INITIAL ASSESSMENT FINDINGS IN PATIENTS WITH CONFIRMED WILSON’S DISEASE

Bacground. The optimization of Wilson’s disease (WD) diagnosis is one of the most disputable problem. Objective. The retrospective study of initial assessment findings under clinical suspicion for WD in 102 patients with the confirmed diagnosis. Material and methods. The results of laboratory tests and Kaiser-Fleischer rings (KF rings) identification under clinical suspicion for WD in 102 patients with the confirmed diagnosis. Results. At stage I, 17 patients (16.7%; 95% CI 10.7–25.1) were defined as having clinically definitive WD based on the combination of low serum ceruloplasmin and KF rings, 4 patients (3.9%; 95% CI 1.5–9.7) – based on the drop of ceruloplasmin level. After stage II, involving 24-hour urinary copper excretion evaluation, the rate of definitive diagnosis of WD reached 24,5% (95% CI 17.2 33.7). After stage III (genotyping for carriage of ATP7B gene mutations) – 56.9% (95% CI 47.2–66.0). Serum free copper increase was found in 54.9% (95% CI 41.4 67.7) of cases. Conclusions. Under clinical suspicion for WD, initial structured ophthalmological, laboratory and molecular-genetic assessment ensured the diagnosis of WD only in 56.9% (95% CI 56.9; 47.2–66.1). Frequent detection of serum free copper increase (54.9%, 95% CI 41.4 67.7) allows to use this test due to its greater availability as compared with 24-hour urinary copper excretion evaluation in WD diagnostics.

Correlation Factors and a Predictive Model of Serum Ceruloplasmin Normalized Wilson’s Disease

Background: The false increase of ceruloplasmin (Cp) in some Wilson’s disease (WD) patients, which overlaps with those in non-WD liver disease patients, decrease the diagnostic accuracy. The aims of our study was to understand the factors affecting WD patients’ Cp normalization, and develop a model using routine predictors to identify WD patients with ambiguous serum Cp.Results: The mixed effects model analysis which executed in longitudinal study revealed that the WD patients’ Cp normalization were significantly associated with the copper burden and liver function indexes, like urinary copper treated with dimercaptopropansulfonate sodium (P=0.000), aspartate aminotransferase (P=0.011), γ-glutamyltransferase (P=0.000), albumin (P=0.000). Multivariate logistic regression analysis in case-control study showed age (P=0.000) and serum creatine (P=0.000) were independent risk factors associated with WD. Based on their regression coefficients, a simplified WD index was derived: 0.001 × age [yr] × Creatine [umol/L]. The AUC value of WD index in total cohort were 0.923 (P=0.000). At a WD index cutoff value of ≤ 1.9 and ≤ 2.5, the positive and negtive predictive value are 88.2% and 89.9% for WD, respectively.Conclusions: The increase of serum Cp in WD patients is related to their excessive copper burden and hepatic injury, common tests can effectively foretell those WD patients with nearly normal serum Cp from other liver injury patients.

Genetic and clinical characteristic of Wilson-Konovalov disease in the Siberian region

Болезнь Вильсона-Коновалова - редкое аутосомно-рецессивное заболевание, которое характеризуется патологическим накоплением меди в печени, головном мозге и других тканях. Дифференциальная диагностика болезни Вильсона-Коновалова представляет собой сложную задачу вследствие выраженной гетерогенности клинических проявлений. Это подчеркивает важность разработки как новых методов диагностики, так и усовершенствования существующих. В рамках настоящего исследования было проведено сравнение клинической диагностики заболевания с результатами молекулярно-генетических исследований. Проанализировано 42 пациента с подозрением на болезнь Вильсона-Коновалова. Произведена оценка значения биохимических показателей метаболизма меди (концентрация церулоплазмина, щелочной фосфатазы, общего билирубина, АСТ, АЛТ сыворотки крови, содержание меди в печени, экскреция меди с мочой) согласно Лейпцигской количественной шкале. Для молекулярно-генетического анализа использовали геномную ДНК. Обогащение интересуемых регионов генома проводилось с помощью ПЦР длинных фрагментов. Для подготовки ДНК библиотек был использован набор Nextera DNA Flex (Illumina, США). Секвенирование проводилось на приборе Illumina MiSeq (Illumina, США). В результате исследования в 62,5% случаев у пациентов, направленных на подтверждение диагноза (по Лейпцигской количественной шкале), были найдены мутации в гене ATP7B, что подтверждает ценность комплексной диагностики по Лейпцигской количественной шкале с учетом клинической симптоматики и лабораторных показателей метаболизма меди. Wilson’s disease is a rare autosomal recessive disorder characterized by abnormal accumulation of copper in the liver, brain, and other tissues. Wilson’s disease differential diagnosis is a difficult task due to the pronounced clinical heterogeneity. This emphasizes the importance of developing both new diagnostic methods and improving existing ones. As part of this study, we compared clinical diagnostics with the results of molecular genetic studies. We analyzed 42 patients with suspected Wilson’s disease. The biochemical parameters copper metabolism values were assessed (serum ceruloplasmin concentration, liver copper content, urinary copper excretion, alkaline phosphatase, total bilirubin, AST, ALT) according to the Leipzig quantitative scale. We used genomic DNA for molecular genetic analysis. Regions of interest in the genome was enriched using long-range PCR. The Nextera DNA Flex kit (Illumina, USA) was used to prepare DNA libraries. Sequencing was performed on an Illumina MiSeq device (Illumina, USA). As a result of the study, in 62.5% of cases in patients aimed at confirming the diagnosis (according to the Leipzig quantitative scale), we found mutations in the ATP7B gene, which confirms the value of a comprehensive diagnosis according to the Leipzig quantitative scale, taking into account the clinical symptoms and copper metabolism laboratory parameters.

