A Pediatric Case of a D-Penicillamine Induced ANCA-associated Vasculitis Manifesting a Pulmonary-Renal Syndrome

D-penicillamine has been reported to cause antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis presenting as rapidly progressive glomerulonephritis or pulmonary-renal syndrome mostly in adults. We report a pediatric case of D-penicillamine induced ANCA-associated vasculitis that manifests as a pulmonary-renal syndrome with a mild renal manifestation. A 13-year-old girl who has been taking D-penicillamine for five years under the diagnosis of Wilson disease visited the emergency room because of hemoptysis and dyspnea. She had diffuse pulmonary hemorrhage, microscopic hematuria, and proteinuria. Myeloperoxidase ANCA was positive, and a renal biopsy revealed pauci-immune crescentic glomerulonephritis. Under the diagnosis of D-penicillamine-induced ANCA-associated vasculitis, D-penicillamine was switched to trientine, and the patient was treated with plasmapheresis, glucocorticoid, cyclophosphamide, and mycophenolate mofetil. Pulmonary hemorrhage improved rapidly followed by the disappearance of the hematuria and proteinuria five months later.

Co-administration of trientine and flaxseed oil on oxidative stress, serum lipids and heart structure in diabetic rats.

The administration of flaxseed oil or flaxseed oil plus trientine in diabetic rats reduced triglyceride, very low density lipoprotein, and total cholesterol. Furthermore, the combined treatment significantly increased superoxide dismutase activity and attenuated serum Cu2+. The results suggest that the administration of flaxseed oil plus trientine is useful in controlling serum lipid abnormalities, oxidative stress, restoring heart structure, and reducing serum Cu2+ in diabetic rats.

Doença de Wilson em crianças e adolescentes: como fazer diagnóstico precoce / Wilson's disease in children and adolescent: a key to an early diagnosis

A doença de Wilson é uma desordem autossômica recessiva do metabolismo do cobre, que leva à impregnação desse metal em diversos tecidos como o fígado, cérebro, córnea e rins. Tem prevalência de 1:40.000 e evolui de forma progressiva e fatal se não tratada. Seu diagnóstico depende de suspeição clínica e exames laboratoriais, podendo ser difícil nos pacientes assintomáticos ou com insuficiência hepática grave. A tríade clássica de apresentação é hepática, neurológica e oftalmológica. Na criança, a forma de apresentação mais comum é a hepática (aguda ou crônica). Os critérios diagnósticos são baseados na presença de ceruloplasmina baixa, cobre em urina de 24 horas e cobre livre elevados e avaliação oftalmológica à procura do anel de Kayser-Fleischer. O tratamento medicamentoso deve ser instituído o quanto antes, de forma a evitaremse as lesões teciduais do excesso de cobre, daí a grande importância do diagnóstico precoce. A droga de escolha é a D-penicilamina, mas é necessário o monitoramento de seus possíveis efeitos colaterais e eventuais pioras do quadro neuropsiquiátrico. Existem outras drogas, como a trientina, tetratiomolibdato e o zinco, que também têm efeito na redução do cobre orgânico. (AU)

Wilson disease is an authossomal recessive disorder of copper metabolism that leads to the impregnation of the metal in different tissues such as the liver, brain, cornea and kidneys. There is a prevalence of 1:40,000 and evolution is progressive and fatal if untreated. The diagnosis depends on clinical suspicion and laboratory tests, and may be difficult in situations such as the asymptomatic patients or with severe liver insufficiency. The classic triad presentation is the hepatic, neurological and ophthalmologic disease. In children, the most common is the hepatic (acute or chronic). The diagnosis criteria are based on the presence of low ceruloplasmine, elevated copper in 24-hour urine and high seric copper and ophthalmologic evaluation in search of Kayser Fleischer ring. The medication treatment must be established as soon as possible so as to prevent tissue lesions due to copper excess, hence the great importance of early diagnosis. The drug choice is the D-penicilamin, with careful monitoring of side effects and attention for occasional worsening of the neuropsychiatric state. There are other drugs as trientine, tetratiomolibdato and zinc that also have an effect on the reduction of organic copper. (AU)

