Wilson's disease

Dysregulation of Copper Metabolism in a Patient With Acute-on-Chronic Liver Failure Worked up for Fulminant Wilson Disease

Wilson disease (WD) is estimated present in 6%-12% of patients younger than 40 years hospitalized with acute liver failure (ALF). Fulminant WD carries a poor prognosis without treatment. A 36-year-old man with HIV, chronic hepatitis B virus, and alcohol use had ceruloplasmin 6.4 mg/dL and 24-hour urine copper 180 μg/L. WD workup was otherwise negative, including ophthalmic examination, hepatic copper quantification, ATP7B sequencing, and brain MRI. ALF commonly features copper dysregulation. Few studies on WD biomarkers have included fulminant WD. Our patient with WD biomarkers and other causes of liver failure highlights the need to study copper dysregulation in ALF.

Brain susceptibility changes in neurologically asymptomatic pediatric patients with Wilson's disease: evaluation with quantitative susceptibility mapping

Background Wilson's disease (WD) is a copper metabolism disorder that causes hepatolenticular degeneration. It is important to diagnose WD before central nervous system involvement. Purpose To demonstrate the early susceptibility changes associated with the copper accumulation in the brain of neurologically asymptomatic pediatric patients with WD using quantitative susceptibility mapping (QSM). Material and Methods Twelve patients with neurologically asymptomatic WD (mean age = 13.7 ± 3.3 years) and 14 age-matched controls were prospectively examined using a 1.5-T clinical scanner. Routine magnetic resonance (MR) sequences and a three-dimensional multi-echo spoiled gradient echo (GRE) sequence were used and QSM maps were reproduced. The quantitative susceptibility of corpus striatum, thalamus, substantia nigra, and pons were analyzed with the region of interest analysis on QSM maps. The susceptibility values of two groups were statistically compared using a two-sample t-test. Results Conventional MR images of the patients and control group were similar. However increased magnetic susceptibility in the thalamus, pons and left posterior putamen were observed in the patients compared to the control group ( p < 0.05). Conclusion We observed statistically increased susceptibility values in the brains of neurologically asymptomatic patients with WD although the conventional MR images were normal. This might be compatible with early brain impairment, before neurological symptoms occur.

Living Donor Liver Transplantation for Wilson's Disease Associated with Fulminant Hepatic Failure: A Case Report

Patient: Female, 17

Final Diagnosis: Fulminant Wilson’s disease

Symptoms: General jaundice • malaise • abdominal pain

Medication: —

Clinical Procedure: ICU

Specialty: Transplantology

Magnetic Susceptibility Changes in the Basal Ganglia and Brain Stem of Patients with Wilson's Disease: Evaluation with Quantitative Susceptibility Mapping

Objectives:

Wilson’s disease (WD) is characterized with the accumulation of copper in the liver and brain. The objective of this study is to quantitatively measure the susceptibility changes of basal ganglia and brain stem of pediatric patients with neurological WD using quantitative susceptibility mapping (QSM) in comparison to healthy controls.

Methods:

Eleven patients with neurological WD (mean age 15 ± 3.3 years, range 10–22 years) and 14 age-matched controls were prospectively recruited. Both groups were scanned on a 1.5 Tesla clinical scanner. In addition to T₁- and T₂-weighted MR images, a 3D multi-echo spoiled gradient echo (GRE) sequence was acquired and QSM images were derived offline. The quantitative measurement of susceptibility of corpus striatum, thalamus of each hemisphere, midbrain, and pons were assessed with the region of interest analysis on the QSM images. The susceptibility values for the patient and control groups were compared using two-sample t-test.

Results:

One patient with WD had T₁ shortening in the bilateral globus pallidus. Another one had hyperintensity in the bilateral putamen, caudate nuclei, and substantia nigra on T₂-weighted images. The rest of the patients with WD and all subjects of the control group had no signal abnormalities on conventional MR images. The susceptibility measures of right side of globus pallidus, putamen, thalamus, midbrain, and entire pons were significantly different in patients compared to controls (P < 0.05).

Conclusion:

QSM method exhibits increased susceptibility differences of basal ganglia and brain stem in patients with WD that have neurologic impairment even if no signal alteration is detected on T₁- and T₂-weighted MR images.

Copper and zinc in the serum, urine, and hair of patients with Wilson's disease treated with penicillamine and zinc

The purpose of this study was to determine the different levels of copper and zinc in the serum, urine, and scalp hair of patients with Wilson's disease receiving different, currently accepted methods of treatment to reduce the copper load (penicillamine-group 1, n = 8; zinc-group 2, n = 8; penicillamine+zinc-group 3, n = 8). Blood, urine, and hair samples were collected from the patients. All three treatments resulted in a significant decrease of the serum copper levels. Significantly increased levels of zinc in the serum were detected in the patients in groups 2 and 3 (19.1 and 18.8 micromol/l, respectively; p < 0.05). Copper excretion in the urine significantly increased during its administration to groups 1 and 3 (11.5 and 7.94 micromol/24 h respectively; p < 0.001) due to the effect of penicillamine. The administration of zinc as monotherapy (group 2) or in combination with penicillamine (group 3) led to an increase of its excretion (25.3 and 22.4 micromol/24 h, respectively; p < 0.01). Only an insignificant rise of the copper content in the hair was found in all three groups of patients. The content of zinc in the hair did not differ significantly in any of the groups in comparison with the control group.