Aceruloplasminemia: MRI and Biochemical Profile Clue to Early Diagnosis in an Adolescent

Aceruloplasminemia (ACP) is a rare autosomal recessive genetic disorder with systemic and brain iron overload, secondary to ceruloplasmin gene mutation, usually presents in adults with neurological manifestations. An abnormal biochemical profile may be the only clue in an adolescent patient, that is, microcytic anemia, low transferrin saturation, hyperferritinemia, and should warrant a possible diagnosis of ACP, which can be established by low serum ceruloplasmin levels and appropriate genetic testing. We present a case of an adolescent patient in whom ACP was suspected when brain magnetic resonance imaging showed iron overload in basal ganglia, thalami, red nuclei, dentate nuclei, and choroid plexus and later on confirmed by biochemical profile. The final diagnosis was confirmed by the presences of a novel mutation on genetic analysis. To the best of our knowledge, our case is the second description of ACP with choroid plexus hemosiderosis.We proposed in this article that the combination of parenchymal and choroid plexus iron overload should prompt the suspicion of ACP.

Assessment of Diagnostic Value of Serum Ceruloplasmin for Wilson’s Disease in Children

Background: Serum ceruloplasmin is one of the major diagnostic parameters for Wilson’s disease (WD). Age and gender difference of serum ceruloplasmin remain controversy. This study aims to assess diagnostic value of serum ceruloplasmin for WD in children. Methods: Serum ceruloplasmin were measured in 317 WD patients, 21 heterozygotes, 372 healthy control children and 154 non-WD patients. Receiver operating characteristic (ROC) curve was used to determine the diagnostic accuracy of serum ceruloplasmin for WD in children. Results: Among healthy controls, serum ceruloplasmin was mildly low in the infants younger than 6 months, and then presented around 26–33 mg/dl from 6 months to 15 years. Few (8.1%) of healthy children had serum ceruloplasmin < 20 mg/dL. Serum ceruloplasmin was 5.7 ± 4.7 mg/dl in WD patients, 25.6 ± 5.9 mg/dl in heterozygous carriers. Only 1.9% of WD patients had serum ceruloplasmin > 20 mg/dL. Serum ceruloplasmin had gender difference, higher in healthy boys than healthy girls, and also higher in asymptomatic WD boys than asymptomatic WD girls (p < 0.01, p < 0.05). Serum ceruloplasmin presented genotypic difference. WD patients with R778L homozygotes exhibited lower level of serum ceruloplasmin than WD patients without R778L (p < 0.05). The ROC curve revealed that serum ceruloplasmin, at a cutoff value of 16.8 mg/dL, had the highest AUC value (0.990) with a sensitivity of 95.9% and a specificity of 93.6%. Conclusions: Serum ceruloplasmin is a reliable diagnostic criteria for WD in children. Gender and genotypic difference of serum ceruloplasmin should be considered. The cutoff value of serum ceruloplasmin < 16.8 mg/dL may provide the highest accuracy for diagnosis of WD in children.

Case Report: Using basic liver function tests as a guide to suspected Wilson’s disease

We present a case of a 36-year-old female patient who presented with subacute liver disease with a history of alcohol abuse. On basic liver function tests (LFT), she had aspartate transaminase / alanine transaminase > 2.2 and alkaline phosphatase / total bilirubin < 4. This pattern in acute liver failure patients signifies Wilson’s disease. Its presence in our patient with subacute liver disease also prompted us to suspect Wilson’s disease and we extended the liver disease screen to include slit lamp eye examination for Kayser-Fleischer rings, serum ceruloplasmin and 24-hour urinary copper level, which led to the diagnosis. She improved clinically and biochemically with zinc acetate therapy. As screening for rare diseases is not always possible in low-income countries, this case demonstrates the usefulness of the basic LFT as a guide for suspecting Wilson’s disease in patients with liver disease.

