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Diagnosis of Wilson disease Author Marshall M Kaplan, MD Section Editors Elizabeth B Rand, MD Bruce A Runyon, MD Deputy Editor Anne

C Travis, MD, MSc, FACG Disclosures Last literature review version 19.3: septiembre 2011 | This topic last updated: diciembre 14, 2010 (More) INTRODUCTION Wilson disease (hepatolenticular degeneration) is an autosomal recessive defect of cellular copper export. Reduced biliary excretion leads to accumulation of copper, initially in the liver and then in other tissues, particularly the brain. Tissue copper deposition causes a multitude of signs and symptoms that reflect hepatic, neurologic, hematologic, and renal impairment. The incorporation of copper into ceruloplasmin is also impaired. Patients most often present with liver disease (which can range from an asymptomatic elevations in the serum aminotransferase or bilirubin concentrations to fulminant hepatic failure to chronic hepatitis) or with neuropsychiatric disease [1]. (See "Pathogenesis and clinical manifestations of Wilson disease".) The diagnosis of Wilson disease will be reviewed here, while treatment issues are discussed separately. (See "Treatment of Wilson disease".) A consensus guideline from the American Association for the Study of Liver Diseases (AASLD) has also been published [2,3]. The guideline as well as other AASLD guidelines, can be accessed through the AASLD web site at http://www.aasld.org/practiceguidelines/Pages/default.aspx. DIAGNOSIS The diagnosis of Wilson disease is based upon the clinical setting combined with compatible, biochemical, histologic and physical findings. The classical presentation (a patient who is between the ages of 5 and 40 with a decreased serum ceruloplasmin and detectable Kayser-Fleischer rings) represents only about one-half of patients ultimately diagnosed with Wilson disease [4]. Recommendations from the AASLD Recommendations for diagnosis of Wilson disease have been proposed in a guideline issued by the AASLD. The proposed recommendations differ depending upon whether Wilson disease is being considered in a patient with unexplained liver disease or in a patient with a neurological disorder or psychiatric disease without known liver disease (table 1 and algorithm 1 and algorithm 2) [2,3]. Age As noted above, most patients present between the ages of five and 40. However, the range of ages in case reports spans from age three to 80 [5-7]. Thus, age alone should not be used as the basis for excluding the diagnosis. Kayser-Fleischer rings Patients in whom Wilson disease is suspected should have a slit-lamp examination for detection of Kayser-Fleischer rings. Kayser-Fleischer rings are brownish or graygreen rings that represent fine pigmented granular deposits of copper in Descemet's membrane in the cornea close to the endothelial surface; copper is primarily deposited in a granular complex with sulfur, which gives the ring its color. They are usually most pronounced at the inferior and superior

