The porphyrias are metabolic disorders, each resulting from the deficiency of a specific enzyme in the heme biosynthetic pathway (Fig. 358-1 and Table 358-1). These enzyme deficiencies are inherited as autosomal dominant, autosomal recessive, or X-linked traits, with the exception of porphyria cutanea tarda (PCT), which usually is sporadic (Table 358-1). The porphyrias are classified as either hepatic or erythropoietic, depending on the primary site of overproduction and accumulation of their respective porphyrin precursors or porphyrins (Tables 358-1 and 358-2), although some have overlapping features. For example, PCT, the most common porphyria, is hepatic and presents with blistering cutaneous photosensitivity, which is usually a manifestation of the erythropoietic porphyrias. The major manifestations of the acute hepatic porphyrias are neurologic, including neuropathic abdominal pain, peripheral motor neuropathy, and mental disturbances, with attacks often precipitated by steroid hormones, certain drugs, and nutritional changes such as dieting. While hepatic porphyrias are symptomatic primarily in adults, rare homozygous variants of the autosomal dominant hepatic porphyrias usually manifest clinically prior to puberty.
The human heme biosynthetic pathway indicating in linked boxes the enzyme that, when deficient, causes the respective porphyria. Hepatic porphyrias are shown in yellow boxes and erythropoietic porphyrias in pink boxes.
Table 358-1 Human Porphyrias: Major Clinical and Laboratory Features |Favorite Table|Download (.pdf)
Table 358-1 Human Porphyrias: Major Clinical and Laboratory Features
|Principal Symptoms||Increased Porphyrin Precursors and/or Porphyrins|
|Porphyria||Deficient Enzyme||Inheritance||NV or CP+||Enzyme Activity % of Normal||Erythrocytes||Urine||Stool|
|5-ALA dehydratase-deficient porphyria (ADP)||ALA-dehydratase||AR||NV||˜5||Zn-Protoporphyrin||ALA, Coproporphyrin III||—|
|Acute intermittent porphyria (AIP)||HMB-synthase||AD||NV||˜50||—||ALAa, PBG, Uroporphyrin||—|
|Porphyria cutanea tarda (PCT)||URO-decarboxylase||AD||CP||˜20||—||Uroporphyrin, 7-carboxylate porphyrin||Isocoproporphyrin|
|Hereditary coproporphyria (HCP)||COPRO-oxidase||AD||NV & CP||˜50||—||ALA, PBG, Coproporphyrin III||Coproporphyrin III|
|Variegate porphyria (VP)||PROTO-oxidase||AD||NV & CP||˜50||—||ALA, PBG, Coproporphyrin III||Coproporphyrin III Protoporphyrin|
|Congenital erythropoietic porphyria (CEP)||URO-synthase||AR||CP||1–5|
|Erythropoietic protoporphyria (EPP)||Ferrochelatase||ARa||CP||˜20–30||Protoporphyrin||—||Protoporphyrin|
|X-linked protoporphyria (XLP)||ALA-synthase 2||XL||CP||>100c||Protoporphyrin||—||Protoporphyrin|
Table 358-2 Human Heme Biosynthetic Enzymes and Genes