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Protoporphyria, erythropoietic, 1(EPP1)

MedGen UID:
1643471
Concept ID:
C4692546
Disease or Syndrome
Synonyms: EPP1; Erythropoietic Protoporphyria, Autosomal Recessive; Ferrochelatase deficiency; Heme synthetase deficiency
 
Gene (location): FECH (18q21.31)
 
Monarch Initiative: MONDO:0008319
OMIM®: 177000

Disease characteristics

Erythropoietic protoporphyria (EPP) is characterized by cutaneous photosensitivity (usually beginning in infancy or childhood) that results in tingling, burning, pain, and itching within 30 minutes after exposure to sun or ultraviolet light and may be accompanied by swelling and redness. Symptoms (which may seem out of proportion to the visible skin lesions) may persist for hours or days after the initial phototoxic reaction. Photosensitivity remains for life. Multiple episodes of acute photosensitivity may lead to chronic changes of sun-exposed skin (lichenification, leathery pseudovesicles, grooving around the lips) and loss of lunulae of the nails. Approximately 20%-30% of individuals with EPP have some degree of liver dysfunction, which is typically mild with slight elevations of the liver enzymes. Up to 5% may develop more advanced liver disease which may be accompanied by motor neuropathy similar to that seen in the acute porphyrias. [from GeneReviews]
Authors:
Manisha Balwani  |  Joseph Bloomer  |  Robert Desnick, et. al.   view full author information

Additional description

From MedlinePlus Genetics
Porphyria is a group of disorders caused by abnormalities in the chemical steps that lead to heme production. Heme is a vital molecule for all of the body's organs, although it is most abundant in the blood, bone marrow, and liver. Heme is a component of several iron-containing proteins called hemoproteins, including hemoglobin (the protein that carries oxygen in the blood).

Other types of porphyria, called acute porphyrias, primarily affect the nervous system. These disorders are described as "acute" because their signs and symptoms appear quickly and usually last a short time. Episodes of acute porphyria can cause abdominal pain, vomiting, constipation, and diarrhea. During an episode, a person may also experience muscle weakness, seizures, fever, and mental changes such as anxiety and hallucinations. These signs and symptoms can be life-threatening, especially if the muscles that control breathing become paralyzed. Acute porphyrias include acute intermittent porphyria and ALAD deficiency porphyria. Two other forms of porphyria, hereditary coproporphyria and variegate porphyria, can have both acute and cutaneous symptoms.

The porphyrias can also be split into erythropoietic and hepatic types, depending on where damaging compounds called porphyrins and porphyrin precursors first build up in the body. In erythropoietic porphyrias, these compounds originate in the bone marrow. Erythropoietic porphyrias include erythropoietic protoporphyria and congenital erythropoietic porphyria. Health problems associated with erythropoietic porphyrias include a low number of red blood cells (anemia) and enlargement of the spleen (splenomegaly). The other types of porphyrias are considered hepatic porphyrias. In these disorders, porphyrins and porphyrin precursors originate primarily in the liver, leading to abnormal liver function and an increased risk of developing liver cancer.

Researchers have identified several types of porphyria, which are distinguished by their genetic cause and their signs and symptoms. Some types of porphyria, called cutaneous porphyrias, primarily affect the skin. Areas of skin exposed to the sun become fragile and blistered, which can lead to infection, scarring, changes in skin coloring (pigmentation), and increased hair growth. Cutaneous porphyrias include congenital erythropoietic porphyria, erythropoietic protoporphyria, hepatoerythropoietic porphyria, and porphyria cutanea tarda.

Environmental factors can strongly influence the occurrence and severity of signs and symptoms of porphyria. Alcohol, smoking, certain drugs, hormones, other illnesses, stress, and dieting or periods without food (fasting) can all trigger the signs and symptoms of some forms of the disorder. Additionally, exposure to sunlight worsens the skin damage in people with cutaneous porphyrias.  https://medlineplus.gov/genetics/condition/porphyria

Clinical features

From HPO
Cholelithiasis
MedGen UID:
3039
Concept ID:
C0008350
Disease or Syndrome
Hard, pebble-like deposits that form within the gallbladder.
Liver failure
MedGen UID:
88444
Concept ID:
C0085605
Disease or Syndrome
A disorder characterized by the inability of the liver to metabolize chemicals in the body. Causes include cirrhosis and drug-induced hepatotoxicity. Signs and symptoms include jaundice and encephalopathy. Laboratory test results reveal abnormal plasma levels of ammonia, bilirubin, lactic dehydrogenase, and alkaline phosphatase.
Hemolytic anemia
MedGen UID:
1916
Concept ID:
C0002878
Disease or Syndrome
A type of anemia caused by premature destruction of red blood cells (hemolysis).
Eczematoid dermatitis
MedGen UID:
3968
Concept ID:
C0013595
Disease or Syndrome
Eczema is a form of dermatitis that is characterized by scaly, pruritic, erythematous lesions located on flexural surfaces.
Edema
MedGen UID:
4451
Concept ID:
C0013604
Pathologic Function
An abnormal accumulation of fluid beneath the skin, or in one or more cavities of the body.
Hypertriglyceridemia
MedGen UID:
167238
Concept ID:
C0813230
Finding
An abnormal increase in the level of triglycerides in the blood.
Low tissue ferrochelatase activity
MedGen UID:
1052392
Concept ID:
CN377526
Finding
Concentration or activity of Ferrochelatase (FECH; EC 4.99.1.1) below the lower limit of normal. FECH enzyme can be measured in multiple tissues including leukocytes and cultured fibroblasts. FECH is the terminal enzyme of the heme biosynthetic pathway, and catalyzes the insertion of iron into protoporphyrin to form heme.
Pruritus
MedGen UID:
19534
Concept ID:
C0033774
Sign or Symptom
Pruritus is an itch or a sensation that makes a person want to scratch. This term refers to an abnormally increased disposition to experience pruritus.
Erythema
MedGen UID:
11999
Concept ID:
C0041834
Disease or Syndrome
Redness of the skin, caused by hyperemia of the capillaries in the lower layers of the skin.

