1. 1. A family investigation was performed in eleven cases of Porphyria Cutanea Tarda (PCT). 2. 2. By using clinical findings, quantitative measurements and thin layer chromatography (TLC) of urinary porphyrins, overt and subclinical PCT patients have been identified. 3. 3. In the overt type, skin manifestations are present, excretion of urinary porphyrins is increased and the TLC pattern of porphyrins in urine is characteristic for PCT. 4. 4. In the subclinical type, patients have no clinical symptoms, excretion of porphyrins in urine might be normal or enhanced and TLC pattern of urinary porphyrins is typical for PCT. 5. 5. By applying these criteria a clear distinction between hereditary and non-hereditary PCT was possible. 6. 6. Among the 11 families studied, in four families where PCT was hereditary, four members have the overt type and ten relatives the subclinical type. 7. 7. In seven families where PCT was non-hereditary only the propositus has overt PCT and not a single relative showed any clinical or biochemical abnormality. © 1980.Fil:Stella, A.M. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales; Argentina.Fil:del C. Batlle, A.M. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales; Argentina

de Xifra, E.A.W.

del C. Batlle, A.M.

Lenczner, M.

Magnin, P.H.

Stella, A.M.

English

LAReferencia - Red Federada de Repositorios Institucionales de Publicaciones Científicas Latinoamericanas

