The varied manifestations of Wilson's disease

Tremor in childhood

Tremor in childhood is not commonly described in the literature; but it is also likely underappreciated. The etiology of childhood tremor encompasses a wide variety of pathologic processes. Tremor may occur in isolation, or in association with other neurologic findings or systemic disorders. This article aims to provide an overview of tremorogenic mechanisms with respect to neuroanatomy and neurophysiology, particularly as they relate to children. Classification of tremors, diagnostic entities in childhood, and treatment will also be discussed. With improved recognition and characterization of childhood tremors, we may gain a better understanding of the pathophysiology of the disease and determine more age-appropriate treatment strategies.

Clinical differentiation of fulminant Wilsonian hepatitis from other causes of hepatic failure

Establishing a diagnosis of fulminant Wilson's disease can be difficult because Kayser-Fleischer rings may not be present and parameters of copper metabolism, including serum and urinary copper, and serum ceruloplasmin levels are neither specific nor diagnostic. In this study, ratios of both the serum alkaline phosphatase to total bilirubin and aspartate transaminase to alanine transaminase were constructed to evaluate their usefulness in differentiating fulminant hepatic failure caused by Wilson's disease (n = 6) from other etiologies (n = 43). An analysis of the data showed that cutoff values of less than 2.0 for the alkaline phosphatase-total bilirubin ratio and greater than 4.0 for the aspartate transaminase ratio were associated with a diagnosis of fulminant hepatic failure caused by Wilson's disease only (P less than 0.001). The alkaline phosphatase-total bilirubin ratio of less than 2.0 provided 100% sensitivity and specificity in identifying fulminant hepatic failure caused by Wilson's disease from other types of fulminant hepatic failure.

Fulminant hepatic failure during perinatal period in a pregnant woman with Wilson's disease

Wilson's disease associated with hepatic failure is not common and the underlying mechanism triggering the event is not known at present. We treated a 28-year-old Japanese woman with Wilson's disease who developed hepatic failure associated with hemolytic crisis just after delivery. She was diagnosed as having Wilson's disease at 12 years of age, at which time she started taking D-penicillamine. She had previously delivered two children without difficulty. When she found out she was pregnant this time, she stopped taking D-penicillamine in contrast to taking it faithfully during her first two pregnancies. On the day of delivery of her full-term baby, jaundice developed accompanied with severe hemolytic crisis. Plasma exchanges and blood transfusion were performed and D-penicillamine administration was started again. She gradually recovered and apparently was following a good clinical course. However, on day 30 the second hemolytic crisis occurred and subsequent liver failure led her to death on day 50. At autopsy her liver was cirrhotic and showed massive necrosis. Prophylactic oral administration of D-penicillamine and careful observation are therefore recommended to prevent hemolytic crisis during the perinatal period.

Presenting symptoms and natural history of Wilson disease

The presenting symptoms of Wilson disease and its natural history as related to age are described based on 283 cases collected in Japan. The disease presented with a variety of signs and symptoms; the most frequent were in order of frequency jaundice, dysarthria, clumsiness, tremor, drooling, gait disturbance, malaise and arthralgia. The mean age at onset of the disease was 12.0 years. Hepatic and osteoarthral symptoms developed early and neurological symptoms late. Fifty-eight cases developed neurological symptoms only, 28 cases had hepatic symptoms only, and in 26 cases hepatic symptoms were followed by neurological symptoms. A higher mortality rate was observed in hepatic, hepato-haematological and hepato-renal cases mainly due to acute hepatic failure resulting in death only a few weeks after onset. Cases having only neurological symptoms showed a more favourable prognosis with a longer survival.

Wilson's disease: clinical presentation and use of prognostic index

As the results of treatment in Wilson's disease are so dependent on the stage at which penicillamine therapy is started, the antecedent history in 34 patients with Wilson's disease was analysed with particular respect to the earliest manifestations of the disease. Lethargy and anorexia (70%) jaundice (56%) and abdominal pain (48%) were the commonest symptoms and less common were intellectual deterioration (22%) and recurrent epistaxes (22%). The duration of symptoms before diagnosis ranged from five days to three years (mean 10.5 months) and in only five of the patients was the diagnosis established before referral. Analysis of the physical signs at presentation showed hepatomegaly (81%) and splenomegaly (70%) to be common and the only signs which were significantly more common in the 13 fatal cases were jaundice and ascites. In three of these and in one other patient who survived the clinical course was exceptionally severe and was indistinguishable from fulminant hepatic failure. Based on the severity of abnormality of serum aspartate aminotransferase, bilirubin, and prothrombin time on admission a prognostic index was derived which enabled complete separation of fatal and nonfatal cases and when subsequently used in a further nine index cases correctly predicted the outcome. Two further cases found to have indices in the fatal category did well after liver transplantation, which needs to be considered as soon as the diagnosis is established in cases with such severe liver damage.

Low serum alkaline phosphatase activity in Wilson's disease

Low values for serum alkaline phosphatase activity were observed early in the course of two patients with Wilson's disease presenting with the combination of severe liver disease and Coombs' negative acute hemolytic anemia. A review of other cases of Wilson's disease revealed that 11 of 12 patients presenting with hemolytic anemia had values for serum alkaline phosphatase less than their respective sex- and age-adjusted mean values; in eight, serum alkaline phosphatase activity was less than the lower value for the normal range of the test. Low values for serum alkaline phosphatase were much less common in Wilson's disease patients with more chronic forms of presentation. Copper added in high concentration to serum in vitro did not have an important effect on serum alkaline phosphatase activity. The mechanism responsible for the decrease in serum alkaline phosphatase activity in patients is uncertain.

