Porphyrias and lab diagnosis

saims,indore

1. PORPHYRIAS AND THE LAB DIAGNOSIS GUIDED BY -DR.KAMAL MALUKANI PRESENTED BY- DR.GARGI TIGNATH

2. Cruelly referred to as a Vampire’s disease. Thought to be a cause of the madness of King George III. Can be caused by lead poisoning: The fall of the Roman Empire! INTRODUCTION :

3. Not a ‘vampire’s’ disease Some symptoms of porphyrias have lead people to believe that these diseases provide some basis for vampire legends: Extreme sensitivity to sunlight Anemia This idea has been discarded both for scientific reasons: Porphyrias do not cause a craving for blood. Drinking blood would not help a victim of porphyria .

4. COORDINATED REGULATION OF HEME AND GLOBIN SYNTHESIS: ↓ Heme : inhibits activity of pre-existing  -ALA synthase Diminishes the transport of  -ALA synthase from cytoplasm to mitochondria after synthesis of the enzyme. represses the production of  -ALA synthase by regulating gene transcription. stimulates globin synthesis to ensure that levels of free heme remain low in concentration . Inhibition of the synthase and stimulation of globin synthesis are the most important aspects in balancing hemoglobin production.

5. The term porphyria in greek meaning purple discolouration of some body fluids during attack. The porphyrias are a group of diseases resulting from defects in the synthesis of heme . Inherited enzyme deficiencies in which the enzyme substrate is usually excreted in excess in urine and/or feces. During acute attacks, high levels of porphobilinogen are excreted, but between attacks levels of porphobilinogen may be increased or normal. Definition :

6. Heme is mainly required in bone marrow(for hemeglobin synthesis) and in liver (for cytocrome synthesis). On the basis of that porphyrias are divided into Erythropoietic porphyrias and Hepatic porphyrias . Hepatic porphyrias mainly affects nervous system , while erythropoietic porphyrias primarily affects - skin .

7. Neuropsychiatric: 1.Acute intermittant porphyrias (AIP) 2.ALA dehydratase porphyria (ADP) Cutaneous (photosensitivity): 1.congenital erythropoietic porphyria (CEP) 2.porphyria cutanea tarda (PCT) 3.Erythropoietic porphyria (EPP) Mixed: 1.Hereditary copro-porphyria (HCP) 2.Variegate porphyria (VP) Classification Based On Predominant Clinical Manifestations

8. Hepatic: 1.AIP 2.ADP 3.HCP 4.VP Erythrocytic : 1.CEP 2.EPP Both: 1.PCT Classification Based On Site Of Expression Of Disease :

9. Acute: 1.AIP 2.ADP 3.HCP 4.VP Nonacute ( cutaneous ): 1.PCT 2.EPP 3.CEP Classification Based On Mode Of Presentation Of Disease

10. ALA DEHYDRATASE-DEFICIENT PORPHYRIA (ADP) Rare, autosomal recessive . Caused by -severe deficiency of ALA dehydratase activity Age- children or young adults specific gene mutations ,affected homozygotes have <10% of normal ALA dehydratase activity in erythrocytes. As there are multiple causes for deficient ALA dehydratase activity, It is important to confirm the diagnosis of ADP by mutation analysis. HEPATIC PORPHYRIAS

11. clinical presentation depends on the amount of residual ALA dehydratase activity. commonly affects- male adolescents symptoms resembling those of AIP-abdominal pain and neuropathy. Infants–presents with more severe disease, including failure to thrive beginning at birth. Earlier age of onset & more severe manifestations -reflects significant deficiency of ALA dehydratase activity. Clinical Features

12. Diagnosis : significantly elevated levels of -plasma and urinary ALA -urinary coproporphyrin (COPRO) III. ALAD activities in erythrocytes were <10% of normal. Differential diagnosis – 1.Hereditary tyrosinemia type1 ( fumarylacetoacetase deficiency- succinylacetone -(which accumulates in hereditary tyrosinemia is structurally similar to ALA) 2. Lead poisoning

13. lead inhibits ALA dehydratase - ↑ urinary excretion of ALA and COPRO III- cause manifestations resembling acute porphyrias . Heterozygotes are clinically asymptomatic , do not excrete increased levels of ALA can be detected by- Intermediate levels of erythrocyte ALA dehydratase activity or specific mutation in the ALAD gene.