Inr. J. Biochum. Vol. 12. pp. 873 io 877 0 Pergamon Press Ltd 1980. Printed m Great Brmin 0020.71lX.80.II01.0873802C0/0 STUDIES ON THE EXCRETION PATTERN OF PORPHYRINS AND ITS USE AS A TOOL FOR DIAGNOSING BOTH SYMPTOMATIC AND ASYMPTOMATIC CASES OF PORPHYRIA CUTANEA TARDA PEDRO H. MAGNIN, EVA A. WIDER DE XIFRA, MARIO LENCZNER, ANA M&A STELLA and ALCIRA M. DEL C. BATLLE Centro de Investigaciones sobre Porfirinas y Porfirias, CIPYP, Facultad de Ciencias Exactas y Naturales. Universidad de Buenos Aires y Consejo National de Investigaciones Cientificas y TCcnicas. CONICET, Ciudad Universitaria, Pabell6n II, 4to Piso, Ntiiiez, 1428 Buenos Aires and Servicio de la CBtedra de Dermatologia. Facultad de Medicina, Universidad de Buenos Aires, Hospital Ramos Mejia, Urquiza 609, 1221 Buenos Aires. Argentina Abstract-l. A family investigation was performed in eleven cases of Porphyria Cutanea Tarda (PCT). 2. By using clinical findings. quantitative measurements and thin layer chromatography (TLC) of urinary porphyrins, overt and subclinical PCT patients have been identified. 3. In the overt type, skin manifestations are present, excretion of urinary porphyrins is increased and the TLC pattern of porphyrins in urine is characteristic for PCT. 4. In the subclinical type, patients have no clinical symptoms, excretion of porphyrins in urine might be normal or enhanced and TLC pattern of urinary porphyrins is typical for PCT. 5. By applying these criteria a clear distinction between hereditary and non-hereditary PCT was possible. 6. Among the 1 I families studied, in four families where PCT was hereditary, four members have the overt type and ten relatives the subclinical type. 7. In seven families where PCT was non-hereditary only the propositus has overt PCT and not a single relative showed any clinical or biochemical abnormality. INTRODUCTION Porphyria Cutanea Tarda (PCT) has been regarded as acquired or non-hereditary because of its onset in middle or late life. The most important causative factor is usually considered to be abuse of alcohol and it is also associated with the use of other factors such as estrogens, halogenated hydrocarbons and iron. However it has long been suspected that PCT can be an inheritable disease (WaldenstrBm & Haeger- Aronsen, 1963; Perrot & Thivolet, 1970; McEwin, 1973; Dehlin et al., 1973; Prato et al., 1974; Topi & D’Alessandro, 1977). Specific enzymic defects have been assigned to each porphyria, among them PCT is characterized by a deficiency in the activity of Uroporphyrinogen decar- boxylase and recently a reduction of this enzyme has been found in hepatic tissue and erythrocytes of patients and some of their clinically asymptomatic relatives (Kushner et al., 1976; Benedetto et al., 1978; Felsher et al., 1978: Elder et al.. 1978; Verneuil et al., 1978). This enzymic defect appears to be inherited as an autosomal dominant trait, with a low penetration; however, although measurements of erythrocyte UPG-Dcase levels in PCT patients and their relatives might allow a clear distinction between the acquired and inherited types of PCT, the technique is not always suitable for routine work; moreover, some of these studies have produced contradictory results (Blekkenhorst et a/., 1976). It has been already reported that a systematic study of the urinary and fecal porphyrins using simple screening methods, such as thin layer chroma- tography (TLC) is a very useful technique for per- forming family studies, which can show any minor abnormalities in both clinically symptomatic and asymptomatic PCT patients (Doss et al., 1971 ; With. 1975, 1976; Piiiol-AguadC et al., 1975; Wider de Xifra et al., 1979; Batlle et al., 1979). It is also clear that the hereditary of a case of Por- phyria can only be elucidated by carrying out a study of both the patient and as many blood relatives as possible. This report describes eleven cases