Fulminant hepatic and renal failure complicating Wilson's disease

We report a case of fatal fulminant liver failure complicating Wilson's disease that is unique in several respects. The illness supervened after several years of medical noncompliance in a patient who had been previously diagnosed and successfully treated with penicillamine. Re-institution of penicillamine therapy 2 weeks prior to the fulminant decompensation failed to prevent it. Renal failure in this patient was apparently secondary to rhabdomyolysis. Addition of penicillamine to a peritoneal dialysis solution allowed chelation and removal of over 14 mg per day of copper but without apparent benefit. Exchange transfusion and high dose dexamethasone therapy (24 mg/day) were equally ineffective in reversing the liver failure. Other reported cases have also been fatal. The best treatment for fulminant Wilson's disease is prevention by diagnosis in a pre-symptomatic stage and institution of carefully supervised life-long therapy with penicillamine.

Fatal fulminant hepatitis with hemolysis in Wilson's disease. Criteria for diagnosis

We report a child with the presentation of Wilson's disease as acute fulminant hepatic failure and severe hemolysis. Our review of the literature suggests the following criteria for considering this diagnosis in the child with acute liver failure: discordance between mildly elevated serum transaminases and extremely elevated bilirubin levels; anemia associated with hemolysis (increased reticulocytes in the absence of bleeding); elevated hepatic copper; and other copper metabolic abnormalities (elevated serum copper, excessive 24-hour urine copper excretion, and reduced serum ceruloplasmin). Establishing the correct diagnosis enhances the possibility of detecting asymptomatic siblings or other family members in whom early inauguration preventive therapy should be successful.

Voice change in the pediatric patient. A differential diagnosis

This paper reviews the causes of voice change in the infant and child. Symptoms of dysphonia can be very early evidence of a serious problem, either within the larynx or resulting from a systemic disease. The need to investigate the cause of voice disturbances is stressed. The large number of diseases in which voice change occurs makes a complete examination of the child, both local and systemic, absolutely necessary in order to arrive at a specific diagnosis. The mechanism of voice change is described in each category of the numerous causes of dysphonia.

The genetic basis of ophthalmological disease

The genes of a fertilized ova contain all of the information needed to construct an eye, regulate its function, maintain it in working order, decipher its signals and store the vision it gathers. Analyzing genes in informational and physical terms, the author discusses the genetic basis of eye structure and function. Current knowledge and techniques for genetic study are described, as are specific abnormalities which have a familial or genetic basis.

Laboratory measures of copper metabolism in the differentiation of chronic active hepatitis and Wilson disease in children

The accuracy of the serum ceruloplasmin level in distinguishing chronic active hepatitis from Wilson disease was compared to the 24-hour urinary copper excretion and hepatic copper content in 20 untreated patients with chronic active hepatitis and 25 with Wilson disease. Serum ceruloplasmin levels were decreased in five patients (25%) with chronic active hepatitis and were normal in seven patients (28%) with Wilson disease at the time of diagnosis. The 24-hour urinary copper excretion failed to provide accurate discrimination between the two groups, being elevated in all patients with Wilson disease and in five of eight patients with chronic active hepatitis studied. All patients with Wilson disease had hepatic copper levels greater than 400 microgram/gm dry weight, whereas patients with chronic active hepatitis had levels less than 300 microgram/gm dry weight. The discriminatory value of hepatic copper concentration makes this the most reliable test for differentiating chronic active hepatitis and Wilson disease in children and adolescents. The serum ceruloplasmin level may not be significantly accurate for definitive diagnosis in this age group.

Cholelithiasis and Wilson disease

We have studied three children with Wilson disease who had clinical symptoms suggestive of cholecystitis as well as radiologic evidence of gallstones, subsequently proven at the time of laparotomy. The gallstones from the patients with Wilson disease had an appreciably higher content of cholesterol than gallstones from age-matched children with hemolytic disease. Since gallstones may be present for years before they produce clinical symptoms, young patients with Wilson disease should undergo routine investigation for the presence of stones; cholelithiasis should also be considered in the differential diagnosis of abdominal pain in such patients.

[Insufficiency of the exocrine pancreas in Wilson's disease (author's transl)]

The function of the exocrine pancreas was examined by the secretin-pancreozymin-test in 3 patients with Wilson's disease. In all cases we found a partial insufficiency. At the time of investigation the patients were 6(7)/12, 11(6)/12 and 21 years old. The youngest one was examined before therapy with D-Penicillamin. We suppose that storage of copper in lysosomes causes a cytotoxic damage of the exocrine part of the pancreas requiring substitution therapy in advanced cases.

Treatment of chronic active hepatitis in children

Thirty-eight children with chronic active hepatitis are reported. Their mode of presentation was usually indistinguishable from acute viral hepatitis (63%). Extra hepatic manifestations were more common in those patients with an insidious onset. The twenty-eight patients tested for hepatitis B antigen (HB Ag) were all negative and SGOT values were higher (mean 1000 i.u./l) than those reported in adult patients with chronic active hepatitis. Thirty-three patients had marked elevation of serum gammaglobulin (mean 3·78 g/100 ml) and 34% had positive LE cells. All patients had histologic features of ‘aggressive’ hepatitis; in addition five biopsies also showed areas of submassive hepatic necrosis. The initial response to corticosteroid was excellent in all but three patients. To date drug therapy has been suspended in fifteen patients for periods of 3 months to 4 years and 7 months. There have been eight deaths. Three with hepatic insufficiency and two with sepsis. Three others have subsequently died following orthotopic liver transplantation.

Osteoarticular changes and synovial biopsy findings in Wilson's disease

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