poles of the cornea (picture 1). Some healthy patients have a dark ring that appears to be in the cornea when examined under moderate magnification in ambient light. Such rings are not Kayser-Fleischer rings, which are best identified under slit-lamp examination. The likelihood of a positive test appears to be related to the type of presentation: rings are present in approximately 50 to 60 percent of patients who present with isolated hepatic involvement compared with more than 90 percent of patients who present with neurologic involvement [4,5,8-11]. However, the absence of Kayser-Fleischer rings does not exclude the diagnosis even in patients with neurologic disease. Furthermore, Kayser-Fleischer rings are not absolutely specific for Wilson disease, having been rarely reported in other chronic cholestatic diseases such as primary biliary cirrhosis and in children with neonatal cholestasis [12]. Kayser-Fleischer rings gradually disappear with effective medical treatment for Wilson disease or following liver transplantation. Their reappearance suggests noncompliance with therapy. Sunflower cataracts Kayser-Fleischer rings are not the only ocular manifestation of Wilson disease. Sunflower cataracts (which represent copper deposits in the lens) may also be seen by slitlamp examination [13,14]. Their prevalence in Wilson disease is not well-established. Like KayserFleischer rings, the cataracts gradually disappear with treatment of the Wilson disease. Neuropsychiatric disease Neurologic disorders are present in up to 35 percent of patients with Wilson disease. Signs include a Parkinsonian-like tremor, rigidity, clumsiness of gait, slurring of speech, inappropriate and uncontrollable grinning (risus sardonicus), and drooling. Approximately 10 percent of patients present with psychiatric problems ranging from subtle personality changes and deteriorating performance at school, to overt depression, paranoia, and catatonia. (See "Pathogenesis and clinical manifestations of Wilson disease".) Serum aminotransferases Serum aminotransferases are usually mildly to moderately elevated in patients with Wilson disease, including children and other patients diagnosed in a presymptomatic stage. The AST concentration is usually higher than the ALT. The degree of elevation correlates poorly with the extent of histologic injury [15,16]. Serum ceruloplasmin concentration Most patients with Wilson disease have low serum ceruloplasmin levels. A very low level (<50 mg/L or <5 mg/dL) provides strong evidence for the diagnosis of Wilson disease. However, the serum ceruloplasmin level alone does not reliably establish or exclude the diagnosis. Further testing, usually urinary copper excretion, assessment for KayserFleischer rings, or liver biopsy, is required. Ceruloplasmin is a 132-kd protein synthesized by hepatocytes and secreted into the circulation. Ceruloplasmin is the major carrier of copper in the blood and each molecule of ceruloplasmin can carry six copper atoms. Ceruloplasmin bound to copper is referred to as holoceruloplasmin (representing most of secreted ceruloplasmin) while unbound ceruloplasmin is referred to as apoceruloplasmin. The genetic mutations causing Wilson disease (involving the P-type ATPase (ATP7B)) impair the hepatic incorporation of copper into apoceruloplasmin to form ceruloplasmin, leading to a reduction in the serum ceruloplasmin concentration. (See "Pathogenesis and clinical manifestations of Wilson disease".) Normal values for serum ceruloplasmin vary by age. They are low during early infancy to approximately six months, peak in early childhood to levels higher than in adulthood (approximately

30 to 50 mg/dL) then decline to the adult range (20 to 35 mg/dL). There are conditions that can increase serum ceruloplasmin levels, eg, cholestatic liver diseases and the use of birth control pills. A serum ceruloplasmin concentration less than 20 mg/dL in a patient who also has Kayser-Fleischer rings is considered to be diagnostic. In most series of patients with Wilson disease, approximately 85 to 90 percent of patients have serum ceruloplasmin concentrations below 20 mg/dL [1,9,17]. Among patients with less specific clinical manifestations, a serum ceruloplasmin level below 5 mg/dL should be considered as highly suspicious for Wilson disease. Potential problems Serum ceruloplasmin alone has a low positive predictive value in patients undergoing evaluation for liver disease. One of the largest prospective studies to address this issue focused on 2867 patients undergoing evaluation for liver disease of whom 17 had a low serum ceruloplasmin (<20 mg/dL). Only one of these patients was ultimately diagnosed with Wilson disease (positive predictive value of 6 percent) [18]. The other patients had a variety of conditions:

Heterozygous carriers three patients Acute viral hepatitis three patients Chronic hepatitis two patients Drug-induced liver disease three patients Alcohol-induced liver disease two patients Malabsorption three patients

Multiple other series have demonstrated high, low, and normal values in adults and children with and without Wilson disease [4,5,19-21]. One cause of normal serum ceruloplasmin in some patients with Wilson disease is the presence of acute inflammation in the liver, which can increase serum values to the normal range. Other causes include pregnancy, during estrogen supplementation, and with use of oral contraceptives [1]. As noted above, a variety of conditions can lead to low serum ceruloplasmin levels other than Wilson disease. These include:

Disorders that cause marked renal or enteric protein loss such as nephrotic syndrome or protein-losing gastroenteropathy (such as celiac disease) as well as severe end-stage liver disease of any cause. Approximately 10 to 20 percent of asymptomatic heterozygote carriers have serum ceruloplasmin levels less than 20 mg/dL. Certain rare diseases such as Menkes disease (an X-linked disorder of copper transport), aceruloplasminemia (a rare disorder associated with mutations in ceruloplasmin causing it not to be synthesized), and copper deficiency in patients receiving inadequate copper with parenteral nutrition [21-23].