14. Acute attacks is similar to that of AIP severely affected infants- supported by hyperalimentation . periodic blood transfusions Intravenous hemin Liver transplantation. TREATMENT OF ADP

15. Acute Intermittent Porphyria (AIP) AD diseases resulting from the half-normal level of HMB synthase activity. Disease is widespread Clinical expression is highly variable Activation of the disease is often related to environmental or hormonal factors

16. Common precipitating factors include: 1.Endogenous and exogenous steroids 2.Porphyrinogenic drugs 3.Alcohol ingestion 4.Low-calorie diets, usually instituted for weight loss Attacks can be prevented by avoiding known precipitating factors.

17. CAUSATIVE FACTORS : Induction of the rate-limiting hepatic enzyme ALA synthase in heterozygotes with half-normal HMB synthase activity AIP almost always latent before puberty –suggests adult levels of steroid hormones are important for clinical expression. Heterozygous for HMBS mutations, causes for attacks of AIP prior to puberty. Symptoms are more common in women, suggesting a role for estrogens or progestins .

18. Premenstrual attacks are probably due to endogenous progesterone. Exacerbated by exogenous steroids, including OCP preparations containing progestins pregnancy ,usually well tolerated,suggesting -beneficial metabolic changes - ameliorates effects of high levels of progesterone.

19. Important link between nutritional status and the attacks in acute porphyrias . Increased carbohydrate intake may ameliorate attacks

20. CLINICAL FEATURES Neurovisceral symptoms rarely occur before puberty Abdominal pain, the most common symptom, is usually steady and poorly localized but may be cramping. Ileus , abdominal distention & decreased bowel sounds are common. Fever, and leukocytosis are usually absent or mild (symptoms are neurologic rather than inflammatory). Nausea; vomiting; constipation

21. Tachycardia; hypertension – sympathetic overactivity Mental symptoms Pain in the limbs, head,neck or chest Muscle weakness – proximal muscles Sensory loss- axonal degeneration Dysuria and urinary incontinence Progression to respiratory and bulbar paralysis and death occurs especially when the diagnosis and treatment are delayed .

22. COMPLICATIONS : Sudden death-results from sympathetic overactivity and cardiac arrhythmia. Treatment of seizures is difficult because most antiseizure drugs can exacerbate AIP When an attack resolves- Abdominal pain may disappear within hours paresis begins to improve within days and may continue to improve over several years

23. Diagnosis Urine and Plasma ALA and PBG levels - are substantially ↑during acute attacks, become normal only after prolonged latency. [ Normal urinary PBG excretion-0–4 mg/24 h;50-150 μmol /24 hrs] [ Normal urinary ALA excretion - 1–7 mg/24 h ;8–53 μmol/24 h]. Diagnosis of an acute attack in a patient with biochemically proven AIP is based primarily on clinical features. Excretion of ALA and PBG decreases over a few days after intravenous hemin administration.

24. Urine During Attack Of AIP

25. No history of symptoms -have normal urinary excretion of ALA and PBG. 1.Detection of the family’s HMBS mutation will diagnose asymptomatic family members. 2.Prognosis of individuals with HMBS mutations is generally favorable Fecal porphyrins are usually normal or minimally increased in AIP, in contrast to HCP and VP.

26. Hepatic imaging is recommended at least yearly for early detection of these tumors. Allogeneic liver transplant The long-term risk of hypertension and chronic renal disease is increased in AIP. Chronic, low-grade abnormalities in liver function tests are common, the risk of hepatocellular carcinoma is increased.

27. HEREDITARY COPROPORPHYRIA (HCP) AD,due to half-normal activity of COPRO oxidase . Disease presents with acute attacks, as in AIP. Cutaneous photosensitivity also may occur but much less commonly than in VP. Acute attacks and cutaneous photosensitivity may occur together or separately. HCP is less common than AIP and VP.

28. Clinical Features HCP is influenced by the same factors that cause attacks in AIP. The disease is latent before puberty, and symptoms,which are virtually identical to those of AIP, are more common in women. HCP is generally less severe than AIP. Blistering skin lesions are identical to PCT and VP and begin in childhood in rare homozygous cases.

29. Diagnosis : COPRO III is markedly ↑ in the urine and feces in symptomatic patients. Often persists, especially in feces, when there are no symptoms. Urinary ALA and PBG levels ↑ during acute attacks, but may revert to normal when symptoms resolve. Plasma porphyrinsare usually N or only slightly ↑- in cases with skin lesions. Diagnosis of HCP -confirmed by ↑ fecal porphyrins (consisting almost entirely of COPRO III ,distinguishes it from other porphyrias ).

