Penicillamine-induced Elastosis Perforans Serpiginosa in Wilson Disease: Is Useful Switching to Zinc?

Prevalence and Significance of Autoantibody Seropositivity in Children with Wilson's Disease

Autoantibodies occur in healthy subjects as well as in children with Wilson's disease (WD), but their prevalence and significance are unknown. Thus, we aimed to assess the prevalence of autoantibodies and autoimmune markers, and their relationship to liver injury in WD children. The study included 74 WD and 75 healthy children as a control group. Patients with WD underwent transient elastography (TE) examinations, as well as determination of liver function tests, copper metabolism markers, and serum immunoglobulins (Ig). In the sera of the WD patients and controls, anti-nuclear (ANA), anti-smooth muscle, anti-mitochondrial, anti-parietal cell, anti-liver/kidney microsomal, anti-neutrophil cytoplasmic autoantibodies, and specific celiac antibodies were determined. Among the autoantibodies, only the prevalence of ANA in children with WD was higher than in the controls. There was no significant relationship between the presence of autoantibodies and liver steatosis or stiffness after TE. However, advanced liver stiffness (E > 8.2 kPa) was related to IgA, IgG, and gamma globulin production. The type of treatment did not influence the prevalence of autoantibodies. Our results suggest that autoimmune disturbances in WD might not be directly related to liver damage as expressed by steatosis and/or liver stiffness after TE.

Wilson's disease- management and long term outcomes

Wilson's disease (WD) is an autosomal recessive genetic disorder of copper metabolism leading to liver or brain injury due to accumulation of copper. Diagnosis is based on: clinical features, biochemical tests including plasma ceruloplasmin concentration, 24h urinary copper excretion, copper content in the liver, and molecular analysis. Pharmacological therapy comprises chelating agents (penicillamine, trientine) and zinc salts which seem to be very effective. Still, poor compliance is a major problem. Adolescents and patients with psychiatric disorders usually have problems with adherence to treatment. As transition is a vulnerable period transition ''training'' should start before the planned transfer, preferably already in early adolescence in cooperation between adult and pediatric clinics. Response to treatment is assessed based on physical examination, normal liver function tests and monitoring of copper metabolism markers. Liver transplantation has a well-defined role in Wilsonian acute hepatic failure according to the prognostic score. The long-term survival in WD patients seems to be very similar as for the general population if disease is early diagnosed and correctly treated. WD patients with a longer delay from diagnosis to therapy and who present with neurological and psychiatric symptoms have worse quality of life.

Pediatric Pseudo-pseudoxanthoma Elasticum Resulting From D-Penicillamine Treatment for Wilson Disease

We describe a 14-year-old boy with Wilson disease (WD) who first developed pseudo-pseudoxanthoma elasticum (PPXE) after 4.5 years of treatment with D-penicillamine. Although previously reported cases have occurred in adults following at least a decade of high-dose D-penicillamine use, this case demonstrates that D-penicillamine-induced PPXE can present in children with shorter treatment courses. Upon this diagnosis, the patient was switched from D-penicillamine to trientine, with adequate cupriuresis and stabilization of the skin lesion. Prompt diagnosis and management of PPXE in children can limit systemic progression and prevent long-term complications.

EDTA-modified mesoporous silica as supra adsorbent of copper ions with novel approach as an antidote agent in copper toxicity

PURPOSE

Mesoporous silica (MS) have been considered as a biocompatible compound and found to have various pharmaceutical applications. Recently, novel approaches in applications of MS as antidote agents were introduced. In this study, the capacity of ethylenediaminetetraacetic acid modified mesoporous silica (MS-EDTA) was evaluated in in vitro and in vivo adsorption of copper (Cu).

METHODS

The MS-EDTA was characterized by fourier transform infrared (FT-IR) and X-ray diffraction, while surface area was determined by N2 adsorption-desorption technique. Morphological studies were observed by high resolution-transmission electron microscopy and field emission-scanning electron microscopy and the sizes were determined by dynamic light scattering. The capacity of these particles for copper adsorption was investigated in vitro in both 1.2 and 7.2 pH. In in vivo animal study, the Cu adsorption efficiency of MS-EDTA in Cu-overdosed mice was evaluated. In this case, an animal model of acute copper poisoning was prepared.

RESULTS

The MS-EDTA with surface area of 352.35 was synthesized. Scanning electron microscope showed spherical particle formation with less than 500 nm in size. Transmission electron microscope images showed porous and honeycomb structure. FT-IR spectroscopy showed an appropriate formation of functional groups. Particle efficiency was investigated for Cu adsorption. MS-EDTA in both media showed a high adsorption capability for Cu (II) adsorption in pH=1.2 and pH=7.2. In addition, the study of Langmuir, Freundlich, and Redlich-Peterson adsorption models showed that copper adsorption by MS-EDTA followed the Freundlich model with multi-layer adsorption. In vivo evaluation showed that MS-EDTA could alleviate the symptoms of acute copper poisoning by lowering Cu plasma levels.

CONCLUSION

Structural evaluation showed successful formation of MS-EDTA. In vitro analysis demonstrated that supreme Cu adsorption occurs in both pH conditions (7.2 and 1.2), and was especially more favorable in simulated intestinal pH (7.2). The in vivo studies in animal models with acute Cu poisoning showed that MS-EDTA could be a potent antidote agent.

Wilson's Disease in Children: A Position Paper by the Hepatology Committee of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition

BACKGROUND

Clinical presentations of Wilson's disease (WD) in childhood ranges from asymptomatic liver disease to cirrhosis or acute liver failure, whereas neurological and psychiatric symptoms are rare. The basic diagnostic approach includes serum ceruloplasmin and 24-hour urinary copper excretion. Final diagnosis of WD can be established using a diagnostic scoring system based on symptoms, biochemical tests assessing copper metabolism, and molecular analysis of mutations in the ATP7B gene. Pharmacological treatment is life-long and aims at removal of copper excess by chelating agents as D-penicillamine, trientine, or inhibition of intestinal copper absorption with zinc salts. Acute liver failure often requires liver transplantation. This publication aims to provide recommendations for diagnosis, treatment, and follow-up of WD in children.

METHODS

Questions addressing the diagnosis, treatment, and follow-up of WD in children were formulated by a core group of ESPGHAN members. A systematic literature search on WD using MEDLINE, EMBASE, Cochrane Database from 1990 to 2016 was performed focusing on prospective and retrospective studies in children. Quality of evidence was assessed according to the GRADE system. Expert opinion supported recommendations where the evidence was regarded as weak. The ESPGHAN core group and ESPGHAN Hepatology Committee members voted on each recommendation, using the nominal voting technique.