Liver disease in pregnancy

Liver diseases in pregnancy may be categorized into liver disorders that occur only in the setting of pregnancy and liver diseases that occur coincidentally with pregnancy. Hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of hemolysis, elevated liver tests and low platelets (HELLP), acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy are pregnancy-specific disorders that may cause elevations in liver tests and hepatic dysfunction. Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis, Wilson disease, and viral hepatitis may also be seen in pregnancy. Management of liver disease in pregnancy requires collaboration between obstetricians and gastroenterologists/hepatologists. Treatment of pregnancy-specific liver disorders usually involves delivery of the fetus and supportive care, whereas management of chronic liver disease in pregnancy is directed toward optimizing control of the liver disorder. Cirrhosis in the setting of pregnancy is less commonly observed but offers unique challenges for patients and practitioners. This article reviews the epidemiology, pathophysiology, diagnosis, and management of liver diseases seen in pregnancy.

Systemic translocation of (70)zinc: kinetics following intratracheal instillation in rats

Mechanisms of particulate matter (PM)-induced cardiotoxicity are not fully understood. Direct translocation of PM-associated metals, including zinc, may mediate this effect. We hypothesized that following a single intratracheal instillation (IT), zinc directly translocates outside of the lungs, reaching the heart. To test this, we used high resolution magnetic sector field inductively coupled plasma mass spectrometry to measure levels of five stable isotopes of zinc ((64)Zn, (66)Zn, (67)Zn, (68)Zn, (70)Zn), and copper in lungs, plasma, heart, liver, spleen, and kidney of male Wistar Kyoto rats (13 weeks old, 250-300 g), 1, 4, 24, and 48 h following a single IT or oral gavage of saline or 0.7 micromol/rat (70)Zn, using a solution enriched with 76.6% (70)Zn. Natural abundance of (70)Zn is 0.62%, making it an easily detectable tracer following exposure. In IT rats, lung (70)Zn was highest 1 h post IT and declined by 48 h. Liver endogenous zinc was increased 24 and 48 h post IT. (70)Zn was detected in all extrapulmonary organs, with levels higher following IT than following gavage. Heart (70)Zn was highest 48 h post IT. Liver, spleen and kidney (70)Zn peaked 4 h following gavage, and 24 h following IT. (70)Zn IT exposure elicited changes in copper homeostasis in all tissues. IT instilled (70)Zn translocates from lungs into systemic circulation. Route of exposure affects (70)Zn translocation kinetics. Our data suggests that following pulmonary exposure, zinc accumulation and subsequent changes in normal metal homeostasis in the heart and other organs could induce cardiovascular injury.

Role and support for hepatologists at liver transplant programs in the United States

Liver transplantation has evolved into a successful option for patients with end-stage liver disease. Transplant hepatologists are involved in the management of patients with end-stage liver disease both before and after liver transplantation. The goals of this study were to evaluate the roles that transplant hepatologists play at liver transplantation programs in the United States and the demand for and institutional support provided for these physicians. A web-based questionnaire was sent via e-mail to the medical directors of all 108 United Network for Organ Sharing-recognized liver transplant programs during the fall of 2006. Follow-up e-mails were sent and phone calls were made to those not completing the survey within 4 weeks. The survey was completed by 72 (67%) medical directors. The average number of liver transplants performed per center was 62, and a broad range of program sizes were represented. The number of transplant hepatologists increased in proportion to the number of transplants performed on an annual basis but lagged behind the number of surgeons and transplant coordinators. On average, 33 liver transplants were performed per year per transplant hepatologist. Transplant hepatologists were involved in all aspects of pretransplant and posttransplant care at all but 10% of these institutions; they provided virtually all pretransplant care at all of these programs and all long-term posttransplant care at 45% of these programs. Overall, 94% of liver transplant programs provided direct salary support and/or ancillary personnel for their transplant hepatologists. Despite this, over half of transplant hepatologists and 75% of those that received no direct salary support performed endoscopic procedures on a regular basis. Eighty-one percent of programs were recruiting additional transplant hepatologists. In conclusion, although the vast majority of transplant hepatologists receive institutional support, this support appears to be inadequate. The current shortage of transplant hepatologists is likely to increase if appropriate support mechanisms are not implemented.

Swallowing dysfunction in Wilson's disease: a scintigraphic study

Although dysphagia is a common complaint of patients with Wilson's disease (WD) and pneumonia is an important cause of death in these patients, swallowing function remains an underinvestigated field in this condition. The aim of this study was to characterize swallowing dynamics in WD patients. Eight WD patients and 15 age-matched controls underwent scintigraphic evaluation of oral and pharyngeal deglutition. Patients had significantly slower oral transit (P = 0.008) and a greater percentage of oral residue (P = 0.006) when compared to controls. Two of eight patients were free of neurological symptoms at time of examination. Impaired oropharyngeal function was found in patients without dysphagia and without neurological symptoms. Our findings indicate that WD may present with objective swallowing dysfunction, even in the absence of neurological manifestations. Further studies are necessary to investigate the impact of this dysfunction on morbidity and mortality in WD.