30. Neurologic symptoms are treated as in AIP . Phlebotomy and chloroquine are not effective for the cutaneous lesions. Treatment

31. . VARIEGATE PORPHYRIA (VP) AD, due to deficient activity of PROTO oxidase , seventh enzyme in the heme biosynthetic pathway. Presents with neurologic symptoms, photosensitivity, or both. VP is particularly common in South Africa, 3 of every 1000 whites have the disorder.

32. Clinical Features skin photosensitivity, acute neurovisceral crises, or both. Acute attacks identical to those in AIP , precipitated by same factors as AIP Blistering skin lesions similar to PCT, but more difficult to treat , usually of longer duration. Homozygous VP : Associated with photosensitivity Neurologic symptoms Developmental disturbances, including growth retardation, in infancy or childhood;

33. Diagnosis ↑Urinary ALA and PBG during acute attacks, but return to normal more quickly than in AIP. ↑ fecal protoporphyrin and COPRO III ↑ urinary COPRO III are more persistent. Plasma porphyrin levels also ↑,particularly with cutaneous lesions. VP can be distinguished rapidly from all other porphyrias by examining the fluorescence emission spectrum of porphyrins in plasma – VP has a unique fluorescence peak at neutral pH. Increased erythrocyte levels of zinc protoporphyrin , characteristic finding in all homozygous porphyrias .

34. TREATMENT -Variegate Porphyria Acute attacks are treated as in AIP, and hemin should be started early in most cases. Other than avoiding sun exposure, β-Carotene for treating the skin lesions phlebotomy,and chloroquine are not helpful.

35. Porphyria Cutanea Tarda PCT, the most common of the porphyrias , can be [A]sporadic(type 1) [B]familial (type 2) [C] Also develop after exposure to Hepatic URO decarboxylase is deficient in all types of PCT. Generation of an URO decarboxylase inhibitor in the liver, which forms uroporphomethene in the presence of iron and under conditions of oxidative stress.

36. Majority of PCTpatients (~80%) have no UROD mutations sporadic (type 1) disease. Heterozygous for UROD mutations have familial (type 2) Inheritance of UROD mutation from one parent results in- half N enzyme activity in liver and all other tissues. -A significant predisposing factor, but insufficient to cause symptomatic PCT.

37. Causative factors: Inherited UROD mutations in type 2 PCT hepatitis C HIV Excess alcohol Elevated iron levels Estrogens Hemochromatosis gene ( HFE) mutations C282Y and H63D. After exposure to halogenated aromatic hydrocarbons.

38. Blistering skin lesions appears most commonly on the backs of the hands -major clinical feature . These rupture and crust over, leaving areas of atrophy and scarring. Lesions may also occur on the forearms, face, legs, and feet. Skin friability and small white papules termed milia are common, especially on the backs of the hands and fingers. Hypertrichosis and hyperpigmentation,especially of the face. skin over sun-exposed areas becomes severely thickened,with scarring and calcification that resembles systemic sclerosis. Neurologic features are absent . Clinical Features

39. TREATMENT : Porphyria Cutanea Tarda Alcohol, estrogens, iron supplements, and if possible, any drugs that exacerbates the disease should be discontinued. Repeated phlebotomy, to reduce hepatic iron. A unit (450 mL ) of blood can be removed every 1–2 weeks,to gradually reduce excess hepatic iron until the serum ferritin level reaches the lower limits of normal.

40. ERYTHROPOIETIC PORPHYRIAS In the erythropoietic porphyrias , excess porphyrins from bone marrow erythrocyte precursors are transported via the plasma to the skin and lead to cutaneous photosensitivity.

41. X-linked Sideroblastic Anemia (XLSA) Deficient activity of the erythroid form of ALA synthase Associated with ineffective erythropoiesis,weakness , and pallor. Clinical Features : Typically, males with XLSA develop refractory hemolytic anemia, pallor, and weakness during infancy. Secondary hypersplenism , become iron overloaded, and can develop hemosiderosis .

