American Journal of Medical Genetics 76:154–164 (1998)

Early Treatment of Menkes Disease With

Parenteral Cooper-Histidine: Long-Term Follow-Up of
Four Treated Patients
John Christodoulou,1 David M. Danks,2 Bibudhendra Sarkar,3 Kurt E. Baerlocher,4 Robin Casey, 5
Nina Horn,6 Zeynep Tümer,6,7 and Joe T.R. Clarke1*
1
Division of Clinical Genetics, Hospital for Sick Children, Toronto, and Department of Pediatrics, University of
Toronto, Toronto, Ontario, Canada
2
Murdoch Institute for Research into Birth Defects, Melbourne, Australia
3
Department of Biochemistry Research, Hospital for Sick Children, Toronto, and Department of Biochemistry,
University of Toronto, Toronto, Ontario, Canada
4
Paediatrische Klinik, Ostschweizerisches Kinderspital, St. Gallen, Switzerland
5
Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
6
John F. Kennedy Institute, Glostrup, Denmark
7
Department of Medical Genetics, IMBG, Panum Institute, University of Copenhagen, Copenhagen, Denmark

We report on the long-term clinical course
of 4 boys with Menkes disease, treated
from early infancy with parenteral copper-
histidine, with follow-up over 10–20 years.
Three of the 4 had male relatives with a se-
vere clinical course compatible with classi-
cal Menkes disease. As a consequence of
early treatment, our patients have normal
or near-normal intellectual development,
but have developed many of the more se-
vere somatic abnormalities of the related
disorder, occipital horn syndrome, includ-
ing severe orthostatic hypotension in 2. In
addition, 1 boy developed a previously un-
reported anomaly, namely, massive spleno-
megaly and hypersplenism as a conse-
quence of a splenic artery aneurysm. Previ-
ously reported molecular studies in 2 of
these patients had shown gene defects
which would have predicted a truncated
Abbreviations: ATP7A, Menkes disease gene; DA, Dopamine;
DHPG, dihydroxyphenylglycol; DOPA, dihydroxyphenylala-
nine; DOPAC, dihydroxphenylacetic acid; E epinephrine; L-
DOPS, L-dihydroxyphenylserine; MD, Menkes disease; NE,
Norepinephrine; OHS, occipital horn syndrome; ORF, open
reading frame.
Contract grant sponsor: Medical Research Council of Canada;
Contract grant sponsor: Lunenfeld Foundation, Toronto.
John Christodoulou is now at the Department of Paediatrics
and Child Health, University of Sydney and Western Sydney Ge-
netics Program, Royal Alexandra Hospital for Children, West-
mead, New South Wales, Australia.
*Correspondence to: Dr. J.T.R. Clarke, Division of Clinical Ge-
netics, Hospital for Sick Children, 555 University Ave., Toronto,
Ontario M5G 1X8, Canada.
Received 30 June 1997; Accepted 3 September 1997
© 1998 Wiley-Liss, Inc.
and probably nonfunctional gene product.
Despite the favorable effects on the neuro-
logical symptoms, parenteral copper treat-
ment for Menkes disease should still be re-
garded as experimental. The development
of more effective treatments must await a
more precise delineation of the role which
the Menkes protein plays in intracellular
copper trafficking. Am. J. Med. Genet. 76:
154–164, 1998. © 1998 Wiley-Liss, Inc.
KEY WORDS: copper-histidine; mutation;
genotype; phenotype; occipi-
tal horn syndrome; Menkes
disease; therapy
INTRODUCTION
Menkes disease (MD) (MIM 309400) is a rare X-
linked generalized defect in intracellular copper trans-
port [Danks, 1995]. The fact that the clinical picture of
MD is due to a deficiency of copper, resulting in func-
tional defects of a number of key copper-dependent pro-
teins, was first recognized in 1972 [Danks et al.,
1972b]. The responsible gene (ATP7A or MNK) was
isolated in 1993 [Chelly et al., 1993; Mercer et al., 1993;
Vulpe et al., 1993]. It is organized into 23 exons [T̈umer
et al., 1995]. The 8.5-kb mRNA transcript encodes a
copper-transporting P-type ATPase, and is expressed
in all tissues, although only in trace amounts in liver
[Vulpe et al., 1993]. This distribution matches the pat-
tern of copper accumulation in most patient tissues,
suggesting a primary role in the extrusion of copper
from cells expressing the gene. However, this role alone
would not fully explain the clinical manifestations of
the condition and all the abnormalities found in vitro in
cultured cells. Even cells with a greater than normal