Wilson Disease: an Update / 대한간학회지

Wilson disease (WD) is an autosomal recessive disorder of copper transport that results in accumulation of copper primarily in the liver, the brain and the cornea. WD is the most common inherited liver disease with the prevalence of 1: 37,000 in the pediatric population in Korea. Mutations in the ATP7B gene cause failure of copper excretion into the bile and a defective incorporation of copper into ceruloplasmin. More than 300 mutations in the ATP7B gene have been described so far. Mutations differ between ethnic groups. The p.R778L (an allele frequency of 37%), p.A874V (13%), p.L1083F (8%) and p.N1270S (6%) are the common major mutations in Korea. Conflicting results on genotype/phenotype correlations of the most common mutations have been reported in various countries. There seems to be no correlation between the R778L mutation and age of onset or clinical manifestations in Korean patients. None of the laboratory parameters alone allows a definite diagnosis of WD. In a nation-wide survey of WD, low serum ceruloplasmin (100 microgram), high hepatic copper content (>250 microgram/g of dry liver) and Kayser-Fleischer rings were found in 96%, 86%, 88%, and 73% of the 550 Korean patients respectively. A combination of any two of the above 4 laboratory findings is strong support for a diagnosis of WD. For the last couple of years, genetic testing has been playing an increasingly important role in diagnosing WD. Direct DNA sequencing did confirm WD in 98% of the Korean patients. Two mutations were detected in 70% and one mutation in 28% of the patients who showed characteristic biochemical and clinical findings of WD. Genetic testing, either by haplotype analysis or by mutation analysis, is the only reliable tool for differentiating heterozygote carriers from affected asymptomatic patients. The agents of the first choice among chelators and zinc in specific clinical situations of WD is still a matter of debate. Because of frequent side effects and initial neurologic deterioration of penicillamine therapy, less toxic trientine or zinc has gradually replaced penicillamine over the past few years. Trientine or tetrathiomolybdate has been increasingly recommended as the first-line treatment for neurologic WD. Currently, liver transplantation is not recommended as primary treatment for neurologic WD. Recently published data show that initial zinc therapy for asymptomatic/presymptomatic patients and maintenance zinc therapy in patients after long term chelation are safe and effective. Further researches and the new guidelines on the proper management of patients with WD are needed.

Pharmacological studies on mechanisms of aminophylline-induced seizures in rats.

In the present study, the possible role of free radicals in aminophylline-induced seizures was evaluated in albino rats. Aminophylline (theophylline in ethylene diamine; 50 - 300 mg/kg) induced convulsions in rats in a dose-dependent manner, and both incidence of seizure and mortality were maximum at 300 mg/kg. Conventional anti-epileptics, diphenylhydantoin and dizocilpine, as well as adenosine agonists were ineffective in antagonizing these seizures. On the other hand, phosphodiesterase inhibitors, pentoxyphylline and rolipram, showed insignificant seizurogenic effects. Pretreatment with antioxidants (ascorbic acid, alpha-tocopherol, and melatonin) showed differential attenuating effects on aminophylline seizures and lethality. Further, prior administration of 1-buthionine sulfoxamine (BSO, glutathione depletor) and triethyltetramine (TETA, superoxide dismutase inhibitor), precipitated seizures and enhanced lethality in response to subthreshold doses of aminophylline. The present results suggested of the possible involvement of oxidative stress during aminophylline-induced seizures.