The Ameliorative Effects of Arctiin and Arctigenin on the Oxidative Injury of Lung Induced by Silica via TLR-4/NLRP3/TGF-β Signaling Pathway

Silicosis remains one of the most serious diseases worldwide, with no effective drug for its treatment. Our research results have indicated that arctiin and arctigenin could increase the mitochondrial membrane potential, which in turn reduces the production of reactive oxygen species (ROS), blocks the polarization of macrophages, and inhibits the differentiation of myofibroblasts to reduce oxidative stress, inflammation, and fibrosis. Further, our study revealed that arctiin and arctigenin suppressed the activation of NLRP3 inflammasome through the TLR-4/Myd88/NF-κB pathway and the silica-induced secretion of TNF-α, IL-1β, TGF-β, and α-SMA. Besides, the silica-induced increase in the levels of serum ceruloplasmin and HYP was also inhibited. Results of metabolomics indicated that arctiin and arctigenin could regulate the abnormal metabolic pathways associated with the development of silicosis, which involve pantothenate and CoA biosynthesis, cysteine and methionine metabolism, linoleic acid metabolism, and arginine and proline metabolism successively. Furthermore, the analysis of metabolomics, together with network topological analysis in different phases of silicosis, revealed that urine myristic acid, serum 4-hydroxyproline, and L-arginine could be regarded as diagnosis biomarkers in the early phase and formation of pulmonary fibrosis in the latter phases of silicosis. Arctiin and arctigenin could downregulate the increased levels of myristic acid in the early phase and serum 4-hydroxyproline in the latter phase of silicosis. Interestingly, the integration of TLR-4/NLRP3/TGF-β signaling and metabolomics verified the importance of macrophage polarization in the silicosis fibrosis process. To the best of our knowledge, this is the first study reporting that arctiin and arctigenin both can ameliorate silicosis effectively, and the former is a little stronger than its aglycone arctigenin because of its high oral bioavailability, low toxicity, and multimolecular active metabolites as determined by AdmetSAR and molecular docking analysis.

Peculiarities of clinical course of Wilson's disease in children

Purpose — to discover peculiarities of Wilson disease course in children dependently on the variant of liver affection. Materials and methods. Anamnesis of the disease and clinical and paraclinical peculiarities of the course of the disease with consideration of liver affection severity have been studied in 50 children aged 5–17 years. Results. It was estimated that in 52% of children the disease had a form of chronic hepatitis with minimal clinical symptoms, 44% of patients had liver cirrhosis with predominant signs of edematous and ascitic syndrome and 4% had fulminant hepatitis in a debut of the disease. Complicated family anamnesis was detected in 4% of patients. Syndrome of cytolysis predominated in patients with liver damage in the form of chronic hepatitis (р<0.05). Typical biochemical changes in cirrhotic patients were hepatocellular insufficiency with hypoalbuminemia and coagulopathy, hyperbilirubinemia and minimal hypertransaminasemia (р<0.05). Children with cirrhosis in contrast to patients with chronic hepatitis had reliably lower serum ceruloplasmin concentration and reliably higher excretion of copper with urine. Specific for Wilson disease Kayser—Fleischer rings were found out in 36% of patients only. Conclusions. Wilson's disease in children is characterized by progressing course in the form of either chronic hepatitis or liver cirrhosis or, rarely, fulminant hepatitis. Clinical and paraclinical symptoms of the disease are estimated by the severity of liver affection and vary from a course with minimal symptoms in patients with chronic hepatitis to edematous and ascitic syndrome and hepatocellular insufficiency in patients with cirrhosis and fulminant hepatitis. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local Ethics Committee of all participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: Wilson's disease, children, chronic hepatitis, liver cirrhosis, course of the disease.

Co-occurrence of Wilson’s disease and systemic lupus erythematosus: a case report and literature review

Background Wilson’s disease (WD) is a rare autosomal recessive disease associated with defective biliary excretion of copper. The simultaneous occurrence of WD and systemic lupus erythematosus (SLE) has seldom been reported. Therefore, this study aimed to report the co-occurrence of SLE and WD with hepatic involvement in a patient so as to improve the understanding of the coexistence of these two conditions. Case presentation A 35-year-old woman with SLE was found to have liver fibrosis during a routinely abdominal ultrasound examination. Her laboratory evaluation showed low serum ceruloplasmin and high 24 h urine copper levels. The slit-lamp examination revealed the presence of Kayseri–Fleischer ring in her cornea. Liver biopsy demonstrated the enlargement of the portal area with hyperplasia of the fibrous tissue, infiltration of lymphoid plasma cells, swelling of hepatocytes, and steatosis, demonstrating liver fibrosis. Ensuing genetic testing confirmed the diagnosis of WD. Conclusions Clinicians should bear in mind that unexplained liver fibrosis in patients with SLE may be related to WD, so as to avoid a missed or delayed diagnosis.