content of copper show functional deficiencies in cop-
per-dependent enzymes [Royce et al., 1982]. Therefore,
it is likely that the MD protein is also involved in the
transport of copper into some intracellular organelles
[Danks, 1986; Vulpe and Packman, 1995; Tümer and
Horn, 1996].
Most clinical effects of classical MD are explainable
by impaired activity of various copper-dependent en-
zymes, including lysyl oxidase, cytochrome c oxidase,
dopamine b-hydroxylase, tyrosinase, and superoxide
dismutase [Horn et al., 1992; DiDonato and Sarkar,
1997]. In classical cases, the major clinical manifesta-
tions have a prenatal onset, and from birth there is
impairment of growth, the development of skeletal ab-
normalities, tortuosity of blood vessels, premature rup-
ture of membranes, and characteristic facial and hair
abnormalities. The anomalies become more marked
through early infancy and are generally severe by age
3 or 4 months. Temperature instability and severe de-
velopmental retardation, followed by loss of cerebral
functions, seizures, and recurrent urinary tract infec-
tion, often associated with rupture of bladder or ure-
teric diverticuli, and rupture of major arteries, are
among the defects which lead to death, generally before
age 3 years. Very low levels of ceruloplasmin and cop-
per in plasma, and decreased levels of copper in liver in
an appropriate clinical setting, are diagnostic of the
disease.
Definitive biochemical diagnosis is based on the dem-
onstration of intracellular accumulation of copper due
to impaired efflux. Accumulation is evaluated in cul-
tured cells by measuring radioactive copper (64Cu) ac-
cumulation after a 20-h pulse, and impaired efflux is
directly determined after 24-h in pulse-chase studies
[Camakaris et al., 1980; Tønnesen and Horn, 1989].
Following the isolation of ATP7A and characterization
of its genomic organization, mutation analysis became
another diagnostic possibility [T̈umer and Horn, 1996].
However, mutation detection in Menkes disease is
rather challenging: the large ATP7A transcript is or-
ganized into 23 exons [Tümer et al., 1995; Dierick et
al., 1995], and there is marked allelic variability [Das
et al., 1994; Tümer et al., 1997].
In mice and humans, less severe disease phenotypes
have been observed, with the occipital horn syndrome
(OHS) being the mildest [Danks, 1995; Tsukahara et
al., 1994; Horn et al., 1995]. OHS is characterized prin-
cipally by connective tissue abnormalities, with only a
mild effect on intellectual development [Byers et al.,
1980]. Urinary tract diverticuli, hernias, and bony
changes, involving abnormal shape of the upper end of
the radius (leading to radioulnar dislocation), and the
lateral ends of the clavicles and acromion, are particu-
larly characteristic [Sartoris et al., 1984], as is the
presence of a spike of ossification within the occipital
insertion of the paraspinal muscles, i.e., the lesion
which gives the syndrome its name. The distribution of
copper in various tissues is distinctly abnormal and
very similar to that found in MD [Heydorn et al., 1995].
One patient with a mild variant of MD, characterized
by severe cerebellar ataxia, mild intellectual delay, and
only very mild connective tissue abnormalities, was de-
scribed by Procopis et al. [1981] and Danks [1988]. This
Treatment of Menkes Disease 155
patient has not developed the bony changes of OHS,
even at age 18 years [Danks, personal observations].
Another patient originally described as having mild
MD is now manifesting the bony changes of OHS; in
retrospect, this diagnosis would more appropriately de-
scribe the whole of his clinical course [Westman et al.,
1988].
The understanding of MD was greatly aided by the
discovery that the series of allelic mutations in the
mottled mouse, named because of the variegated coat
color in heterozygous females, showed changes in cop-
per distribution almost identical to those found in pa-
tients with the disease [Hunt, 1974]. The brindled mu-
tant is most like classical MD, and much of the knowl-
edge of the human condition was derived from studies
in these mice, which die of neurological damage at
about 14 or 15 days after birth [Danks, 1995]. A single
large dose of copper-histidine injected on day 7 cures
these mice, but the same treatment on day 10 is inef-
fective [Mann et al., 1979; Wenk and Suzuki, 1982].
The blotchy mouse shows mainly connective tissue ab-
normalities, with no apparent brain involvement. The
pattern of copper distribution in tissues is the same as
in the brindled mouse and in patients with classical
MD, but the disturbance is slightly less severe. None-
theless, the severity of impairment of lysyl oxidase is
greater in the blotchy mouse than in the brindled
strain [Royce et al., 1982]. These findings suggest that
the blotchy mouse may be a model for OHS. No benefit
was observed following the same schedule of copper
injections that was so effective in brindled mice [Mann
et al., 1981].
Treatment with various forms of parenteral copper
therapy has been shown to restore the levels of copper
in the liver and plasma to normal, with normal plasma
ceruloplasmin levels. Parenteral therapy for Menkes
disease with various inorganic copper salts, begun ei-
ther before or after neurologic impairment, has never
convincingly shown any significant effect on the devas-
tating neurodegenerative progression of the disease
[Garnica, 1984]. Copper-histidine is naturally present
in normal human serum [Sarkar and Kruck, 1966], and
detailed studies demonstrated the physiologic impor-
tance of copper-histidine [Sarkar, 1981]. Histidine was
shown to enhance the uptake of copper in human tro-
phoblast cells in the presence of serum, and this is
considered to be due to the release of copper bound to
albumin [Mas and Sarkar, 1992]. These findings led us
to use copper-histidine in the treatment of Menkes dis-
ease [Sarkar, 1980, 1984; Procopis et al., 1981; Danks,
1988; Nadal and Baerlocher, 1988; Sherwood et al.,
1989; Sarkar et al., 1993]. Subcutaneous copper-
histidine appears to have been tolerated best and
seems to be the most efficient of the different forms of
treatment tried [Sherwood et al., 1989]. However, even
copper-histidine fails to influence the inexorably pro-
gressive brain disease once severe symptoms have de-
veloped [Williams et al., 1977; Kreuder et al., 1993].
However, more encouraging results have been obtained
when this treatment is started soon after birth [Sher-
wood et al., 1989].
We report here on 4 boys with classical MD who were
