Erythropoietic Protoporphyria - Presentation

Presentation

A common symptom is very painful photosensitivity, manifesting itself as a burning and itching sensation on the surface of the skin. At times the itching sensations are almost unbearable. Rubbing the affected areas with ice can be the only relief, and that is only temporary. The usual anti-itch remedies, including cortisone anti-histamine topical preparations, and Calomine lotion generally provide little or no relief. If a patient presents with a history of anti-itch preparation inefficacy, EPP should be considered.

EPP usually first presents in childhood, and most often affects the face and the upper surfaces of the arms, hands, and feet and the exposed surfaces of the legs. Most patients, if the EPP is not as severe, manifest symptoms with onset of puberty when the male and female hormone levels elevate during sexual development and maintenance. More severe EPP can manifest in infancy. Exposure to even indoor light sources can cause the rash, and the infant, if clothed only in a diaper, will break out everywhere except under the diaper. EPP can be triggered through exposure to sun even though the patient is behind glass. Even the UV emissions from arc welding with the use of full protective mask have been known to trigger EPP.

Prolonged exposure to the sun can lead to edema and blistering. At times the immediate damage can be so severe that the individual can lose the skin in sheets. After many years, chronically sun-exposed skin may become thick and wrinkled if no beta carotene and other carotenoids and no lutein and other xanthophylls are ingested.

Another aspect of the painfulness of EPP is the painful abdomen, which may manifest as generalized pain, or may imitate an appendicitis. Some healthy appendices have been removed due to this mimic. Since porphyria is not that common, most doctors don't even think to do blood porphyrin levels when symptoms present. For doctors that are familiar with porphyria, it is generally considered insignificant and irrelevant compared to the possibility of a pending burst appendix, especially since porphyrin levels cannot be generally be received back immediately due to lab protocols.

Moderate and severe cases can present with pelvic and shoulder girdle muscle weakness. This is because porphyrins are poisonous to the body and produce nerve damage. Damage to nerves of the digestive system not only cause nerve pain in the abdominal area, but also cause slow movement of the bowels, especially the large bowel. Patients can therefore develop a larger than normal diameter of the large bowel, at times causing a condition called megacolon. The damage of nerves to the esophagus and to the stomach valve muscles (sphincters) can cause stomach reflux. One of the ironies of these digestive condition is that one of the medical treatments of these digestive conditions is Reglan, to which some porphyrics have a very strong adverse reaction.

Porphyrin toxins are neurotropic and shut down the nerve trunks one by one until the individual has difficulty with fine motor tasks, like turning phonebook pages, has difficulty speaking (develops dystonic speech that is almost unintelligible), and develops difficulty breathing. The porphyrin neurotoxins have caused some patients to present to the Emergency Room not only in pain but also seeming to be neurotic, or even psychotic. Once glucose is infused, those episodes subside, and if they don't, healthy red blood cell infusion in whole also helps, due to the naturally occurring glucose in the infused blood. These patients will often present with a very enlarged spleen due to having to process defective red blood cells. At times poking around on the spleen can cause elevation of body temperature by at least two degrees Fahrenheit. The liver may also be tender.

People with EPP are also at increased risk to develop gallstones. In a small percentage of cases, protoporphyrin accumulates to toxic levels in the liver, leading to liver failure.