The method used for measuring ceruloplasmin may also influence the results. Serum ceruloplasmin can be determined enzymatically, by antibody-dependent assays, radial immunodiffusion, and nephelometry. The results are generally similar except the immunologic and the immunodiffusion assays, which may overestimate the ceruloplasmin levels since they do not discriminate between apoceruloplasmin and holoceruloplasmin [24]. Determination of ceruloplasmin activity using a method based on oxidation of 0-dianisidine dihydrochloride had sensitivity and specificity of 94 and 100 percent in one report but more studies are needed [25]. Serum copper concentration While total copper body stores are increased in Wilson disease, serum copper is decreased in proportion to the reduction in serum ceruloplasmin. Measurement of serum copper levels includes both ceruloplasmin-bound and nonceruloplasmin-bound copper. Elevated or

normal levels of serum copper in the setting of a decreased serum ceruloplasmin indicates that the concentration of nonceruloplasmin-bound copper is increased. Serum nonceruloplasmin-bound copper levels are greater than 25 mcg/dL in the majority of untreated patients with Wilson disease (normal <15 mcg/dL). Marked elevation may be seen in fulminant hepatic failure due to Wilson disease, where copper is released suddenly from tissue stores. Although the concentration of nonceruloplasmin-bound copper has been proposed as a marker of Wilson disease, its interpretation can cause confusion since it is not usually measured directly. The concentration of nonceruloplasmin-bound copper can be estimated from the serum total copper and serum ceruloplasmin concentrations [2]. There is approximately 3.15 mcg of copper per mg of ceruloplasmin. Thus, nonceruloplasmin bound copper can be approximated by the difference between the serum copper concentration (in mcg/dL not mg/dL) and the serum ceruloplasmin concentration multiplied by 3.15. When expressed in SI units, the serum copper and ceruloplasmin levels should be expressed as mcg/L; the conversion factor is still 3.15. The non-ceruloplasmin-bound copper can also be measured directly with atomic absorption [26]. The sensitivity, specificity, and predictive values of the nonceruloplasmin-bound copper concentration as a diagnostic test for Wilson disease have not been well-established. Values may be influenced by a variety of conditions. In particular, levels may be elevated in acute liver failure of any etiology and in patients with chronic cholestasis while decreased values have been reported in patients overusing zinc supplements [21,27,28]. In addition, values depend upon the specific methods used for measuring copper and ceruloplasmin. These uncertainties suggest that the best use of serum copper determinations is probably for monitoring patients on therapy rather than for the diagnosis of Wilson disease. Urinary copper excretion Urinary copper excretion is useful for the diagnosis of Wilson disease and for monitoring therapy. Wilson disease is typically associated with 24-hour urinary copper excretion of >100 mcg (>1.6 micromol), although lower values have been described in up to 25 percent of presymptomatic patients with confirmed disease [19,29]. Values in the Wilson disease range can also be seen in patients with other forms of chronic active liver disease [20,30]. The collection should be made during a 24-hour period; spot urine collections have too much variability to be reliable. Normal values vary among laboratories but are in the range of 30 to 40 mcg/day (450 to 600 nanomol/day) [5]. A value >40 mcg/day (>600 nanomol/day) warrants further investigation [31]. Care should be taken to avoid copper contamination of the urine collection containers. The container should be rinsed with distilled (not tap) water. In addition, a small amount of hydrochloric acid (30 mL of 6N solution) is usually added to prevent the precipitation of copper hydroxide and thereby obtain falsely low urinary copper values, which occurs when the urine is alkaline. Urinary creatinine should also be measured to help assure the completeness of the collection. (See "Patient information: Collection of a 24-hour urine specimen".) Penicillamine challenge Because urinary copper excretion can be increased in a variety of liver diseases, penicillamine challenge has been proposed as a means to increase specificity. Penicillamine greatly increases urinary copper excretion in patients with Wilson disease and to a lesser extent in patients with other forms of liver disease. The challenge test has been best-studied in children [21,32]. A 500 mg dose of penicillamine is given at the beginning and then again at 12 hours during a 24 hour urine collection. Urinary copper excretion greater than 1600 mcg per 24 hours (>25 micromol) is much more likely in Wilson disease compared with other types of liver disease.