Professional guidelines

PubMed

Fung MA, Murphy MJ, Hoss DM, Berke A, Grant-Kels JM
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Recent clinical studies

Etiology

Pathman L, Bennett M, d'Udekem Y, Phillips R
Australas J Dermatol 2022 Feb;63(1):e60-e62. Epub 2021 Nov 24 doi: 10.1111/ajd.13751. PMID: 34817070
Phillips JD
Mol Genet Metab 2019 Nov;128(3):164-177. Epub 2019 Apr 22 doi: 10.1016/j.ymgme.2019.04.008. PMID: 31326287Free PMC Article
Ramanujam VS, Anderson KE
Curr Protoc Hum Genet 2015 Jul 1;86:17.20.1-17.20.26. doi: 10.1002/0471142905.hg1720s86. PMID: 26132003Free PMC Article
Elder G, Harper P, Badminton M, Sandberg S, Deybach JC
J Inherit Metab Dis 2013 Sep;36(5):849-57. Epub 2012 Nov 1 doi: 10.1007/s10545-012-9544-4. PMID: 23114748
Biesalski HK, Obermueller-Jevic UC
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Diagnosis

Zeng Q, Wu D, Tang H
Gastroenterology 2024 Jan;166(1):27-30. Epub 2023 Aug 12 doi: 10.1053/j.gastro.2023.07.028. PMID: 37579823
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Genet Med 2021 Jan;23(1):140-148. Epub 2020 Sep 2 doi: 10.1038/s41436-020-00951-8. PMID: 32873934Free PMC Article
Ramanujam VS, Anderson KE
Curr Protoc Hum Genet 2015 Jul 1;86:17.20.1-17.20.26. doi: 10.1002/0471142905.hg1720s86. PMID: 26132003Free PMC Article
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Med J Aust 1973 May 5;1(18):872. doi: 10.5694/j.1326-5377.1973.tb110769.x. PMID: 4716224

Therapy

Barman-Aksözen J, Andreoletti M, Blasimme A
Orphanet J Rare Dis 2023 Oct 16;18(1):325. doi: 10.1186/s13023-023-02941-w. PMID: 37845740Free PMC Article
Pathman L, Bennett M, d'Udekem Y, Phillips R
Australas J Dermatol 2022 Feb;63(1):e60-e62. Epub 2021 Nov 24 doi: 10.1111/ajd.13751. PMID: 34817070
Luger TA, Böhm M
J Invest Dermatol 2015 Apr;135(4):929-931. doi: 10.1038/jid.2015.16. PMID: 25785940
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Med J Aust 1973 May 5;1(18):872. doi: 10.5694/j.1326-5377.1973.tb110769.x. PMID: 4716224

Prognosis

Elder G, Harper P, Badminton M, Sandberg S, Deybach JC
J Inherit Metab Dis 2013 Sep;36(5):849-57. Epub 2012 Nov 1 doi: 10.1007/s10545-012-9544-4. PMID: 23114748
Lecha M, Puy H, Deybach JC
Orphanet J Rare Dis 2009 Sep 10;4:19. doi: 10.1186/1750-1172-4-19. PMID: 19744342Free PMC Article
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Clinical prediction guides

Takami T, Itatani Y, Shibuya R, Kiyasu Y, Kasahara K, Nishizaki D, Okamura R, Okada T, Nishigori T, Hoshino N, Hisamori S, Tsunoda S, Hida K, Kawada K, Obama K
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Heerfordt IM, Fontenete S, Lerche CM, Wulf HC
Photodiagnosis Photodyn Ther 2022 Mar;37:102629. Epub 2021 Nov 16 doi: 10.1016/j.pdpdt.2021.102629. PMID: 34798346
Phillips JD
Mol Genet Metab 2019 Nov;128(3):164-177. Epub 2019 Apr 22 doi: 10.1016/j.ymgme.2019.04.008. PMID: 31326287Free PMC Article
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Recent systematic reviews

Snast I, Kaftory R, Sherman S, Edel Y, Hodak E, Levi A, Lapidoth M
Photodermatol Photoimmunol Photomed 2020 Jan;36(1):29-33. Epub 2019 Aug 21 doi: 10.1111/phpp.12501. PMID: 31374130
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