of PCT. where a family investigation was performed with good col- laboration from all relatives. to obtain further infor- mation about the existence of two forms of PCT: acquired and hereditary. The biochemical studies include analysis of the urine. blood and feces for por- phyrins and for precursors, when available fine needle liver biopsy for porphyrins, and study of the TLC pattern of urinary porphyrins. MATERIALS AND METHODS Urinary, fecal and blood porphyrin determinations were performed by the solvent fractionation method described by Rimington (1971). The porphyrin methyl esters were analyzed qualitative and quantitatively by TLC (With. 1975; Wider de Xifra et al.. 1979). ALA and PBG were assayed in urine according to Mauzerall & Granick (1956). Porphyrins were investigated in liver biopsy smears by flu- orescence microscopy and by solvent extraction, esterifi- cation and TLC. RESULTS AND DISCUSSION TO establish a diagnosis of PCT the following cri- teria were used: (i) the presence of the clinical syn- 873 874 PEDRO H. MAGNIN rt (11. Table 1. Clinical and laboratory data of four families with porphyria cutanea tarda Urine Age Clinical Liver Porphyrins Type of Family Case Sex (years) syndrome biopsy (g/24 hr) TLC PCT CM IIb F 47 No 705 Abnt Subclinical IIC M 45 No 154 Abn Subclinical IId M 48 No 415 Abn Subclinical IIIb M 21 No 50 NS ~ 111~ (pr.)* M 29 Yes + 1165 Abn Overt IIId F 29 No 20 N IVa M 3 No IO N IVb M 4 No 16 N IVC F 6 No 934 Abn Subclinical CJ IIa F 64 No 16 Abn Subclinical IIb F 66 No 23 Abn Subclinical IIc (pr.) M 52 Yes + 1633 Abn Overt IIIa F 18 No 36 N IIIb F 24 No 18 N FB Ia (pr.) M 70 Yes + 573 Abn Overt IIb F 42 No 104 Abn Subclinical IIIa F 10 No 58 Abn Subclinical IIIb F 16 No 65 Abn Subclinical CM1 Ib (pr.) F 66 Yes + 4416 Abn Overt IIa M 38 No 620 Abn Subclinical IIb F 40 No 13 N * pr. = propositus. t Abn = abnormal. $ N = normal. drome, skin fragility and blisters on the sun exposed skin areas, occasionally hypertrichosis and hyperpig- mentation; (ii) increased urinary excretion of por- phyrins, particularly highly carboxylated porphyrins, uro and heptacarboxylic porphyrins; (iii) abnormal and characteristic fluorescence pattern of the urinary methyl ester porphyrins on TLC, with strong bands at the uroporphyrin (8-COOH porphyrin) as well as at By applying these criteria we can identify two types of PCT: overt and subclinical. In the overt type, skin lesions are present, excretion of urinary porphyrins is increased and the TLC pattern is characteristic. Patients with subclinical PCT have no cutaneous manifestations, excretion of highly carboxylated por- phyrins in urine might be normal or increased but TLC of the methyl esters of that urine shows the the 7&rb6xyl porphyrin zone. FNvlLY CM a b c FAMILY CMI typical pattern for-PCT. FAMILY CJ FAMILY FB I II m a b a b KEY Male Female 0 0 Not Tested q @ Normal 83 $ Deceased w . overt PCT 0 @ Subclinical PCT Propositus Fig. I. Pedigree of four families with hereditary PCT. Excretion patterns of porphyrins 875 In both PCT patients and all their relatives urinary excretion of PBG and ALA was normal. Free erythro- cyte protoporphyrin was also within the normal range in all cases. Liver biopsy specimens were only avail- able from some of the PCT patients, which showed intensive red autofluorescence, and contained large amounts of uro and heptacarboxylic porphyrins. For the purposes of discussion we have divided the 11 families studied in two groups: Group I comprises four families where PCT has been defined as heredi- tary and Group II includes seven families, where PCT was non-hereditary or acquired. In Table 1 and Fig. 1, the clinical and laboratory data and the pedigree of families of Group I are shown respectively. If we carefully analyze these find- ings it is clear that among the 21 members examined, four were the patients (CM IIIc, CJ IIc, FB Ia and