42. PS – hypochromic , microcytic anemia striking anisopoikilocytosis and polychromasia leukocytes and platelets appear normal. Hb , MCV and MCHC- reduced Bone marrow examination Hypercellularity with a left shift and megaloblastic erythropoiesis with an abnormal maturation. Prussian blue-staining sideroblasts are observed. Levels of urinary porphyrin precursors and of both urinary and fecal porphyrins are normal. Definitive diagnosis requires the demonstration of mutations in the erythroid ALAS2 gene Diagnosis

43. Severe anemia may respond to pyridoxine supplementation. This cofactor is essential for ALA synthase activity, and mutations in the pyridoxine binding site of the enzyme have been found in association with XLSA. TREATMENT -X-Linked Sideroblastic Anemia

44. Congenital Erythropoietic Porphyria (CEP) Also known as Günther’s disease, AR disorder. It is due to the markedly deficient, but not absent, activity of URO synthase - results in accumulation of URO I and COPRO I isomers. CEP is associated with hemolytic anemia and cutaneous lesions.

45. Clinical Features : Severe cutaneous photosensitivity typically begins in early infancy. skin over light-exposed areas is friable and bullae and vesicles -prone to rupture & infection. . Secondary infections of cutaneous lesions - lead to disfigurement of the face & hands. Hemolysis due to marked ↑ in erythrocyte porphyrins leads to splenomegaly .

46. odontoporphyria Porphyrins are deposited in teeth and in bones; teeth are brownish and fluoresce on exposure to long-wave ultraviolet light.

47. Skin thickening, focal hypo- and hyperpigmentation , and hypertrichosis of the face and extremities are characteristic

48. Diagnosis URO and COPRO (mostly type I isomers) accumulate in 1.Bone marrow 2.Erythrocytes 3.Plasma 4.Urine 5. Feces( predominant porphyrin in feces is COPRO I). Diagnosis of CEP can be confirmed by 1.Demonstration of markedly deficient URO synthase activity 2 .Identification of specific mutations in the UROS gene.

49. Molecular analyses of the mutant alleles from unrelated patients have mutations in the UROS gene, erythroid -specific promoter of the UROS gene. Genotype/phenotype correlations can predict the severity of the disease. CEP phenotype may be modulated by sequence variations in the erythroid specific ALA synthase 2, mutation of which typically causes XLP. One mutation (p.ArgR216WTrp) in GATA1, encoding the X-linked erythroid -specific transcription factor GATA binding protein 1 ( GATA1)- identified in CEP, thrombocytopenia, and β thalassemia

50. Severe cases often require transfusions for anemia. Chronic transfusions - to suppress erythropoiesis -effective in reducing porphyrin production Splenectomy -reduces hemolysis & ↓ transfusion requirements. Protection from sunlight & minor skin trauma β-Carotene prompt treatment of complicating bacterial infections. TREATMENT :Congenital Erythropoietic Porphyria

51. ERYTHROPOIETIC PROTOPORPHYRIA (EPP ) Deficient activity of ferrochelatase (FECH), the last enzyme in the heme biosynthetic pathway. Most common erythropoietic porphyria in children after PCT second most common porphyria in adults FECH activities as low as 15–25% of normal in lymphocytes and cultured fibroblasts. Protoporphyrin accumulates in bone marrow reticulocytes and then appears in plasma, is taken up in the liver, and is excreted in bile and feces. Protoporphyrin transported to the vessels in the skin - nonblistering photosensitivity.

52. intronic 3 (IVS3) alteration - results in the low expression of the normal enzyme. In about 10% of EPP families, two FECH mutations have been found. Deletion mutations in exon 11 of the ALAS2 gene have causing XLP that is clinically indistinguishable from EPP. Deletion of the C-terminal amino acids of ALAS2 results in Its increased activity and the accumulation of protoporphyin . . most symptomatic patients (~90%) with this autosomal recessive Disorder- -mutation in one FECH allele

53. Clinical Features Skin photosensitivity, usually begins in childhood – Asso.with substantial ↑ in erythrocyte protoporphyrin occurs only in patients with ferrochelatase activities below ~35% of normal. consists of pain,redness and itching-within minutes of sunlight exposure resemble angioedema Vesicular lesions are uncommon.

