, 15, 16]

A far less frequent type of hereditary protoporphyria, now recognized as a separate disorder, is called X-linked dominant protoporphyria (XLDPP, OMIM 300752), or simply XLP. XLP arises from C-terminal deletions or alterations in the gene encoding the erythroid-specific enzyme 5-aminolevulinic acid synthase-2 (ALAS2), increased function of which leads to overproduction of protoporphyrin.[17, 11] Like EPP, XLP is caused by bone marrow heme synthetic dysfunction, but eventuates in a greater ratio of accumulated erythrocyte zinc-protoporphyrin to metal-free protoporphyrin than is typical for EPP. XLP causes an acute, childhood-onset, cutaneous photosensitivity indistinguishable from that of EPP, but appears to have a higher risk for hepatic dysfunction than does EPP.[17] An adult-onset case of XLP in an 89-year-old man with evolving myelodysplasia exhibited somatic mosaicism in erythroid hematopoietic cells associated with an ALAS2 mutation that predicted a C-terminal deletion.[18]

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Pathophysiology

Protoporphyrin is a lipophilic molecule capable of transformation to excited states by absorption of light energy. Excited-state protoporphyrin mediates photoxidative damage to biomolecular targets in the skin,[19] resulting in immediate phototoxic symptoms variously described as tingling, stinging, or burning that may be followed by the appearance of erythema, edema, and purpura.[3, 19] Excess protoporphyrin is formed during maturation of erythroid cells in the bone marrow and is present at the highest levels in reticulocytes and young erythrocytes.[20] Metal-free protoporphyrin escapes from red blood cells into the plasma, from which it is cleared by the liver and secreted into bile. Protoporphyrin-rich bile facilitates gallstone formation.[21] Toxic effects of protoporphyrin deposition in the liver may lead to life-threatening hepatic dysfunction.[21, 22, 23]

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Epidemiology

Frequency

United States

Until a recently established registry for protoporphyria sponsored by the American Porphyria Foundation collects sufficient data, accurate enumeration in the United States cannot be provided, but is probably similar to data from European countries. A study of 155 North American individuals exhibiting the protoporphyria phenotype identified 15 with ALAS2 mutations and 140 with FECH anomalies.[24] The ALAS2/FECH ratio of approximately 10% in this study is greater than ratios reported in European populations.

International

Estimates of one erythropoietic protoporphyria case in populations of 75,000-200,000 have been reported for several Western European populations and in the South African population of European ancestry.[2, 5, 25, 26, 27] X-linked dominant protoporphyria remains rare but has been identified in increasing numbers.[9, 11, 17, 24, 28, 29, 30]

Race

Erythropoietic protoporphyria has been reported most often in people with white heritage, but it has also been reported in persons with Japanese, Chinese, East Indian, or north or central African ancestry. X-linked dominant protoporphyria has been identified chiefly among individuals of Western European ancestry but also in an African American and Pacific Islander[11] and a Japanese boy.[28]

Sex

Erythropoietic protoporphyria and X-linked dominant protoporphyria occur in both males and females.

Age

Photocutaneous symptoms usually appear during childhood,[3] but they also may be noted for the first time in adult life.[14, 15, 16, 18, 30] Gallstones may become symptomatic in young adulthood or in middle age.[3] Liver failure and its complications, sufficiently severe to result in liver transplantation and/or death, may develop in children and adolescents as well as adults.[21, 23, 31, 32, 33]

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Prognosis

In the absence of hepatic failure, individuals with erythropoietic protoporphyria (EPP) have normal life expectancies.

Painful cutaneous photosensitivity reduces the sunlight tolerance of individuals with protoporphyria and may influence their lifestyles over entire lifetimes.[3]

An increased prevalence of cholelithiasis in both men and women can result in signs and symptoms of gallstone disease at relatively early ages.[3]

Hepatotoxic effects of excess protoporphyrin deposition have led to liver dysfunction that progressed to life-threatening severity in approximately 2-5% of known cases of protoporphyria.[5]

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Contributor Information and Disclosures
Author

Maureen B Poh-Fitzpatrick, MD Professor Emerita of Dermatology and Special Lecturer, Columbia University College of Physicians and Surgeons

Maureen B Poh-Fitzpatrick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, New York Dermatological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine

Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

Günter Burg, MD Professor and Chairman Emeritus, Department of Dermatology, University of Zürich School of Medicine; Delegate of The Foundation for Modern Teaching and Learning in Medicine Faculty of Medicine, University of Zürich, Switzerland

Günter Burg, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, International Society for Dermatologic Surgery, North American Clinical Dermatologic Society, and Pacific Dermatologic Association

Disclosure: Nothing to disclose.

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