treated with parenteral copper-histidine soon after
156 Christodoulou et al.
birth, 3 of whom are now 20, 18, and 10 years old, while
one died recently at age 10 3/12 years. To our knowl-
edge, these are the oldest treated patients. Each has
been reported previously in brief papers describing spe-
cific signs of their disease, the formulation of copper-
histidine, or associated mutations. This is the first
comprehensive clinical report of these patients as a
group and of their responses to early copper therapy.
The neurological outcome in each is most encouraging;
however, 2 have developed many of the signs of OHS,
especially the bony features, and they have experi-
enced severe postural hypotension, a manifestation re-
ported in OHS.
CLINICAL REPORTS
Patient 1
M.F. was reported previously by Farrelly et al.
[1984], Sherwood et al. [1989], and Sarkar [1984,
1994]. He is the fourth child of nonconsanguineous
French-Canadian parents. He has a normal brother
and sister, now 24 and 21 years old, respectively. An-
other brother, with classical Menkes disease, died at
31⁄2 years following a severe neurodegenerative course.
M.F. was born by spontaneous delivery at 37 weeks of
gestation with a birth weight of 2,470 g. He was un-
usual looking, with a bulbous nose, puckered lips, and
sparse hair. In addition, he seemed lethargic, fed
poorly, and had several hypothermic episodes during
the first 2 weeks of life. Menkes disease was confirmed
on the basis of falling plasma copper and the cerulo-
plasmin levels in the first 2 weeks, in spite of treatment
with oral copper chloride supplements.
Between age 1–3 months, he was treated with daily
intravenous infusions of copper chloride, initially at a
dose of 150 mg/kg/day. From age 3 months treatment
was changed to daily subcutaneous injections of cop-
per-histidine, with a starting dose of 600 mg/day. There
was a good biochemical response to this treatment, as
judged by weekly plasma total copper and ceruloplas-
min quantitations. A liver biopsy at 6 months showed
no evidence of excessive copper accumulation. Copper-
histidine therapy was temporarily suspended for 1
month at age 11 months because plasma ceruloplasmin
and copper levels became supranormal. Despite admin-
istration of lower doses of copper-histidine subcutane-
ously (100–200 mg/day), levels again became high,
leading to the intermittent administration of D-
penicillamine (125–250 mg/day) commencing at 19
months, given orally at a once-a-day dosage for a
month at a time, while continuing the copper-histidine
therapy. Subsequently, incremental changes in the
copper-histidine dose were made on the basis of plasma
copper and ceruloplasmin levels. Using this regimen
until age 6 years, it was possible to maintain plasma
ceruloplasmin and copper in the normal range. He
never showed any problems attributable to copper
treatment.
The first year of life, 9 months of which were spent in
hospital, was marked by recurrent infections, chronic
diarrhea, failure to thrive, and normochromic anemia.
During the next 8 years, he enjoyed good health, with
height and weight advancing along the 3rd centile for
his age. He required surgery for correction of bilateral
strabismus, nasal polypectomy, and extractions of re-
tained primary dentition. Psychomotor development
was somewhat delayed: he sat unaided at 10 months,
was cruising by 21 months, walked unaided at 2 years,
and was riding a tricycle by age 3 1/2 years. He uttered
his first intelligible words at 2 years, and was talking
in short sentences by 2 1/2 years. He was toilet-trained
by 31⁄2 years. During the first few years of life, fine
motor and cognitive abilities were better than gross
motor and verbal skills. He never had seizures.
Formal assessment at age 9 1/2 years showed a full-
scale IQ of 87 (Wechsler Intelligence Scale for Chil-
dren-Revised) and normal brain stem-evoked poten-
tials. Progressive deterioration in exercise tolerance
had been noted. He was able to walk only 15–30 m and
could not stand for prolonged periods. He felt most
comfortable in a squatting position. Fainting spells
lasting up to 30 sec occurred every few months. Apart
from mild postural hypotension, no explanation for his
symptoms could be found. By 14 years, he could only
walk short distances with a very stooped posture,
spending most of his time in a wheelchair. To negotiate
stairs he would crawl up on all fours and squat at the
top for several minutes to prevent syncope. At age 141⁄2
years, he had a syncopal episode on standing, and was
found to be bradycardic at the time. Treatment with
atropine (0.01 mg/kg) resulted in a brisk increase in
heart rate, and a rapid clinical recovery.
Examination at age 14 1/2 years showed an elon-
gated face with a paucity of facial movements, low-set
ears, poor muscle bulk, generalized hypotonia with a
stooped posture, marked kyphoscoliosis, a narrow
chest wall, and mild pectus excavatum (Fig. 1). Marked
gingival hyperplasia and class II dental malocclusion
were present. Cutis laxa was very prominent, with hy-
perextensible skin, and large redundant axillary skin
folds. In addition, he had generalized joint hyperexten-
sibility, except at the elbows due to bilateral radioulnar
dislocation. Muscle strength was marginally reduced,
and deep tendon reflexes were normal. He had a pale
complexion, with dry skin and hyperkeratotic papular
lesions on the extensor aspects of his arms and legs.
His hair was coarse, but it did not show pili torti. Pu-
bertal development was Tanner stage V. Blood pres-
sure supine was 104/53 mm Hg, with heart rate at 67
beats per min; in a sitting position, blood pressure
dropped to 55/32 mm Hg, and there was a reflex in-
crease in the heart rate to 85 beats per min. There was
no increase in blood pressure following immersion of
the hand in ice-cold water, or following a mental arith-
metic challenge, suggesting that his postural hypoten-
sion may have an autonomic basis.
Investigation of the episodes of hypotension included
24-hr Holter cardiac monitoring, EEG, urine toxicology
screen, plasma electrolytes, calcium, phosphate, mag-
nesium, glucose, lactate, ammonium, liver enzymes,
pancreatic amylase, and cortisol, all of which were nor-
mal. CT scan of the head, and abdominal ultrasound
studies, showed no evidence of intracerebral or intra-
abdominal bleeding, respectively. Hemoglobin was
93 g/l, with the blood film showing a persistent normo-
chromic, normocytic red cell morphology, while the
 Treatment of Menkes Disease 157

