Acute intermittent prophyria (AIP) is an autosomal dominant disease that results from a defect in the
enzyme porphobilinogen deaminase.
Acute intermittent porphyria is the most common of
hepatic porphyrias and can tax the therapeutic capabilities of the physician to the limit. Motor weakness is a major feature of an acute attack, and flaccid
paralysis of all extremities can occur rapidly, within a matter of days. The acute attacks may be life threatening.
Hematin (
Heme Arginate) should be given early during an acute attack to prevent neurologic sequel.
Hemodialysis and
hemoperfusion have been tried in the treatment of acute attacks of AIP with success. As
hematin is not available in India, a severe acute attack of AIP in a patient was managed with
hemodialysis successfully. Later,
hematin was imported and provided to the patient. An 18-year-old girl was admitted to our hospital with recurrent
abdominal pain and 2 episodes of convulsions. She had undergone an
appendectomy earlier at another hospital for
abdominal pain. On evaluation, she had
hyponatremia, episodic abnormal behavior, generalized
muscle pain,
hypertension, and
sinus tachycardia. In view of the above clinical picture, a clinical diagnosis of
acute intermittent porphyria was made. Her 24-hr urinary
porphobilinogen was 90.8 mg/day (<2 mg-normal) and alpha amino levalunic
acid was 108.8 mg/day (1-7 mg-normal), consistent with the diagnosis. Her
hyponatremia was corrected. Arrangements were made to import
hematin and she was managed with
dextrose infusion. Meanwhile, she developed flaccid quardriparesis with
urinary incontinence and
bulbar palsy. Her brain MRI was normal. Her nerve conduction study was suggestive of motor radiculoneuropathy. Specific treatment for severe porphyric crisis was planned. She failed to improve with
dextrose infusion alone. As
hematin was not readily available in the country, other therapeutic options were considered. As few case reports of AIP being successfully treated with
hemodialysis were available, the option of dialytic support was explained to the family. After procuring informed consent, she was subjected to
hemodialysis for 4 hr in the first day, increasing to 6 hr a day for the next 6 days. Her
abdominal pain and
myalgia subsided on the third day of dialysis. Her lower limb muscle power improved and she became ambulant by the fourth day.
Urinary retention improved within 4 days.
Hematin was imported by then from the United States. Later, 2 doses of
hematin (4 mg/kg-160 mg in 20%
albumin) were given via a central vein. She was maintained on physiotherapy. Repeat nerve conduction study revealed recovery. She has been provided with a list of drugs that have to be avoided. Currently, she is on outpatient follow-up with occasional
abdominal pain, which subsides with intravenous
dextrose therapy.