In rare case, birth control implant found to trigger porphyria attack

Case details may help improve emergency care for AHP patients: Report

Andrea Lobo, PhD avatar

by Andrea Lobo, PhD |

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In a rare case, a young woman in Illinois experienced a porphyria attack and began developing symptoms of acute hepatic porphyria (AHP) a few days after having a progestin birth control implant placed inside her left arm, according to a new report.

The clinicians noted that AHP has rarely been reported following an implant of progesterone-based contraceptives. Moreover, the disease in young women usually starts with nonspecific symptoms, and is often overlooked in acute care.

Given that, data from this case will contribute to improving emergency care for such patients, the researchers said, noting that “diagnosis leads to prevention of recurrent attacks” and that “early treatment of acute porphyria spares the patient significant morbidity.”

The case was described in a study, “Implanted Progestin Causing Pain and Psychiatric Disturbances in Porphyria Attack: A Case Report,” published in the journal Clinical Practice and Cases in Emergency Medicine.

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Porphyria is caused by disruptions in the production of heme, a molecule that’s required for oxygen transport in the body. When a given step in the heme production pathway is disrupted, porphyrins and their precursors accumulate to toxic levels in different tissues and organs, ultimately leading to porphyria symptoms, which can include pain, gastrointestinal problems, and mental health issues, such as hallucinations.

In this report, researchers described the case of a 25-year-old woman who started experiencing AHP symptoms after having a progesterone-based birth control implanted.

The woman was treated for the porphyria attack at a hospital’s emergency department. She was experiencing an altered mental state and lower abdominal pain that had been lasting for several days. She also was confused and agitated, and was unable to sleep. Additionally, the patient reported difficulty in urinating, despite having the urge to do so and drinking plenty of water.

Her mother reported she had an episode of urinary incontinence and appeared to be delusional. She also stated that, on the previous day, her daughter had fallen and struck her head.

According to the mother, the young woman 10 days earlier had an etonogestrel birth control implant, which contains a man-made form of progesterone, placed in her left arm.

A physical examination revealed the patient had high blood pressure, and fast heart and respiratory rates. She had a contusion to her forehead, and her abdomen was flat and soft.

She was treated with droperidol for nausea, and morphine, which failed to ease her pain. A set of CT scans of her head, neck, and abdomen were negative for acute illness.

Because the patient’s sodium levels were below reference levels, she was given a continuous into-the-vein or intravenous infusion of sodium chloride. In the meantime, she was transferred to the intensive care unit and given treatment to control her high blood pressure and fast heart rate.

The patient also complained of weakness, and her creatine kinase, a marker of muscle damage, was found to be elevated.

Her urine was found to be red, and her porphyrin and porphobilinogen (PBG) urine levels were significantly elevated; PBG is a porphyrin precursor. Porphyrin levels in the blood also were elevated, further supporting a diagnosis of AHP.

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Woman requires inpatient care for more than 1 month after porphyria attack

Clinicians suspected that the woman’s birth control implant might have triggered an AHP attack, and they decided to remove it the following day.

The patient was given a solution containing 10% of dextrose, a type of sugar, which can inhibit heme production and treat mild porphyria attacks. Although her mental state improved, she could not walk around and be discharged.

She then was transferred to a specialized care center, where she received four hemin infusions per day.

Inpatient care followed for 33 days, during which the woman continued to experience severe muscle weakness and other issues that prevented her from walking. These problems required the patient to do physical therapy. While in the hospital, she completed a total of 14 sessions.

After being discharged, she attended another 22 sessions of physical therapy over the course of three months. She had a second porphyria attack five months after her initial symptoms, which resolved with four days of hemin infusion.

Genetic testing revealed the presence of mutation compatible with a final diagnosis of acute intermittent porphyria, the most common type of AHP.

The patient was advised to begin preventive treatment with hemin or Givlaari (givosiran) if she experienced more than four to six attacks per year.

According to the researcher, this case highlights that “urine testing for PBG and urine porphyrins should be initiated early in patients with clinical suspicion of AHP.”