hydroxyphenylglycol (DHPG), were both markedly de-

creased. In contrast, the plasma dihydroxyphenylala-
nine (DOPA) concentration was within normal range,
while DA was unrecordably low. The concentration of
dihydroxyphenylacetic acid (DOPAC), which is the ma-
jor degradative metabolite of DOPA, was within nor-
mal range.
The postural hypotension was treated initially with
the peripheral a-adrenergic agonist, midodrine. There
was no clinically significant response after 1 week. Af-
ter 1 week of combined therapy with midodrine and
fludrocortisone (3.75 mg t.i.d. and 150 mg b.i.d., respec-
tively), he could stand without syncopal symptoms.
One month after starting this therapy, the blood pres-
sure change from supine to standing was 120/70 mm
Hg to 80/60 mm Hg, with a change of heart rate from 66
to 97 beats per min.
Currently aged 20 years, he is functioning well, apart
from avoiding sporting activities, in year 12 at a nor-
mal school. He has persistent chronic diarrhea, which
he has had since early infancy. He has had no further
syncopal episodes, and continues on midodrine, fludro-
cortisone, and copper-histidine, with no adverse effects.
A number of radiological procedures were performed
over the years, which are summarized in Table I. Bi-
lateral metaphyseal spurs developed at the elbows at
4 1/2 years, bilateral radial head dislocation developed
at 9 1/2 years, and occipital ‘‘horns’’ developed at 16
years.

Patient 2

T.L. had a maternal uncle who died at age 8 years

and 9 months of MD after a clinical course character-
ized by severe, progressive mental retardation, typical
facial appearance, and hair changes, associated with
low levels of liver copper, high levels of copper in intes-
tinal mucosa, and typical abnormalities of copper
transport in cultured skin fibroblasts [Baerlocher et
al., 1983; Gerdes et al., 1988]. T.L. was diagnosed with
MD at age 6 weeks when his plasma copper and ceru-
loplasmin levels were shown not to be rising in the