Transition metal-induced apoptosis in lymphocytes via hydroxyl radical generation, mitochondria dysfunction, and caspase-3 activation: an in vitro model for neurodegeneration

BACKGROUND

Redox transition metals have been implicated as crucial players in pathogenesis of neurodegenerative diseases. Intracellular signaling mechanism(s) responsible for oxidative stress and death in single-cell model exposed to metals has not yet been fully elucidated. The objective of the study was to determine the mechanism by which metals induced apoptosis in human peripheral blood lymphocytes (PBL).

METHODS

PBL were exposed to 50, 100, 250, 500, and 1,000 microM (Fe2+), (Mn2+), (Cu2+), and (Zn2+)-(SO4). Apoptotic/necrotic morphology was assessed with acridine orange/ethidium bromide staining. Further evaluations comprised production of H2O2, generation of hydroxyl radical (.OH), disruption of mitochondrial transmembrane potential (DeltaPsim), caspase-3 activation, and activation of NF-kappaB and p53 transcriptional factors.

RESULTS

Morphologic analysis showed that 500 microM provoked maximal percentage of apoptosis (22-30% AO/EB) and minimal necrosis (3-7%), whereas low concentrations were innocuous but 1,000 microM induced mainly necrosis (>40% AO/EB). Metals generated both H2O2 and (.OH) by Fenton reaction. Hydroxyl scavengers protected PBL from metal-induced apoptosis. All metals induced mitochondrial depolarization (17-62% nonfluorescent cells) and activated caspase-3 concomitantly with apoptotic morphology (25-32% AO/EB) at 24 h, and neither NF-kappaB nor p53 transcription factor showed activation.

CONCLUSIONS

This study provides evidence that redox-active (Fe2+), (Mn2+), (Cu2+), and (Zn2+) ion-induced apoptosis in PBL by (H2O2)/(.OH) generation, resulting in mitochondria depolarization, caspase-3 activation, and nuclear fragmentation independent of NF-kappaB and p53 transcription factors activation. Our data highlight the potential use of lymphocytes as a model to screen antioxidant strategies designed to remove H2O2/.OH associated with metal-catalyzed reactions in neurodegenerative disorders.

[Wilson's disease. Clinical presentation, treatment and evolution in 21 cases]

PURPOSE

Wilson's disease is characterized by neuropsychiatric symptoms with frequent extrapyramidal and intellectual presentations. They have an insidious evolution that leads to a late diagnosis and less therapeutic effectiveness in the advanced forms.

METHODS

We report 21 cases of Wilson's disease with neurological complications, emphasizing clinical semiology, diagnostic means and problems of the therapeutics in our country.

RESULTS

The average age at the beginning of the disease was 17.6 years, with a female prevalence (8/13). The signs at first were mostly all neurological (71.4%), then psychiatric (19%) or hepatic (19%). The most common neurological signs were dystonia of members (81%), dysarthria (76%), tremors (76%) or disorders of motoricity (71.4%). Sometimes there were sialorrhea or disorders of the handwriting. The Kayser-Fleischer ring was present in 19 patients. Eighteen patients had clinical and/or biological hepatic involvement. The diagnosis was confirmed by biochemical examinations, which found a low rate of copper in blood, a sinking rate of ceruloplasmin and a very high rate of urinary copper. The cerebral computer tomography shows a cortical and/or subcortical atrophy (37%), and/or a low density of the central grey cores (35%). The treatment was based on D-penicillamine and/or zinc sulfate, according to the availability of the drugs. The evolution was favourable among 18 patients (85%) and not good in 42.8% of the cases. Six of the first patients had poor evolution after many years of follow-up. Finally, only 12 patients (57%) had a very good outcome. The family investigation made among 17 patients revealed 13 family cases. The only predictive factor of a poor evolution was the therapeutic noncompliance (P = 0.006).

CONCLUSIONS

The neurological presentations are traditional during the Wilson's disease, but are often ignored. We must suspect the disease in children when faced with disorders of handwriting or school failures and in the adult, when faced with neurological symptoms in a patient having a hepatic disease. We must not hesitate to consider it even given purely psychiatric signs, and we had better know to seek the neurological ones.

Wilson's disease: copper unfettered

Wilson's disease is a rare autosomal recessive inherited disorder of copper metabolism. Hepatic excretion of copper is impaired due to mutation of the gene for a copper-transporting adenosine triphosphatase, ATP7B. Copper accumulation in liver, brain, and other tissues may cause a wide spectrum of hepatic, neuropsychiatric, and other clinical manifestations. The diagnosis may be supported by measurement of serum ceruloplasmin, urinary copper excretion, and hepatic copper content as well as by detection of Kayser-Fleischer rings. Several treatments are available to increase urinary excretion and decrease intestinal absorption of copper.