In the largest validation study, the challenge test was performed in 75 consecutive children with a variety of liver problems of whom 17 were ultimately diagnosed with Wilson disease [21]. Serum ceruloplasmin and total copper levels were significantly lower in patients with Wilson disease compared with other groups, but three children had normal ceruloplasmin levels while seven had normal total copper levels. No significant difference was found between nonceruloplasmin bound copper and hepatic copper levels in patients with Wilson disease compared to those with other causes of liver disease. Similarly, baseline 24 hour urinary copper excretion was significantly higher in Wilson disease patients compared with controls, but six patients had values that overlapped with those seen in other causes of liver disease. Specificity increased following penicillamine challenge; urinary copper excretion greater than 1600 mcg per 24 hours (>25 micromol) was found in 15 of 17 patients with Wilson disease compared with only 1 of 58 with other disorders (sensitivity and specificity of 88 and 98 percent, respectively). The penicillamine-challenge is unreliable to exclude the diagnosis in asymptomatic siblings, has not been evaluated for differentiating heterozygous carriers from affected homozygotes, has not been as wellstandardized in adults, and is not used commonly [4,30,33]. Recommendations from the AASLD are described above. (See 'Recommendations from the AASLD' above.) Hepatic copper concentration Quantitative hepatic copper determination in patients with Wilson disease usually reveals more than 250 mcg of copper per gram of dry weight (normal <50 mcg per gram of dry weight) [34]. This is generally considered to be the gold standard for diagnosis. However, normal hepatic copper concentration has been described in patients with Wilson disease [4]. There are several possible explanations for this occurrence:

Reports describing such patients may have been limited by use of older laboratory equipment and use of insufficiently sized specimens. There can be variability in copper distribution within the liver with fibrosis and cirrhosis contributing to sampling error [35,36]. In one study of patients with fulminant hepatic failure, for example, the liver removed at the time of transplantation showed a 500-fold variation in copper distribution in different areas of the liver that were evaluated [36]. In patients with fulminant hepatic failure, massive release of copper from necrotic hepatocytes can lead to normal tissue concentration in biopsy material.

One of the largest studies to evaluate test characteristics of hepatic copper determination compared hepatic copper content from 114 liver biopsies of patients with Wilson disease with 219 patients with noncholestatic liver disease and 26 patients without liver disease (a liver biopsy had been performed for various reasons but no liver disease was found) [37]. The following observations were made:

Liver copper content was >250 mcg/g in 95 patients with Wilson disease (sensitivity 83 percent) but was between 50 and 250 mcg/g in 15 patients and below 50 in 4. It did not correlate with age, the grade of fibrosis, or the presence of stainable copper. Among patients with noncholestatic liver disease, liver copper content was >250 mcg/g in 3 patients (1.4 percent) and between 50 and 250 mcg/g in 20 patients (9.1 percent). Among patients without liver disease, the average hepatic copper content was 35 mcg/g (95% CI 12.5-80.8 mcg/g); only two patients with WD fell into the 95% CI of the control subjects.