Wilson disease / 한양의대학술지

Wilson disease is an autosomal recessive disorder caused by a deficient ATP7B activity. Copper is an important mineral in the body involved in mitochondrial respiration, melanin biosynthesis, dopamin metabolism, iron homeostasis, antioxidant activity and peptide amidation. Liver is an important organ in copper metabolism related to storing and excretion of bile acids. Copper transport in the liver is a complicated process including different transporter proteins. Generally, Wilson disease shows heterogenous clinical features and symptoms may differ between siblings in a family. This finding suggests that other genes or envrionmental factors may play important roles on determination of disease phenotypes. Clinical symptoms of the disease are mainly related to liver dysfunction and neurologic deterioration. Early diagnosis is important in order to prevent serious complications. Lowered serum ceruloplasmin level and increased urine copper excretion are diagnostic criteria in practice. Histopathologic findings are nonspecific for the diagnosis. Treatment of the disease includes administration of chelating agent such as penicillamine and trientine, dietary restriction of copper, and liver transplantation when chelating agents are not successful.

Early Onset of Minimal change Nephrotic Syndrome during Treatment with D-penicillamine in a Patient with Wilson s Disease

Wilson s disease is an autosomal recessive disorder characterized by degenerative changes in the brain, liver, and cornea. Treatment includes D-penicillamine, trientine, and zinc sulfate. D-penicillamine has been used frequently as first line therapy for Wilson s disease. However, nephrotoxicity can occur after D-penicillamine treatment. Among them membranous glomerulopathy is the most common histological abnormality but minimal change lesions have also been reported. Nephrotic syndrome is a late complication of D-penicillamine treatment but very rarely can occur within 2 months after treatment of D-penicillamine. We report the early development of minimal change nephrotic syndrome in a 3-year-old girl with Wilson s disease 3 weeks after initiation of D-penicillamine.

Wilson's disease.

Wilson's disease (WD), an inborn error of copper (Cu) metabolism, is now one of the leading liver diseases in children in India. The clinical presentation can be extremely varied viz.,--all forms of acute and chronic liver disease, minimal to severe neurological disease, psychiatric problems, bony deformities, hemolytic anemia and endocrine manifestations. A high index of suspicion is necessary along with a judicious battery of investigations for diagnosis. Hepatic copper estimation is the most reliable test but is not easily available in India. Liver biopsy may not be possible because of bleeding problems and histological features are often not diagnostic of WD. In the absence of hepatic Cu, a low ceruloplasmin, high 24 hour urinary copper and presence of KF rings aid in making the diagnosis. The mainstay of initial therapy is Cu-chelators like D-Penicillamine, and Trientine for reduction in body copper to sub-toxic levels. Subsequent maintenance therapy is necessarily lifelong with D-Penicillamine, Trientine or Zinc. Children on therapy must be monitored regularly for response, side-effects, compliance and rehabilitation. Response to therapy may be unpredictable, but acute and early presentations like fulminant hepatic failures have a poor outcome. All siblings must be screened for WD as early diagnosis and treatment result in a good outcome. The identification of the WD gene on chromosome 13 has led to the possible use of molecular genetics (haplotype and mutational analyses) in the diagnosis of WD. Parent groups/associations must take active part in holistic management of WD.

A Case of Minimal Change Nephrotic Syndrome Associated with D-penicillamine Therapy of Wilson's Disease / 대한소아소화기영양학회지

Wilson's disease is a treatable autosomal recessive inherited disorder of copper metabolism due to mutation of the copper transporting gene. The basic strategy of treatment is to reduce the amount of copper in the liver and other tissues by administering both a low copper diet and copper-chelating agents. D-penicillamine is the first choice as a copper-chelating agent. Some serious side effects could occur in 3~5% of all patients following D-penicillamine therapy. We report a 19 year-old male with Wilson's disease who developed nephrotic syndrome 6 months after the initiation of D-penicillamine therapy. Prednisolone was administered to control nephrotic syndrome and D-penicillamine was switched to trientine. Urinary remission was achieved within a week and maintained thereafter. Nephrotic syndrome was proven to be MCNS by kidney biopsy.