TABLE I. Radiological Procedures Performed on Patient 1

Age
Fig. 1. Patient 1 at age 17 years. Note elongated, myopathic face, low- (years) Procedure
set ears, narrow chest wall, pectus excavatum, redundant axillary skin
folds, dislocation of radial heads, kyphosis, pes planus, and poor truncal 0.6 Cranial CT
muscle tone.
Vertebral arteriogram
white cell and platelet counts were normal. Results of Aortogram
clotting studies were also normal. The plasma copper
was 6.8 mmol/l (nromal, 10.5–23.0), while the cerulo- 0.9 Skeletal survey
plasmin was 132 mg/l (normal, 180–450), prompting an
increase of the daily copper-histidine dose from 700 to 2 Aortogram
800 mg/day of elemental copper. Echocardiography
3 Skull radiograph
showed mild left atrial and left ventricular dilatation, 4.75 Radiograph of elbows
and mild mitral regurgitation. 9.75 Skeletal survey
Supine plasma and 24-hr urinary catecholamine lev-
els are summarized in Table II. Urinary excretion of
norepinephrine (NE) and metanephrine were mark- 14.5 Cerebral CT
edly decreased below normal, while dopamine (DA) ex-
Skull radiograph
cretion was normal. Plasma NE, and its metabolite di-
Findings
Normal brain substance,
vessels abnormal
Elongated and dilated
cerebral vessels
Markedly tortuous
intraabdominal arteries
Osteoporosis, Wormian
bones in skull
Slight worsening of arterial
varicosities
Normal, no ‘‘occipital horn’’
Bilateral metaphyseal spurs
Osteoporosis, bilateral
dislocation radial heads,
tibial bowing
No change to vessels, no
hemorrhage
‘‘Occipital horn’’ present
158 Christodoulou et al.
TABLE II. Neurotransmitter Studies Performed on Patient 1
During Acute Admission for Life-Threatening Syncope*
Patient Controls
Plasma catecholamine concentrations (pg/ml)
DOPA 1,572 1,789 ± 149a
DA 0 26 ± 11
NE 20 252 ± 30
DHPG 34 1,292 ± 113
DOPAC 1,857 2,388 ± 662
DOPA:DHPG 46 <2
DOPA:DHPG 55 <2
Urinary catecholamines (mmol/mol creatinine)
DA 172 60–220b
NE <2 10–50
E n.d. 2–11
Metanephrine 0.07 20–100
*DOPA, dihydroxyphenylalanine; DA, dopamine; NE, norepinephrine;
DHPG, dihydroxyphenylglycol; DOPAC, dihydroxyphenylacetic acid; E,
epinephrine; n.d., not detected. Plasma analyses were kindly performed by
Dr. S.G. Kaler, Department of Health and Human Sciences, National In-
stitutes of Health, Bethesda, Maryland.
a
Mean ± SEM (n 4 13).
b
Range.
manner expected in normal babies during the first 6
weeks of life. At that time, serum copper was 2.5 mmol/l
and ceruloplasmin was 121 mg/l. His early treatment
was reported elsewhere [Nadal and Baerlocher, 1988].
Copper treatment was commenced at 7 weeks with a
5-day intravenous infusion of copper acetate (250–500
mg of elemental copper per day), followed by intramus-
cular copper (1,000–1,400 mg of elemental copper per
week in 1–3 doses, as copper-EDTA until age 18
months, and then as copper-histidine). Penicillamine
was given orally from age 6 months (250 mg once a
week until age 2 years and then 150 mg on alternate
days 12 hr after each copper injection). On this treat-
ment, the plasma copper increased to above 10 mmol/l
by age 3 months and was maintained in the range of
10–20 mmol/l thereafter. Liver copper was measured at
7 weeks, 6 months, and 3 years with levels of 0.21, 0.19,
and 0.12 mmol/g dry weight, respectively (normal
range, 0.47–0.94).
Clinically, there were no neurological abnormalities
at the time the treatment was started, and he was re-
garded as neurologically normal at 10 months. He
stood at age 11 months and began taking steps on his
own by 18 months. However, when he began walking a
few months later, he showed marked ataxia, and was
only able to walk unaided at 5 1/2 years of age. CT scan
of the head at this time showed cerebellar vermis hy-
poplasia. Single-word speech started in the second
year, but speech was always inarticulate and still re-
mains a problem.
An EGG performed at 6 weeks was normal. Subse-
quently, the EEG was abnormal, with generalized ir-
regular polyspike waves, but was unchanged by so-
dium valproate therapy.
He is now 18 years old. His height, weight, and head
circumference are close to the 50th centile. Ataxia is
still a major problem, and speech is dysarthric. Intel-
lectually he is mildly retarded and is in the 9th class at
a school for handicapped children, where he fulfills the
tasks of the 4th–5th school year. He can walk short
distances without a stick, but he prefers to use a special
bicycle. Skeletal radiographs show none of the anoma-
lies seen in patients 1 and 4. His blood pressure supine
is 110/60 mm Hg. It falls to 80/50 mm Hg when he
stands, but soon corrects to 100/60 mm Hg without
symptoms. No treatment of this problem has yet been
attempted. There has been no chronic diarrhea, uri-
nary tract infections, or ultrasound evidence of renal
tract abnormalities. His current copper-histidine dose
is 2,400 mg alternate daily.
Patient 3
R.H. was born at 35 weeks of gestation to healthy,
nonconsanguineous parents of Northern European ex-
traction. His clinical findings have been reported
briefly [Sherwood et al., 1989; Sarkar et al., 1993].
Birth weight was 2,150 g. Neonatally, he exhibited
marked hypotonia, temperature lability with a ten-
dency to hypothermia, feeding difficulty, and transient
hypoglycemia. At age 3 weeks he developed intractable
vomiting, and underwent pyloromyotomy for treat-
ment of hypertrophic pyloric stenosis. On the basis of
his marked hypotonia, failure to thrive, temperature
instability, skeletal abnormalities, tortuous arteries
seen on angiography, and abnormal hair, a diagnosis of
Menkes disease was considered and subsequently con-
firmed by the demonstration of abnormally low plasma
copper (3.6 mmol/l) and ceruloplasmin (50 mg/l) levels.
At 1 month, treatment was started with subcutaneous
injections of copper-histidine, 500 mg daily.
After 1 month of treatment, plasma copper was
14.4 mmol/l, and ceruloplasmin was 260 mg/l, both
within normal range. He had chronic diarrhea, which
persisted until his death at 10 3/12 years. He also
showed mild persistent normochromic normocytic ane-
mia. Inguinal herniorrhaphies were performed in the
first few weeks of life. He had one episode of twitching,
suggestive of seizure activity, in the neonatal period;
however, there were no further episodes and an EEG
done at age 11 months was normal.
His most difficult medical problems had been recur-
rent and severe urinary tract infections associated with
multiple large-bladder diverticula. Rupture of a blad-
der diverticulum on one occasion in childhood precipi-
tated life-threatening peritonitis. After undergoing ma-
jor reconstructive urological surgery, he had only three
minor urinary tract infections in the years leading up
to his death. He also required orthodontic care for
treatment of severe dental malocclusion.
Developmentally, he did very well. He experienced
moderate gross motor delay and some mild delay in
verbal and fine motor/adaptive function; however, so-
cialization had been age-appropriate. At 10 years, he
was in school in an age-appropriate grade. He had re-
cently been diagnosed as having attention deficit dis-
order, which was also diagnosed in his father and an
older otherwise healthy brother. At this age he enjoyed
excellent general health, and was active, sociable, and
intellectually normal, but had persistent diarrhea, av-
eraging 4–5 loose stools daily, with the severity of di-
arrhea increasing dramatically during intercurrent ill-
nesses. Weight was at the 10th centile, and height at

