Diagnosis of the Porphyrias

First-line Testing for the Acute Porphyrias

Table 1. First-line Testing for Patients in Whom Acute Porphyria is Suspected

Symptoms	Test	Laboratories
Acute attacks of severe abdominal pain, nausea, vomiting, rapid heartbeat and other symptoms.	Spot or 24 hour urine delta-aminolevulinic acid (ALA) and porphobilinogen (PBG)*	UTMB, ARUP, Mount Sinai**, Mayo, Quest, LabCorp
Blistering skin photosensitivity (with or without acute attack symptoms)	Plasma total porphyrins	UTMB, ARUP, Mayo, Quest, LabCorp

*Take sample when symptoms are present

Acute porphyrias

An acute porphyria should be suspected if patient presents with neurolvisceral signs and symptoms. The first-line screening test is measurement of urinary porphobilinogen (PBG). PBG is markedly increased in all patients during acute porphyria attacks and not markedly elevated in other medical conditions that can present with similar symptoms. Therefore, this test is both sensitive and specific for diagnosing an acute porphyria. An exception is ADP, in which ALA is elevated but not PBG. However, the condition is not usually under consideration because of its extreme rarity.

Measurement of PBG is often combined with ALA and total urine porphyrins. In some patients with acute porphyria, urinary porphyrins may remain increased longer than ALA and PBG. However, mild increases in urinary porphyrins can occur in other medical conditions and is therefore much less specific than increases in ALA and PBG. In urgent situations, a “stat” PBG for diagnosis is not available through any of the large reference labs. While the report is pending, initial management of the patient should be tailored to the possibility of acute porphyria, correcting fluid and electrolyte imbalances, pain control, and avoidance of medications that could worsen an attack (such as phenytoin for seizures). Patients with progressive neurological signs should be started on intravenous hemin. Intravenous dextrose can be administered while hemin is being prepared but should not cause a delay of hemin infusion.

If urine ALA and PBG are normal during an attack, it essentially rules out an acute porphyria. If urine ALA and PBG are markedly increased, a diagnosis of an acute porphyria is confirmed and further testing is needed to identify the type of acute porphyria. A minor (~2-fold) elevation in urine porphyrins (especially coproporphyrin) with normal ALA and PBG is nonspecific and may not require further testing.

Table 2. Second-line Biochemical Testing for Acute Porphyrias: Laboratory Findings to Differentiate Between AIP, HCP and VP.

Acute Porphyria	HMBS activity in RBCs	Urine PBG	Urine ALA	Urine porphyrins	Fecal porphyrins	Plasma porphyrins
AIP	Decreased in ~90% of cases	elevated	elevated	Markedly increased; mostly uroporphyrin	Normal or slightly increased	Normal or slightly increased
HCP	normal	elevated	elevated	Markedly increased; mostly coproporphyrin	Markedly increased; mostly coproporphyrin III	Normal or slightly increased
VP	normal	elevated	elevated	Markedly increased; mostly coproporphyrin III	Markedly increased; mostly protoporphyrin	Markedly increased; Fluorescence peak (at neutral pH) at ~626nm
ADP	normal	normal	elevated	Markedly increased; mostly coproporphyrin III	Normal or slightly increased	Normal or slightly increased

Labs that can be used for second-line testing include: UTMB, ARUP, Mayo, Quest, and LabCorp

Cutaneous porphyrias

The screening tests vary by specific symptoms for the cutaneous porphyrias. Total plasma porphyrins should be done for blistering skin photosensitivity. If this test is normal, cutaneous porphyrias that cause blistering skin lesions are effectively excluded. Further testing may be needed if total plasma porphyrins are increased. For suspected EPP/XLP, which has non-blistering photosensitivity, an erythrocyte protoporphyrin test is more specific. Urine ALA and PBG testing is not informative for any of the cutaneous porphyrias.

Table 3. Testing for Cutaneous Porphyrias: Laboratory Findings to Differentiate Between CEP, PCT, and EPP/XLP

Porphyria	Urine porphyrins	Erythrocyte porphyrins	Plasma fluorescence emission peak	Laboratories
CEP	Increased; mostly uro- and coproporphyrin I	Increased; mostly Zn-proto, copro-, and uroporphyrin	615-620nm	UTMB, ARUP, Mayo, Quest, LabCorp
PCT & HEP	Increased; mostly uro- and heptacarboxylate porphyrin	normal	615-620nm
EPP	normal	Increased; mostly protoporphyrin; free-proto significantly greater than Zn-protoporphyrin	626-634nm	UTMB, ARUP, Mayo
XLP	normal	Increased; mostly protoporphyrin; free-proto equal to Zn-protoporphyrin	626-634nm

For all the porphyrias genetic testing is recommended to confirm the diagnosis as well as biochemical testing. The following table lists the causative genes for each type of porphyria.

Table 4 Genes Responsible for the Porphyrias

Porphyria	Enzyme Name	Gene Symbol	Laboratories that do Genetic Testing
AIP	Hydroxymethylbilane synthase	HMBS	Mount Sinai Genetic Testing Lab, Mayo Clinic Molecular Genetics Lab
VP	Protoporphyrinogen oxidase	PPOX
HCP	Coproporphyringen-III oxidase	CPOX
CEP	Uroporphyrinogen III synthase	UROS
PCT & HEP	Uroporphyrinogen decarboxylase	UROD
EPP	Ferrochelatase	FECH
XLP	5-aminolevulinate synthase 2	ALAS2

**The Mount Sinai Lab only tests for urine ALA and PBG

 

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