Long-term Clinical Follow-up of Korean Children with Wilson Disease; Twenty Years' Experience

PURPOSE: To investigate the clinical features of long-term follow-up, and the treatment responses in Korean children with Wilson disease(WD). METHODS: The clinical data from ninety-two children with WD, diagnosed at Seoul National University Hospital from 1976 to 1999, were reviewed. Mean duration of follow-up was 5+/-4.5 years. We analysed the patient's records based on the clinical manifestations, laboratory findings, and responses to the treatment. RESULTS: Age of initial presentation was 9.6+/-2.6 years. Mean age of patients who developed neurologic symptoms was 11.6 years. Initial manifestations were characterized as hepatic(70.6%), neurologic(6.5%), and both hepatic and neurologic(10.9%). Kayser-Fleischer(KF) rings were observed in 59 patients(64.1%). All neurologic patients had KF rings. Level of serum ceruloplasmin was low in 91 patients(98.9%). Multiple nodules in the liver and high signal intensity lesions in basal ganglia of the brain were observed on magnetic resonance imaging. Seventy-six patients(82.6%) showed favorable responses to penicillamine(PNC) and the rest of the patients with poor responses were treated with zinc sulfate, trientine, or liver transplantation. Neurologic symptoms improved with PNC in ten out of sixteen patients. However, despite PNC treatment, six patients deteriorated neurologically. Factors affecting the poor response to PNC were associated with the presence of fulminant hepatitis, hemolysis, and KF ring. Ten patients expired due to fulminant hepatitis(9), and hepatocellular carcinoma(1). Most of them died within five months after initial presentations. Ten-year survival rate was 85.4%. CONCLUSION: WD in children begins with various manifestations. PNC is an effective and safe drug to treat WD in most cases. However, the supplementary modalities such as zinc sulfate, trientine and liver transplantation should be considered when the patients show poor responses or adverse reactions to PNC.

Uso del trien en el tratamiento de la enfermedad de Wilson / Use of trien in the treatment of wilson's disease

Enfermedad de Wilson es una afección autosómica, que se caracteriza por el acúmulo de cobre a nivel de los tejidos con afinidad especial por hígado y cerebro. con una incidencia baja de 1/200.000, en las poblaciones estudiadas, exceptuando el Japón con el 1 por ciento (isla Mikura). Estudios en Venezuela han demostrado un foco importante en el área central, que da un 20 por ciento de la población con afectación leve. La D-penicilamina primera droga utilizada en esta enfermedad pero que presenta el problema de los múltiples efectos secundarios, entre otros trombocitopenia, neutropenia y síndrome lupoide así como su alto costo, que dificultan el manejo del paciente. El trien nueva droga descrita desde 1968 aunque no disponible comercialmente, ha sido utilizada en 40 pacientes sin efectos secundarios. En Venezuela se ha utilizado en 5 pacientes con muy buenos resultados, a propósito presentamos los efectos en un paciente asintomático con cirrosis por enfermedad de Wilson, quien con dos años de tratamiento con 300 mg Tid., presentó normalización de las pruebas de funcionalismo hepático y mejoría leve de la imagen histopatológica y sin efectos secundarios. El costo del Trien es 50 veces más económico y sin efectos secundarios hasta ahora, de allí que su utilización es recomendable

Consideraçöes a respeito do tratamento da degeneraçäo hepatolenticular / The management of hepatolenticular degeneration

Säo revistos aspectos referentes ao tratamento da degeneraçäo hepatolenticular. Inicialmente é abordada a evoluçäo dos conhecimentos a respeito da terapêutica dessa moléstia. Analisa-se posteriormente dados relativos ao modo de emprego da D-Penicilamina e seus efeitos colaterais, assim como os resultados obtidos com o uso dessa droga. Finalmente, säo avaliados os meios auxiliares e alternativos de tratamento, particularmente os sais de zinco