54. Chronic skin changes include lichenification,leathery pseudovesicles , labial grooving, and nail changes

55. Hepatic complications –characterized by increasing levels of- 1.protoporphyrins in erythrocytes and plasma 2. severe abdominal and back pains, especially in the right upper quadrant-Gallstones

56. Diagnosis substantial increase in erythrocyte protoporphyrin ,-which is predominantly free and not complexed with zinc, is hallmark of EPP. Protoporphyrin levels ↑ in bone marrow, plasma, bile, and feces. Erythrocyte protoporphyrin concentrations increases in other conditions lead poisoning Iron deficiency various hemolytic disorders All homozygous forms of porphyrias sometimes even in acute porphyrias In all these conditions, in contrast to EPP, It is complexed with zinc.

57. Urinary levels of porphyrins and porphyrin precursors are normal. ↓ Ferrochelatase activity in cultured lymphocytes or fibroblasts DNA diagnosis by mutation analysis - to detect FECH mutation. In a suspected EPP, confirm the diagnosis by assay that distinguishes free and zinc- complexed protoporphyrin . Erythrocytes in EPP also exhibit red fluorescence under a fluorescence microscopy at 620 nm .

58. 20% of EPP patients - minor abnormalities of liver function About 5% of patients -accumulation of protoporphyrins – chronic liver disease -progress to liver failure -death. Protoporphyrin is insoluble, excess amounts form crystalline structures in liver cells - ↓hepatic bile flow- bile duct epithelium , damaged by toxic bile, leads to biliary fibrosis. Prognosis, complications and Treatment

59. Avoiding sunlight exposure and wearing clothing designed to provide protection Oral β-carotene (120–180 mg/ dL ). Afamelanotide,an α- melanocyte -stimulating hormone (MSH). Cholestyramine and other porphyrin absorbents -like activated charcoal -interrupts enterohepatic circulation of protoporphyrin and promote its fecal excretion, leading to some improvement. Treatment:

60. Splenectomy – In hemolysis & significant splenomegaly . Plasmapheresis and intravenous hemin Liver transplantation-in severe liver complications. Bone marrow transplantation.

61. Tests For Porphyrinogen : 1.Ehlrichs Aldehyde Test 2.Watson Schwartz Test 3.Hoesch’s Test Tests For Total Porphrins In Urine : Spectrophotometry-porphyrins have intense absorbance peak at 400nm. Tests for total porphyrin in feces : - Spectrophotometric estimation of acidic extract of fecal sample(5-10gm wet wt). Tests for porphyrins in erythrocytes and plasma (EDTA-blood sample)- 1.Visual examination of porphyrin fluroscenceand solvent fractionation 2.spectrophotometry. LAB DIAGNOSIS

62. Urine specimens for urobilinogen or porphobilinogen must be fresh. (10-20 ml). If the testing will be delayed- 1.pH should be adjusted to near neutral (pH 7) 2. specimen stored in a refrigerator, where it is stable for about 1 week. Urine may darken if the patient has porphyria , especially if left at room temperature. Laboratory test for porphoblinogen in urine

63. Principle : Ehrlich’s reagent(p- dimethylamino benzeldehyde ) reacts with urobilinogen in urine to produce a pink colour . Intensity of colour depend on amount urobilinogen present. . Ehrlich’s aldehyde test

64. Procedure

65. In the presence of 1.UTI-Nitrites oxidize urobilinogen to urobilin . 2.Antibiotic therapy (gut bacteria which produces urobilinogen are destroyed ). False negative test :

66. The Ehrlich's aldehyde reaction and Watson–Schwartz tests are based on solubility differences between urobilinogen and porphobilinogen . Urobilinogen can be extracted by chloroform and/or butanol , where as porphobilinogen will remain in an aqueous phase. Watson–Schwartz Test

67. Procedure

68. 1.Examine the upper (aqueous) phase. If the color is absent, consider the result of the screening test to be negative and stop. 2. If color is present, separate the upper (aqueous) phase and add 5 mL of butanol . 3. A ‘pink to rose red' color in the lower aqueous layer indicates a positive result -Suggests a concentration of porphobilinogen that is several times normal. 4.A color in the upper butanol layer indicates an increase in urobilinogen concentration. Interpretation

69. Hoesch's Test . Based on the inverse Ehrlich's reaction (i.e., of maintaining an acid solution by adding a small urine volume to a relatively large reagent volume), eliminating the problem of urobilinogen reactivity. The sensitivity is similar to that of the Watson–Schwartz test, but the reaction is for porphobilinogen . Detects about 20-100 mg/L of porphobilinogen , and urobilinogen in amounts up to 200 mg/L does not give a positive result (red color). A yellow color may be caused by urea.