the 90th centile. His skin was dry and thick and coarse
on the extensor aspects of knees and elbows. In addi-
tion, he had mild cutis laxa. A skull radiograph per-
formed at 8 years did not show occipital horns, but he
subsequently developed palpable exostoses in the re-
gion where occipital horns would be expected to de-
velop. In addition, he had bilateral dislocation of the
elbows and severe pectus excavatum. He had no sei-
zures or episodes of syncope, but did experience some
light-headedness from time to time when rising sud-
denly from a recumbent to vertical posture. At the time
of his death his dose of copper-histidine was 500 mg per
day. He died suddenly of peritonitis at 103⁄12 years, pre-
sumably due to rupture of a bladder diverticulum, al-
though an autopsy report is not yet available.
Patient 4
G.V. was diagnosed as suffering from MD prenatally
at 21 weeks of gestation by copper studies performed
on cultured amniocytes sampled at 16 weeks. A brother
died in 1969 at age 14 months because of classical MD
[Danks et al., 1972a,b]. Six other pregnancies, includ-
ing G.V., were all monitored by amniocentesis, result-
ing in 2 healthy girls, a healthy boy, an affected male
pregnancy that was terminated by a prostaglandin in-
duction of labor at 22 weeks of gestation, a normal male
who died in labor as the result of umbilical cord ob-
struction, and G.V., who was predicted to be affected.
The parents decided to continue the pregnancy despite
this diagnosis. Labor was induced at 35 weeks, with
the intention of starting treatment with copper-
histidine immediately after birth.
A liver biopsy was peformed on day 2 of life to provide
a baseline for treatment and to confirm the diagnosis.
Treatment was initiated on day 3 with 100 mg of el-
emental copper daily. The dosage was adjusted accord-
ing to the results of plasma and hepatic copper levels.
Five liver biopsies were performed over the first 2 years
of treatment. Liver biopsy was carried out to monitor
for overdosage, to confirm the reliability of plasma cop-
per measurements as an indication of adequacy of
treatment, and to recognize marginal undertreatment.
TABLE III. Results of Plasma and Hepatic Copper
Measurements and Changes in Dose of Copper (as
Copper-Histidine) for Patient 4
Elemental
Plasma copper Liver copper copper dose
Age (mmol/l) (mg/g) (mg/day)
1 day 6.9 49 100
6 days 7.4
9 days 5.7 200
27 days 8.2 22
58 days 6.9 23 300
4 months 24.0 117 240
6 months 15.0 300
18 months 36
3 years 500
5 years 600
51⁄2 years 900
7 years 22.0
Treatment of Menkes Disease 159
The results of these tests and the consequent adjust-
ments of dosage are shown in Table III.
The only significant health problem during infancy
was a tendency to diarrhea with every intercurrent in-
fection, whether respiratory or gastrointestinal. Some
improvement followed the introduction of lactose-free
milk. However, intermittent diarrhea continued to be a
problem until recently. Motor development was mod-
erately delayed and poor motor coordination was ap-
parent, especially during the first 2 years. He walked
unaided at 16 months and began to talk at 2 years.
Problems with coordination have been less significant
since age 3 years. At 7 years he developed even more
persistent diarrhea, with 15–20 small-volume, poorly
formed stools each day.
At the same age, he began experiencing episodes of
syncope. He was unable to stand for more than 1–2
min. Blood pressure was found to be 90/50 mm Hg su-
pine and 70/30 mm Hg standing. Catecholamine defi-
ciency secondary to dopamine b-hydroxylase deficiency
was suspected, and treatment with L-DOPS (L-
dihydroxyphenylserine) [Mann in’t Veld et al., 1987]
was commenced at a dose of 50 mg 4 times daily. Mean
blood pressures based on 2-hourly measurements were:
pretreatment, 102/56 mm Hg lying, 88/49 mm Hg
standing; on treatment, 117/65 mm Hg lying, 105/57
mm Hg standing. Plasma and urinary levels of epi-
nephrine (E) and NE were below detection limits as
expected, but dopamine levels were not elevated, and
plasma levels of dopamine b-hydroxylase were close to
those in 2 controls. He has become much more ener-
getic and physically active, and no longer suffers epi-
sodes of fainting. His chronic diarrhea has resolved. In
retrospect it was realized that for several years he had
chosen to adopt a squatting position whenever possible
and preferred to get about in a semisquatting position
on a small tricycle, instead of walking. He now walks
and runs.
Clinical examination at this stage revealed bilateral
dislocation of the radial heads with obvious deformity
and lateral bowing of the tibiae just below the knees.
Radiographs showed the expansion of the upper end of
the ulna with radioulnar dislocation, expansion of the
lateral ends of the clavicles and of the acromion, and
small, but quite definite, occipital horns (Fig. 2). Re-
cently he developed urinary infection, and ultrasound
examination showed a bladder diverticulum not ob-
served in previous assessments. Splenomegaly had
been noted some months earlier, and has since taken
on the massive proportions associated with hyper-
splenism. Angiography documented elongation and
tortuosity of the splenic artery and vein, and a splenic
artery aneurysm. Splenectomy is planned in the near
future.
At age 10 years, his postural hypotension and diar-
rhea is still well-controlled by L-DOPS, and his activity
and school performance have improved greatly.
DISCUSSION
In this study we present the long-term clinical out-
comes of 4 unrelated Menkes disease patients treated
160 Christodoulou et al.

Fig. 2. Radiological findings in patient 4. a: Lateral skull radiogram, showing ‘‘occipital horn’’ (see arrow). b: Radiogram of right shoulder region,
showing hammer-shaped distal and expanded medial clavicle, and osteopenia of ribs. c: Radiogram of right upper arm, showing anterolateral dislocation
of the radial head, and a box-like ulnar coronoid process. In addition, the radial head has an abnormal shape, and the olecranon is hypoplastic. All of these
signs are typical of occipital horn syndrome [Herman et al., 1992].

with parenteral copper preparations soon after birth
(Table IV). They are the oldest patients described so far
with the classical severe form of the disease, 3 of whom
are still alive and generally well at ages 20, 18, and 10
years. Three patients (1, 2, and 4) had severely affected
relatives. The other patient (patient 3) had no family
history of MD, but the classical form of the disease was
suggested by defining the underlying genetic defect. In
families affected by classical MD, the severity of the
disease and its rate of progression is remarkably con-
stant in untreated affected male relatives. The out-
comes reported in patients 1, 2, and 4 differed mark-
edly from those in their respective affected relatives. In
a report by Kreuder et al. [1993], copper-histidine
treatment led to normalization of plasma copper and
ceruloplasmin and of CSF copper within 6 weeks,
marked reduction of epileptic discharges, improved
muscular tone, and increased motor activity. The ex-
cessive CSF dopamine level was corrected after 3
months of treatment. No comparable beneficial clinical
effect has been reported in patients treated with cop-
per-histidine injections once severe neurologic symp-
toms have developed [Kaler, 1994]. It is therefore rea-
sonable to attribute the improved outcomes of these 3
patients, and especially their relatively good neurologic
outcome, to early commencement of parenteral copper
preparations before serious clinical effects were evi-
dent.
Recently we identified the underlying genetic defect
in 2 of the patients (1 and 3), who both have single
basepair deletions leading to a frameshift and creation
of a premature stop codon [Tümer et al., 1996]. In pa-
tient 1, the ATP7A mutation is in exon 12 and it is
predicted to result in the production of a truncated pro-
tein lacking the ATPase ‘‘core’’ except for the first four
transmembrane domains. In patient 3, the mutation
lies in exon 4, introducing a termination codon within
the third metal-binding domain, and the resulting
polypeptide would lack the entire ATPase ‘‘core.’’ Both
mutations are severe, and we predict that they would
have resulted in a progressive clinical course if these
patients had gone untreated.
Recently, two mutation reports in other MD patients
treatd with copper-histidine were published [Kaler et
al., 1995, 1996]. One patient had a splice-site mutation
that resulted in two transcripts, one altering the trans-
 Treatment of Menkes Disease 161