CM1 Ia) having overt PCT, blistering photo-enhanced dermatosis was present, porphyrin fluorescence was intense in liver biopsy smears, porphyrinuria was high and the TLC urinary pattern was typically abnormal. Ten other relatives (CM IIb, IIc, IId, and IVc; CJ IIa and IIb; FB IIb, IIIa and IIIb; CM1 IIa) have never developed any cutaneous symptoms, urinary por- phyrin excretion was normal or increased but in all ten, TLC of porphyrins in urine was characteristic of PCT, showing that they have subclinical disease. The remaining seven members studied were completely normal. These four families are therefore an example of her- editary PCT in which ten individuals not having any cutaneous manifestations and some of them having normal urinary excretion, could be diagnosed as sub- clinical cases, because the TLC pattern of porphyrins in urine was characteristic of PCT. In Table 2 the clinical and laboratory data of Group II are shown. Figure 2 illustrates the pedigree of seven families in which PCI was Non-hereditary. From these results, among the 32 members studied, it is clear that in the seven overt PCT patients (TM Ia, LN Ia, TJ Ia, PO Ia, PJ Ia, MRJ Ib and MF Ha) the disorder was acquired because cutaneous manifesta- tions, porphyrinuria and characteristic TLC urinary pattern were only present in the propositus; none of the relatives have ever developed any clinical symp- tom, and both their urinary porphyrin excretion and TLC pattern were normal. Therefore, by using clinical data and quantitation Table 2. Clinical and laboratory data of seven families with non hereditary porphyria cutanea tarda Family Case Urine Age Clinical Liver Porphyrins Type of Sex (years) syndrome biopsy (g/24 hr) TLC PCT TM LN TJ PO PJ MRJ MF Ia W.) M IIa M IIb F IIC F Ia W M IIa M IIb F IIC F IId F Ia (pr.) M IIa F IIb F IIC F Ia (pr.) M IIa F IIb F IIC F Ia (pr.) M IIa M IIb M IIC F IId F IIe F IIf F IIg F Ib (pr.) F IIa M IIb M IIC F la M IIa (pr.) M IIIa M 54 16 18 19 57 26 28 30 37 60 17 21 25 32 4 6 8 60 Yes + 3197 No 19 No 20 No IO Yes + 1243 No 18 No 52 No .lO No 6 Yes + 1538 No 38 No 10 No 12 Yes 4727 No 32 No 12 No II Yes No No No No No No No 39 Yes 14 No 20 No 17 No + 2032 7 13 10 21 22 20 18 686 17 IO 9 80 No 29 22 Yes 7157 1 No 10 Abnl Nf N N Abn N N N N Abn N N N Abn N N N Abn N N N N N N N Abn N N N N Abn N Overt Overt Overt Overt Overt Overt Overt * pr. = propositus. t Abn = abnormal. $ N = normal. 876 PEDRO H. MAGN~N et ui. FAMILY MF ab c 0 Fig. 2. Pedigree of seven ramtEes with ~o~~~~e~editary PCT and TLC of urinary porphyrins we have been able to ELDER G. N., LEE G. B. & T~VEY J. A. ff978f Decreased identify overt and subclinical PCT patients. Among activity of hepantic uroporphyrinogen decarlsoxyiase in the f I fan&es studied, in four of these, FXX was a sporadic porphyria cutanea tarda. (“d. Engl. f. Mpd. 299, hereditary disease. while in seven ather families PCT 234-278. was a Nan-hereditary disorder. FELSHER B. F., NORRIS M. E. & SHAH J. C. (1378) Red &i These findings are in agreement with the hypothesis u~oporphyri~agen decar~xy~se activity in porphyria on the existance of an acquired and an hereditary cutanea tarda and in other forms of porphyria. N. Engl. J. iwed. 299, ~~5-1~8. form of Pff and stress the importancse of carefully KUSKNER J. F., STE~NM~~LLER D. P. & LEE G. R. (1975) The performing compftlte c&G& and biochemical investi- role of iron in the pathagenesis of porphyria cutanea gations of b&b the patients and al! their blood refa- tarda II. fnhibition of ~roporphyr~nogen d~ar~~x~~ase. tives, to be able to determine whetbex or not there is a f, &in. Inwst. %, 561467. pattern of heredity in the family and cons~~e~t~y KUSHNER J P., BARBLITTO A. J. & LEE G. R. (1976) An institute proper therapy and prophylaxis. inherited enzymic defect in porphyria cutanea tarda: de- creased uro~~r~hvrino~en de~rboxylase activitv. J. clin. invesb. 