70. Watson–Schwartz test Detects greater than 6 mg/L and the Hoesch test greater than 11 mg/L of porphobilinogen . More sensitive than the Hoesch test for porphobilinogen May yield a positive result between attacks of acute intermittent porphyria .

71. False-positive reaction : Urorosein urinary pigment related to indoleacetic acid – produces a positive Hoesch test (in response to strong HCl -rose color may be confused with a positive porphobilinogen result. false-positive problems may be excluded by testing the specimen with concentrated HCl (6 mol/L). Urine from a patient having an acute porphyric attack may be dark red in color, necessitating a 1:10 dilution with water prior to test .

72. FALSE POSITIVE RESULTS : Large doses of methyldopa( Aldomet ) . Indoles in some patients with intestinal ileus . Drug- phenazopyridine ( Pyridium ), which becomes orange with HCl . A quantitative porphobilinogen test is necessary- If either the Watson–Schwartz test or the Hoesch test result is questionable; because of the instability of porphobilinogen .

73. Alternative urine screening tests for porphobilinogen are: Micellar electrokinetic capillary chromatographic method , A semiquantitative kit -urine is pretreated with ion-exchange resin & color of the Ehrlich– porphobilinogen adduct is compared to a set of standard.

74. Fluorescence Screening Procedure For Porphyrin Uroporphyrin and coproporphyrin can be detected by fluorescence. An orange-red fluorescence is seen if a positive specimen is placed near an ultraviolet light source.. Principle: In this method, the urine is acidified and the extracted porphyrin exposed to ultraviolet light.

75. 1.Place 5 mL urine in a stoppered glass centrifuge tube. 2.Add 3 mL of a mixture of one part glacial acetic acid with four parts of ethyl acetate 3.Shake and allow to separate. Centrifuging will accelerate the separation . 4.Using a Wood's lamp, observe the upper layer for fluorescence. Inspect the tube in a dark room . Procedure

76. With ultraviolet reflected light- lavender to violet color indicates the presence of porphyrins . Pink to red fluorescence indicates higher levels of porphyrin . Pale blue with no pink color is negative .Normal urine may fluoresce blue. To increase the sensitivity of the test and remove interfering drug metabolites, transfer the upper layer to a glass tube Acidify with 0.5 mL of 3 M HCl (25 mL concentrated HCl diluted to 100 mL with water). Shake. Porphyrins are extracted into the lower aqueous layer and will give a red-orange fluorescence . Results:

77. P recautions for Quantitative estimation Urine specimens for quantitative porphobilinogen - collection: In a dark container containing 5 g sodium carbonate for a 24-hour to produce urine of neutral pH. Frozen specimens are fairly stable, ALA is more stable if urine is acidic Quantitated by eluting from different columns and reacting with Ehrlich's reagent. Micellar electrokinetic capillary chromatographic method -allows separation of ALA and porphobilinogen

78. Coproporphyrin and uroporphyrin can be separated by thin-layer chromatography - Quantitated using ion-exchange columns. Fecal porphyrins can be qualitatively estimated using extraction with ultraviolet (UV) light, or quantitated . In some porphyrias , erythrocytes may show fluorescence when an unstained blood smear is examine microscopically. The nucleated bone marrow erythrocytes give greater fluorescence.

79. Acute abdominal pain(ACUTE PORPHYRIAS) Test for urinary porphobilinogen positive Negative AIP,VP,HCP Exclusion of porphyria Measure fecal COPROIII&PROTOIX Negative protoIX COPROIII AIP VP HCP

80. Cutaneous photosensitivity(CUTANEOUS PORPHYRIAS) Free erythrocyte protoporphyrin Positive Negative EPP urinary/fecal total porphyrin positive Urine-UROI,COPROI Feces-COPROI CEP Urine-UROI Feces-ISOCOPRO PCT

81. TYPE OF PORPHYRIAS URINE FAECES 1.AIP PBG,COPROIII 2.VP PBG,COPROIII PROTOIX 3.HCP PBG,COPROIII COPROIII Diagnostic Pattern Of Conc. Of Heme Precursors In Acute Porphyrias Diagnostic Pattern Of Conc.Of Heme Precursors In cutaneous Porphyrias TYPE OF PORPHYRIA URINE FAECES ERYTHROCYTES 1.CEP UROI,COPROI COPROI 2.PCT UROPORPHYRIN ISOCOPRO 3.EPP PROTOPORPHYRIN