TABLE IV. Summary of Clinical and Biochemical Findings in the Menkes Disease Patients*
Patient 1 Patient 2 Patient 3 Patient 4
(M.F.) (T.L.) (R.H.) (G.V.)
Affected relative Brother Maternal uncle None Maternal half-brother
Gestation at delivery 37 weeks 40 weeks 35 weeks 35 weeks (induced)
Pretreatment signs Facies, hypothermia None Hypothermia, failure Facies
to thrive, bone
changes, vascular
abnormalities,
abnormal hair
Treatment
Copper started (form) 4 weeks 7 weeks (I.V. Cu 4 weeks (Cu-his) 2 days (Cu-his)
(I.V. CuCl2 daily) acetate, then
intramuscular Cu
EDTA and
penicillamine)
Cu-his started 3 months 18 months 4 weeks 2 days
Plasma copper levels 4–10.5 10–20 10–20 10–25
on treatment (mmol/l)
Liver copper NE Decreased NE Normal
Outcome
Present age (years) 20 18 Died 10.25 10
School performance Age-appropriate 4 years behind Age-appropriate 1 year behind
Neurologic deficits Nil Ataxia, apraxia Nil Nil
(cerebellar vermis
hypoplasia)
Occipital horns + − −a +
Other skeletal
abnormalities ++ Nil + ++
Bladder diverticulae − − ++ +
Abnormal hair + Initially present, now No ++
normal
Postural hypotension +++ + + ++
Chronic diarrhea ++ − ++ ++
*NE, not estimated; Cu-his, copper-histidine; EDTA, ethylenediaminetetraacetate.
a
Palpable exostoses in the occipital region.

lational open reading frame (ORF), and the other re-
sulting in the skipping of exon 8, but restoring the ORF
[Kaler et al., 1996]. This patient received copper-
histidine at 8 days of life, and neurological outcome
was described as ‘‘successful’’ when reported at age 18
months [Kaler et al., 1996]. The authors concluded that
the presence of some residual protein would explain
the beneficial effects. On the other hand, 2 other MD
patients treated with copper-histidine did poorly in
spite of early treatment [Kaler et al., 1995]. They were
related to each other, and had identical mutations
which, the authors proposed, would not permit produc-
tion of functional gene product, apparently accounting
for the poor outcomes. While the nature of the muta-
tion could determine the benefit from such treatment,
the differences between the outcomes of early treat-
ment may be attributable, at least in part, to differ-
ences in the formulation of copper-histidine used.
One formulation of copper-histidine used by Kaler et
al. [1995] is different from that used by us or for the
patient reported more recently by Kaler et al. [1996].
The patients for whom treatment has been beneficial
received copper-histidine in 0.9% sodium chloride,
whereas those who did poorly [Kaler et al., 1995] re-
ceived two different formulations of copper-histidine.
These preparations were made in freeze-dried form,
whereas all 4 of our patients received formulation pre-
pared in solution form. The first suboptimal formula-
tion of copper-histidine contained 5% mannitol, which
was later switched to a mannitol-free copper-histidine
preparation. It is known that mannitol binds copper,
and that such carbohydrates can form polymeric spe-
cies with transition metals [Briggs et al., 1981; Whit-
field et al., 1993]. Precise stoichiometric stability con-
stants are not available because of the complexity of
the system. Furthermore, 5% mannitol in the copper-
histidine preparation used by Kaler et al. [1995] rep-
resents a 100-fold excess of mannitol compared to cop-
per in a copper-histidine (1:2) preparation. The exact
nature of the copper complex in the mannitol-
containing preparation is uncertain due to the com-
bined effects of the affinity of mannitol for copper and
its large excess. Copper-histidine solution in 5% man-
nitol was reported to have limited stability [Gautam-
Basak et al., 1993]. The complex nature of the solution
chemistry of copper-histidine itself was pointed out
earlier [Sarkar, 1994]. Additionally, the freeze-drying
process may also contribute to the uncertainties of the
exact nature of the copper complex in these prepara-
tions. Given the severe clinical course of the disease
and the small size of the patient population for com-
parisons, it is important that a common formulation
protocol be used in future studies to eliminate these
uncertainties.
Patients 1 and 2 initially received different forms of
copper prior to the initiation of treatment with copper-
histidine. Patient 1 was started on intravenous copper
chloride prior to administration of copper-histidine at 3
months. Patient 2 was administered copper acetate at
8 weeks, followed by copper-EDTA until age 18
162 Christodoulou et al.
months, when copper-histidine treatment was begun.
The circulating free histidine in blood and biological
fluids should account for the formation of copper-
histidine complex when copper acetate or copper chlo-
ride is administered. For example, the normal range of
the free histidine concentration in plasma is 37–117
mM. However, the amount of copper-histidine so
formed would not be as high as the regularly adminis-
tered dose of copper-histidine, primarily due to the
high affinity of copper for albumin in circulating
plasma [Lau and Sarkar, 1971]. In spite of this, these
other copper preparations appear to have been benefi-
cial in patients 1 and 2 in the early stages. Even in the
case of the administration of 1:1 copper-EDTA in pa-
tient 2, the complex is able to freely equilibrate with
available free histidine to form copper-histidine com-
plex. The stability constants of copper-EDTA (log K 4
18.70) and copper-histidine (log K 4 18.45) are compa-
rable [Kruck and Sarkar, 1973; Martell and Smith,
1974].
There were differences in the details of treatment in
the different patients, especially in the early months,
and interesting differences in the outcomes, but it
would be premature to draw conclusions based on such
a small number of cases. However, our experience,
added to the sound physiological basis for the choice of
copper-histidine (it is one of the forms in which copper
is found in the plasma [Sarkar and Kruck, 1966], and is
probably the form in which copper is taken up by the
liver [Sarkar, 1980; Harris and Sass-Kortsak, 1967;
McArdle et al., 1988]), argues for continued use of this
compound in current and future cases. The dosage regi-
mens described should provide a useful guide for phy-
sicians treating other cases.
The delivery of patient 4 at 35 weeks of gestation and
immediate commencement of treatment did not seem
to confer any specific advantage. This action was based
upon experience with brindled mice in which treat-
ment at 7 days is dramatically more effective than
treatment at 10 days [Mann et al., 1979; Wenk and
Suzuki, 1982]. The 35-week human fetus is still more
developed neurologically than a 7-day postnatal mouse,
and consideration could be given to commencing treat-
ment in utero at an earlier stage of gestation. However,
there is a need to consider alternative therapeutic
strategies, and to study further the optimum dosage of
copper-histidine, along with the timing and method of
administration of treatment regimens.
The residual clinical abnormalities in the 4 patients
are interesting and, at least in patients 1 and 4, re-
semble closely those of OHS. They presumably indicate
that this therapy is not delivering an adequate amount
of copper to lysyl oxidase or to dopamine b-hydroxy-
lase. Conversely, these observations lend strong sup-
port to the view that the MD protein must be involved
in the delivery of copper to copper enzymes as well as in
extrusion of copper from cells [Danks, 1986, 1995;
Vulpe and Packman, 1995; Tümer and Horn, 1996].
The dramatic control of chronic diarrhea in patient 4
by L-DOPS presumably indicates that this symptom is
a consequence of peripheral dopamine b-hydroxylase
deficiency. The disparity between relatively good neu-
rological development achieved and the persisting evi-
dence of peripheral dopamine b-hydroxylase deficiency
suggests that central dopamine b-hydroxylase defi-
ciency is not a major contributor to neurological dam-
age in MD and that the administered copper is man-
aging to find its way to this enzyme in the central ner-
vous system. It has never been clear which copper
enzyme deficiency is responsible for the severe neuro-
logical impairment in untreated cases, but cytochrome
oxidase seems the most likely culprit, and the benefi-
cial effects of treatment in the patients described in
this report would suggest that the administered copper
is reaching this enzyme in the brain. The sparing of the
brain in OHS patients and blotchy mice supports the
view that partial residual function of the MD protein is
sufficient for normal brain development, but not for
connective tissues. Copper therapy has not been re-
ported in OHS patients, but is ineffective in blotchy
mice [Mann et al., 1981]. However, the patient reported
by Westman et al. [1988], who is now 19 years old, has
received copper-histidinate since age 8 years [West-
man, personal communication], and the molecular de-
fect in this patient has been reported [Kaler et al.,
1994].
This report highlights the benefits of institution of
copper-histidine therapy in patients with MD before
the onset of significant neurological symptoms, and
emphasizes the importance of using the correct formu-
lation for efficacious results, in terms of bioavailability
of copper. In order to clarify the issue of therapeutic
efficacy of parenteral copper therapy, we advocate the
careful documentation of outcome in early-treated MD
patients.
However, enthusiasm about the use of copper-
histidine treatment in second and subsequent affected
males in MD families should be tempered by caution,
since the residual abnormalities are quite substantial
in all patients, and some of the connective tissue ab-
normalities may become more disabling later in life. At
present, the treatment should still be regarded as ex-
perimental and not yet a serious alternative to preven-
tion by early prenatal diagnosis and termination of af-
fected pregnancies for those who regard this approach
as acceptable. Copper-histidine treatment is worthy of
consideration for couples who cannot accept this ap-
proach.
ACKNOWLEDGMENTS
B.S. was supported by the Medical Research Council
of Canada and the Lunenfeld Foundation of Toronto.
We thank M. Gautam-Basak and K. Lingertat-Walsh
for helpful comments and advice on copper-histidine
formulation.
REFERENCES
Baerlocher KE, Steinmann B, Rao VH, Gitzelmann R, Horn N (1983):
Menkes’ disease: Clinical, therapeutic and biochemical studies. J In-
herited Metab Dis 6:87–88.
Briggs J, Finch P, Matulewicz MC, Weigel H (1981): Complexes of copper
(II), calcium and other metal ions with carbohydrates: Thin layer li-
gand exchange chromatography and determination of relative stabili-
ties. Carbohydr Res 97:181–188.