Thus, using a cutoff of 250 mcg/g, the sensitivity and specificity for diagnosis of WD were 83 percent (95% CI 75-90%) and 99 percent (95% CI 96-100%). Lowering the cutoff value to 75 mcg/g increased sensitivity but sacrificed specificity (97 and 95 percent, respectively). Because of potential errors in evaluation of hepatic copper concentration, the hepatic copper concentration should always be evaluated in the context of other diagnostic criteria. Wilson disease

has not been excluded in patients who have a hepatic copper concentration less than 250 mcg/g since approximately 15 percent of WD patients fall below this cutoff. On the other hand, a copper concentration greater than 250 mcg of copper per gram of dry weight is virtually diagnostic unless the patient has chronic cholestatic liver disease. These disorders are usually clinically distinct from Wilson disease. Liver histology Histologic findings in patients with Wilson disease are similar to those of autoimmune hepatitis and nonalcoholic steatohepatitis (NASH). Early findings include fatty infiltration within hepatocytes, glycogen inclusions within nuclei, and portal fibrosis (picture 2). A histologic stain for copper deposition can be suggestive. However, copper stains have limited sensitivity; thus, the absence of copper staining does not exclude the diagnosis. Wilson disease should be considered in patients who respond poorly to standard therapy for autoimmune hepatitis. (See "Pathogenesis and clinical manifestations of Wilson disease", section on 'Pathology'.) Genetic testing Genetic testing for Wilson disease became feasible with characterization in 1993 of a genetic defect in a copper transporting ATPase [38-40]. However, the abundance of diseasespecific mutations and their location at multiple sites across the genome have limited molecular diagnosis to kindreds of known patients. Gene tests for Wilson disease are based upon the pattern of di- and trinucleotide repeats around ATP7B. Identification of a specific mutation in a proband allows for genetic testing of first-degree relatives. Thus, screening first-degree relatives with genetic testing is reasonable when a specific mutation in the proband can be identified. (See 'Summary and recommendations' below.) Mutation analysis is not available commercially in the United States. However, haplotype (linkage) analysis is available at some laboratories (Center for Human Genetics, Boston University School of Medicine 617 638-7083). Haplotype analysis can be performed only in families with at least two affected full siblings (and is only applicable to full siblings) where it can be useful for establishing a diagnosis in other full siblings. The pattern of genetic markers around ATP7B in both chromosomes are determined and compared to the same markers in both chromosomes of the affected proband to determine genotypes. Siblings with two matches are affected, those with one are carriers, and those with none are homozygous normal. A positive linkage analysis predicts Wilson disease with 99 percent accuracy in the full sibling. Genetic testing should be discussed with a qualified genetic counselor. In some populations with a higher frequency of a predominant mutation, diagnosis of Wilson disease by screening for specific mutations may be an option. Predominant mutations, for example, have been described in several discreet geographic areas including in Sardinia, Iceland, Korea, Japan, the Canary Islands, and in some Eastern European populations [33,41-45]. An updated list of Wilson mutations can be found on the internet (www.uofa-medical-genetics.org). FULMINANT LIVER FAILURE Patients with fulminant hepatic failure from Wilson disease are often children or young adults; they usually have an associated hemolytic anemia as the hepatocellular necrosis results in the release of copper ions into the circulation. This presentation may be associated with hemoglobinuria, dark urine, and renal failure, has an ominous prognosis, and is considered an indication for urgent liver transplantation. Most patients have not previously been diagnosed with Wilson disease. The trigger that initiates these events is not well-understood but is thought to be an intercurrent illness such as a viral infection or possibly drug toxicity [46]. (See "Pathogenesis and clinical manifestations of Wilson disease".)