58, i~~~-i~7. - Acknawlrdgemertrs-This work was supported by grants McEwm R. (1973) The inheritance of porphyria cutanea fram the CUNICET, the tiniriersity of Buenos Aires and tarda. ?&e’eit. J Attsr. 2, 398-399. the SECYT. A. M. del C. Bathe and E. A. Wider de Xifra MAUZERAU n. & GRAhilCK S. (1956) The occurrence: and hold the post of Scientific Researchers in the CQNJCET. determination of ~-arni~o~~vu~~njc acid and porphobili- We are very grateful to Dr. A. A. Juknat de Ceratnik, Dr nogen in urine, J. biot. Che-tn. 219, 435-445. M. V. Rossetti and Dr V. E. Parera for their valuable help PERROT H. & THIVOLET J. (1970) Le role de I’hireditt dans and also to Miss H. Gasparoli, Mr F. Ortega, Mm f. la porphyrie cuta& tardive dite acquise. Ann. ~~r~~~. Jaievsky and Mr D. Sachetti for their skilfut technical as- Syphiliyr., Paris 97, 5-14. slstance. %%E.-AG~:AD& .f., HERRERO C., At~rzraft J., SMITH S. 6. & BEUXER B, V. (J975) Thin gayer ~hrorna~o~ra~~y and counter cnrrent anaiysis in Porphyria Br. 2. I)ermat. 93, REFERENCES X7-289, PRATO V., MAZZA U., BATTISTENI V. 8r MA~.SARO L, (L974) BATLLE A. M. DEL f.. WIDER DE XIPRA E. A.. STELLA A. M., ~ereditariet~ delfa porfiria ~utanea tarda sintomstj~s. RO.%ZETTI M. Y., MAGNIN P. H., M~LINET A. H, & Miner0u iwed. 65, 3599-3613. LE;“ICZNER M. J. (1979) Control bioquimico de1 trata- miento aiealinizante en la For&a Cutcinea Tardia. Rru. Ary. &#Y?r. in press. BENEDETTO A. V., .IAR~E~ D. O., Kusn~~s J. P. & TAYLOR J. S. (f978) Porphyria Cutanea Tarda in three generations of a single family. N. Engl. J. Mrd. 29g, 3.58-362. ~~~KKE~H~RS~ R., PIMPST~NE N. & EA~..EZ L, (19763 Por- phyria Cutanea Tarda in South Africa: metabolic basis of disordered haem biosynthesis In Pur~~~~~~~~s in ~~~~11 Dfseases &dited by Doss M.) pp. 299-3 I I. Karger, Basel. DEHU~U 0.. ENERBACK L. L LUNDVALL 0. (1973) Por- phyria Cutanea Tarda: a genetic disease? A biochemical and fluorescence microscopical study in four families. Acta med. &and. 194, X5-270. ROSS M., LOOK D., HENNING H., Lurrans C. J., DOL.L.L W. ~52 STROHMEY~~ G. (1971) Chronische hepatische yor- phyrien. Z. K&n. Chem. K&n. 3~~~~1~~~ ‘p, 411-477. RIMINGTON C. (1971) Quantitative determination of por- phobjli~o$eu and porphyrins in urine and porphyrins in feces and eryrhracyr~s. Broadsheet N 70. Association of Ctinicaf Pathologist, London. TOPI G. & D’A~E~~AF;DRo 6. L. Ii9771 fnheritance of Por- phyria Cuianea Tarda. 3r. J, I&mat. 97, 617-627. VF~NEUIL II. DE N~R~MANN Y., Pnw~ N., GRAN~~~A~~ B., AITKEN G., GRELIER M. & NOIRE J. f1978) FamihaI and sporadic porphyria cutanea: two different diseases. IrIb. J. ~j5~~~~~~. 9, 927-932. w~~~~~sT%~~ f. & i"&GER-ARONSZN B. fi9fi7) E)fffi%CWt patterns of human porphyria. Br. &fed. f. 2, 272-276. WIDER DE XEPRA E. A., STELLA A. M., JUKNAT A. A., BATLLE A, M, DEL C., MAGNIN P. H. & CASTEF.,I,A+JOS POSE F. N. M. (1979) Aplicacion de la cromato~a~a en capa detgada en ei estudio de la herencia en Porfiria futanea Tardia. Rev. Ary. &pm. 60, 22623l. Excretion patterns of porphyrins 877 WITH T. K. (1975) Clinical use of porphyrin ester chroma- tography in urine and feces. Dan. Med. Buil. 22, 74-80. WITH T. K. (1976) A simplified system of clinical porphyrin analysis of urine and feces based on TLC. In ~~r~~y~j~s in hulas Disease (Edited by DOSS M.) pp. 492-499. Karger. Basel. 

Studies on the excretion pattern of porphyrins and its use as a tool for diagnosing both symptomatic and asymptomatic cases of porphyria cutanea tarda

http://digital.bl.fcen.uba.ar/Download/paper/paper_0020711X_v12_n5-6_p873_Magnin.pdf

Studies on the excretion pattern of porphyrins and its use as a tool for diagnosing both symptomatic and asymptomatic cases of porphyria cutanea tarda

Abstract

Similar works

Full text

Available Versions

LAReferencia - Red Federada de Repositorios Institucionales de Publicaciones Científicas Latinoamericanas