Byers PH, Siegel RC, Holbrook KA, Narayanan AS, Bornstein P, Hall JG
(1980): X-linked cutis laxa: Defective cross-link formulation in collagen
due to decreased lysyl oxidase activity. N Engl J Med 303:61–65.
Camakaris J, Danks DM, Ackland L, Cartwright E, Borger P, Cotton RG
(1980): Altered copper metabolism in cultured cells from human Men-
kes’ syndrome and mottled mouse mutants. Biochem Genet 18:117–
131.
Chelly J, Tümer Z, Tønnesen T, Petterson A, Ishikawa-Brush Y, Tom-
merup N, Horn N, Monaco AP (1993): Isolation of a candidate gene for
Menkes disease that encodes a potential heavy metal binding protein.
Nat Genet 3:14–19.
Danks DM (1986): Of mice and men, metals and mutations. J Med Genet
23:99–106.
Danks DM (1988): The mild form of Menkes disease: Progress report on the
original case. Am J Med Genet 30:859–864.
Danks DM (1995): Disorders of copper transport. In Scriver CR, Beaudet
AL, Sly WS, Valle D (eds): ‘‘The Metabolic and Molecular Bases of
Inherited Disease,’’ Vol 2, 7th ed. New York: McGraw-Hill, pp 2211–
2235.
Danks DM, Campbell PE, Stevens BJ, Gillespie JM, Walker-Smith J,
Blomfield J, Turner B (1972a): Menkes’ kinky-hair syndrome. Lancet
1:1100–1103.
Danks DM, Campbell PE, Stevens BJ, Mayne V, Cartwright E (1972b):
Menkes’ kinky hair syndrome: An inherited defect in copper absorption
with widespread effects. Pediatrics 50:188–201.
Das S, Levinson B, Whitney S, Vulpe C, Packman S, Gitschier J (1994):
Diverse mutations in patients with Menkes disease often lead to exon
skipping. Am J Hum Genet 55:883–889.
DiDonato M, Sarkar B (1997): Copper transport and its alterations in
Menkes and Wilson diseases. Biochim Biophys Acta 1360:3–16.
Dierick HA, Ambrosini L, Spenser J, Glover TW, Mercer JF (1995): Mo-
lecular structure of the Menkes disease gene (ATP7A). Genomics 28:
462–469.
Farrelly C, Stringer DA, Daneman A, Fitz CR, Sass-Kortsak A (1984): CT
manifestations of Menkes’ kinky hair syndrome (trichopoliodystrophy).
J Can Assoc Radiol 35:406–408.
Garnica AD (1984): The failure of parenteral copper therapy in Menkes
kinky hair syndrome. Eur J Pediatr 142:98–102.
Gautam-Basak M, Gallelli JF, Sarkar B (1993): Formulation of copper-
histidine for the treatment of Menkes disease, a genetic disorder of
copper transport. J Inorg Biochem 51:415.
Gerdes AM, Tønnesen T, Pergament E, Sander C, Baerlocher KE, Wartha
R, Güttler F, Horn N (1988): Variability in clinical expression of Men-
kes syndrome. Eur J Pediatr 148:132–135.
Harris DI, Sass-Kortsak A (1967): The influence of amino acids on copper
uptake by rat liver slices. J Clin Invest 46:659–667.
Herman TE, McAlister WH, Boniface A, Whyte MP (1992): Occipital horn
syndrome: Additional radiographic findings in two new cases. Pediatr
Radiol 22:363–365.
Heydorn K, Damsgaard E, Horn N, Tønnesen T, Mussalo-Rauhamaa H,
Kaitila I (1995): Comparison of trace element distributions in occipital
horn syndrome and Menkes disease with normal subjects by neutron
activation analysis. J Trace Element Exp Med 8:241–247.
Horn N, Tønnesen T, Tümer Z (1992): Menkes disease: An X-linked neu-
rological disorder of the copper metabolism. Brain Pathol 2:351–362.
Horn N, Tønnesen T, Tümer Z (1995): Variability in clinical expression of
X-linked copper disturbance. In Sarkar B (ed): ‘‘Genetic Response to
Metals.’’ New York: Marcel Dekker, pp 285–303.
Hunt DM (1974): Primary defect in copper transport underlies mottled
mutants in the mouse. Nature 249:852–854.
Kaler S (1994): Menkes disease. Adv Pediatr 41:264–304.
Kaler SG, Gallo LK, Proud VK, Percy AK, Mark Y, Segal NA, Goldstein DS,
Holmes CS, Gahl WA (1994): Occipital horn syndrome and a mild Men-
kes phenotype associated with splice site mutations at the MNK locus.
Nat Genet 8:195–202.
Kaler SG, Buist NRM, Holmes CS, Goldstein DS, Miller RC, Gahl WA
(1995): Early copper therapy in classic Menkes disease patients with a
novel splicing mutation. Ann Neurol 38:921–928.
Kaler SG, Das S, Levinson B, Goldstein DS, Holmes CS, Patronas NJ,
Packman S, Gahl WA (1996): Successful early copper therapy in Men-
kes disease associated with a mutant transcript containing a small
in-frame deletion. Biochem Mol Med 57:37–46.
Kreuder J, Otter A, Fuder H, Tümer Z, Tønnesen T, Horn N, Dralle D
Treatment of Menkes Disease 163
(1993): Clinical and biochemical consequences of copper-histidine
therapy in Menkes disease. Eur J Pediatr 152:828–832.
Kruck TPA, Sarkar B (1973): Equilibria of simultaneously existing mul-
tiple species in the copper (II)-histidine system. Can J Chem 51:3549–
3554.
Lau S, Sarkar B (1971): Ternary coordination complex between human
serum albumin, copper (II) and L-histidine. J Biol Chem 246:5938–
5943.
Man in’t Veld AJ, Boomsma F, van den Meiracker AH, Schalekamp MADH
(1987): Effect of unnatural noradrenaline precursor on sympathetic
control and orthostatic hypotension in dopamine-beta-hydroxylase de-
ficiency. Lancet 2:1172–1175.
Mann JR, Camakaris J, Danks DM, Walliczek EG (1979): Copper metabo-
lism in mottled mouse mutants: Copper therapy of brindled (Mobr)
mice. Biochem J 180:605–612.
Mann JR, Camakaris J, Francis N, Danks DM (1981): Copper metabolism
in mottled mouse (Mus musculus) mutants. Studies of blotchy (Moblo)
mice and a comparison with brindled (Mobr) mice. Biochem J 196:81–
88.
Martell AE, Smith RM (1974): ‘‘Critical Stability Constants,’’ Vol 1. New
York: Plenum Press.
Mas A, Sarkar B (1992): Uptake of 67Cu by isolated human trophoblast
cells. Biochim Biophys Acta 1135:123–128.
McArdle JH, Gross SM, Danks DM (1988): Uptake of copper by mouse
hepatocytes. J Cell Physiol 136:373–378.
Mercer JFB, Livingston J, Hall B, Paynter JA, Begy C, Chan-
drasekharappa S, Lockhart P, Grimes A, Bhave M, Siemieniak D,
Glover TW (1993): Isolation of a partial candidate gene for Menkes
disease by positional cloning. Nat Genet 3:20–25.
Nadal D, Baerlocher K (1988): Menkes’ disease: Long-term treatment with
copper and D-penicillamine. Eur J Pediatr 147:621–625.
Procopis P, Camakaris J, Danks DM (1981): A mild form of Menkes’ syn-
drome. J Pediatr 98:97–99.
Royce PM, Camakaris J, Mann JR, Danks DM (1982): Copper metabolism
in mottled mouse mutants. The effect of copper therapy on lysyl oxidase
activity in brindled (Mobr) mice. Biochem J 202:369–371.
Sarkar B (1980): Recent trends in the application of coordination chemistry
in biology and medicine. In Benerjea D (ed): ‘‘IUPAC [International
Union of Pure and Applied Chemistry] Coordination Chemistry,’’ Vol
20. New York: Pergamon Press, pp 191–200.
Sarkar B (1981): Transport of copper. In Sigel H (ed): ‘‘Metal Ions in Bio-
logical Systems,’’ Vol 12. New York: Marcel Dekker, pp 233–281.
Sarkar B (1984): Specificity of metal-binding in normal physiology and
biochemical alterations in disease conditions: Wilson’s and Menkes’
disease. In Arora RB, Vohora SB, Khan MSY (eds): ‘‘First International
Conference on Elements in Health and Disease.’’ New Delhi: Institute
of History of Medicine and Medical Research, pp 27–41.
Sarkar B (1994): Copper-histidine therapy for Menkes disease: A reply. J
Pediatr 125:337–338.
Sarkar B, Kruck T (1966): Copper amino acid complexes in human serum.
In Peisach J, Aisen P, Blumberg W (eds): ‘‘Biochemistry of Copper.’’
New York: Academic Press, pp 182–196.
Sarkar B, Lingertat-Walsh K, Clarke JTR (1993): Copper-histidine therapy
for Menkes disease. J Pediatr 123:828–830.
Sartoris DJ, Luzzatti L, Weaver DD, MacFarlane JD, Hollister DW, Parker
BR (1984): Type IX Ehlers-Danlos syndrome: A new variant with pa-
thognomonic radiographic features. Radiology 152:665–670.
Sherwood G, Sarkar B, Sass-Kortsak A (1989): Copper histidinate therapy
in Menkes’ disease: Prevention of progressive neurodegeneration. J
Inherited Metab Dis [Suppl] 12:393–396.
Tønnesen T, Horn N (1989): Prenatal and postnatal diagnosis of Menkes
disease, an inherited disorder of copper metabolism. J Inherited Metab
Dis 12:207–214.
Tsukahara M, Imaizumi K, Kawai S, Kajii T (1994): Occipital horn syn-
drome: Report of a patient and review of the literature. Clin Genet
45:32–35.
Tümer Z, Horn N (1996): Menkes disease: Recent advances and new in-
sights into copper metabolism. Ann Med 28:121–129.
Tümer Z, Vural B, Tønnesen T, Chelly J, Monaco AP, Horn N (1995):
Characterization of the exon structure of the Menkes disease gene us-
ing Vectorette PCR. Genomics 26:437–442.
Tümer Z, Horn N, Tønnesen T, Christodoulou J, Clarke JTR, Sarkar B
(1996): Early copper-histidine treatment for Menkes disease. Nat
Genet 12:11–13.
164 Christodoulou et al.
Tümer Z, Lund C, Tolshave C, Vural B, Tønnesen T, Horn N (1997): Iden-
tification of point mutations in 41 unrelated patients affected with
Menkes disease. Am J Hum Genet 60:63–71.
Vulpe C, Packman S (1995): Cellular copper transport. Annu Rev Nutr
15:293–322.
Vulpe C, Levinson B, Whitney S, Packman S, Gitschler J (1993): Isolation
of a candidate gene for Menkes disease and evidence that it encodes a
copper-transporting ATPase. Nat Genet 3:7–13.
Wenk G, Suzuki K (1982): The effect of copper supplementation on the
concentration of copper in the brain of the brindled mouse. Biochem J
205:485–487.
Westman JA, Richardson DC, Rennert OM, Morrow G (1988): Atypical
Menkes steely hair disease. Am J Med Genet 30:853–858.
Whitfield DM, Stojkowski S, Sarkar B (1993): Metal coordination to car-
bohydrates. Coord Chem Rev 122:171–225.
Williams DM, Atkin CL, Frens DB, Bray PF (1977): Menkes’ kinky hair
syndrome: Studies of copper metabolism and long term copper therapy.
Pediatr Res 11:823–826.