According to a guideline from the AASLD, the following features should considered when the diagnosis of fulminant hepatic failure due to Wilson disease is suspected [2]:

Coombs-negative hemolytic anemia with features of acute intravascular hemolysis Coagulopathy unresponsive to vitamin K Rapidly progressive renal failure Serum aminotransferases typically less than 2,000 IU/L (AST often greater than ALT) Normal or markedly subnormal alkaline phosphatase (<40 IU/L) (see "Enzymatic measures of cholestasis (eg, alkaline phosphatase, 5-nucleotidase, gamma-glutamyl transpeptidase)")

Diagnosis in the setting of fulminant hepatic failure requires a high index of suspicion, since many of these features can be seen in fulminant hepatic failure due to viral or toxic causes. The relatively modest elevation in aminotransferases and low serum alkaline phosphatase may provide clues. One series suggested that the ratio of alkaline phosphatase (in IU/L) to total serum bilirubin (in mg/dL) is typically less than two [47]. Serum ceruloplasmin levels are usually decreased, while urinary copper and serum copper are increased. Kayser-Fleischer rings are present in approximately one-half of patients. SCREENING FAMILY MEMBERS First-degree relatives of patients diagnosed with Wilson disease should be screened. Recommendations for screening have been suggested in a guideline from the AASLD (algorithm 3). Appropriate screening includes a history and physical examination, liver biochemical tests, complete blood count, serum ceruloplasmin, slit-lamp examination for KayserFleischer rings, 24 hour basal urinary copper determination, and genotyping studies based upon the proband. We usually perform the first four tests (ie, history and physical, liver biochemical tests, complete blood count and serum ceruloplasmin) and proceed with further testing only in patients with suggestive features. SUMMARY AND RECOMMENDATIONS

Guidelines for diagnosis and screening have been proposed by the American Association for the Study of Liver Diseases (table 1 and algorithm 3 and algorithm 1 and algorithm 2). We suggest that patients in whom Wilson disease is suspected undergo initial screening with liver biochemical tests, a complete blood count, serum ceruloplasmin, 24-hour basal urinary copper, and slit-lamp examination for Kayser-Fleischer rings. A serum ceruloplasmin concentration less than 20 mg/dL in a patient who also has KayserFleischer rings is considered to be diagnostic. In most series of patients with Wilson disease, approximately 85 to 90 percent of patients have serum ceruloplasmin concentrations below 20 mg/dL. Among patients with less specific clinical manifestations, a serum ceruloplasmin level below 5 mg/dL should be considered as highly suspicious for Wilson disease. (See 'Diagnosis' above.) We suggest that patients without Kayser-Fleischer rings but with abnormal liver biochemical tests or 24 hour urine copper excretion of >40 mcg (>600 nanomol) undergo a liver biopsy with stains for copper and quantitative copper determination. The diagnosis is established with a copper concentration of >250 mcg/g dry weight and consistent liver histology. We suggest that patients who have Kayser-Fleischer rings but have a normal serum ceruloplasmin undergo a liver biopsy with stains for copper and quantitative copper determination. The diagnosis of fulminant Wilson disease should be considered in the clinical setting described above. (See 'Fulminant liver failure' above.) Relatively low serum aminotransferases (less than 2000 IU/L), a low serum alkaline phosphatase (<40 IU/L) and a Coombs negative hemolytic anemia, if present, are suggestive of possible Wilson disease.

Genetic testing to confirm the diagnosis is a reasonable option, although a specific mutation will not be identified in all patients. Commercially available gene tests for Wilson disease are based upon the pattern of di- and trinucleotide repeats around ATP7B. Identification of a specific mutation in a proband allows for genetic testing of first-degree relatives. Genetic linkage analysis (applicable only to full siblings) is available in some laboratories as noted above. Patients in whom genetic testing is considered should be referred to a qualified genetic counselor. First-degree relatives of patients diagnosed with Wilson disease should be screened. Appropriate screening includes a history and physical examination, liver biochemical tests, complete blood count, serum ceruloplasmin, slit-lamp examination for Kayser-Fleischer rings, 24 hour basal urinary copper determination, and genotyping studies based upon the proband. We usually perform the first four tests (ie, history and physical, liver biochemical tests, complete blood count, and serum ceruloplasmin) and proceed with further testing only in patients with suggestive features.

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