Hepatitis B virus infection in patients with Wilson disease: A large retrospective study

BACKGROUND

Wilson disease (WD) is the most common genetic metabolic liver disease. Some studies have shown that comorbidities may have important effects on WD. Data on hepatitis B virus (HBV) infection in patients with WD are limited.

AIM

To investigate the prevalence and clinical impact of HBV infection in patients with WD.

METHODS

The clinical data of patients with WD were analyzed retrospectively, and the data of patients with concurrent WD and HBV infection were compared with those of patients with isolated WD.

RESULTS

Among a total of 915 WD patients recruited, the total prevalence of current and previous HBV infection was 2.1% [95% confidence interval (CI): 1.2%-3.0%] and 9.2% (95%CI: 7.3%-11.1%), respectively. The main finding of this study was the identification of 19 patients with concurrent WD and chronic hepatitis B (CHB) infection. The diagnosis of WD was missed in all but two patients with CHB infection. The mean delay in the diagnosis of WD in patients with concurrent WD and CHB infection was 32.5 mo, which was significantly longer than that in patients with isolated WD (10.5 mo). The rates of severe liver disease and mortality in patients with concurrent WD and CHB infection were significantly higher than those in patients with isolated WD (63.1% vs 19.3%, P = 0.000 and 36.8% vs 4.1%, P < 0.001, respectively). Binary logistic regression analysis revealed a significantly higher risk of severe liver disease at the diagnosis of WD in patients with current HBV infection [odds ratio (OR) = 7.748; 95%CI: 2.890-20.774; P = 0.000)] or previous HBV infection (OR = 5.525; 95%CI: 3.159-8.739; P = 0.000) than in patients with isolated WD.

CONCLUSION

The total prevalence of current HBV infection in patients with WD was 2.1%. The diagnosis of WD in CHB patients is usually missed. HBV infection is an independent risk factor for severe liver disease in WD patients. The diagnosis of WD should be ruled out in some patients with CHB infection.

Unilateral K-F ring in Wilson's disease

Wilson's disease, also called hepatolenticular degeneration, has varied clinical manifestations and poses diagnostic challenges. Kayser-Fleischer ring, when present, is considered pathognomic of Wilson's disease. Although its presence is most commonly seen with the neuro-psychiatric form of the disease, it can also be present in hepatic form and asymptomatic patients. We report a case of unilateral Kayser-Fleischer ring in the normal, functional eye of a patient which subsequently led to the diagnosis of Wilson's disease in the patient. This case also highlights the examination of the normal appearing eye in all the patients presenting with complaints in only one eye.

Wilson's Disease Update: An Indian Perspective

Wilson's disease (WD) is an autosomal recessive disorder due to ATP7B gene mutation, resulting in defective copper metabolism, with the liver and brain being primarily affected. WD being a treatable disorder, early diagnosis and proper management may result in near complete recovery. It has received significant attention over the past 50 years, with several Indian contributions. This study collates published Indian studies on WD in Pubmed and Embase databases and puts them in perspective. Several Indian case series suggest WD may be more prevalent than thought. Commonly detected ATP7B mutation in India is p.C271X. Although initial Indian series reported significant osseomuscular presentation, neuropsychiatric and hepatic manifestations dominated the later reports. A significant male predominance is observed in the Indian series. Pure hepatic presentation starts earlier than neurological or osseomuscular WD. A positive family history may be seen in nearly 50% of Indian WD cases, with a high rate of consanguinity. Up to two-third of the Indian cases may be initially misdiagnosed, with a mean diagnostic delay of up to 2 years. Abnormalities in serum ceruloplasmin and 24-hour urinary copper has been reported in more than four-fifth cases. Brain MRI is abnormal in nearly all neurological WD cases. Copper chelation remains the mainstay of therapy, with D-penicillamine being the most widely used chelator in India. Global Assessment Scale for WD is a comprehensive tool for clinical monitoring. Hepatic presentation carries a five-time higher mortality risk than neurological, with up to 90% Indian neurological WD cases recovering back to pre-morbid functionality with adequate therapy.

Investigation of corneal topographic and densitometric properties of Wilson's disease patients with or without a Kayser-Fleischer ring

BACKGROUND

To investigate the topographic measurements and densitometry of corneas in Wilson's disease (WD) patients with or without a Kayser-Fleischer ring (KF-r) compared to healthy individuals.

METHODS

This cross-sectional study included 20 WD patients without a KF-r (group I), 18 WD patients with a KF-r (group II), and 20 age-matched controls (group III). The Pentacam high resolution imaging system is used to determine corneal topographic measurements and densitometry.

RESULTS

Mean age for groups I, II and III was 25.40 ± 6.43 years (14-36 years), 25.38 ± 6.96 years (16-39 years), 23.60 ± 6.56 years (17-35 years), respectively (P = 0.623). There was no significant difference between the groups in terms of the anterior corneal densitometry values (P > 0.05), while the 6-10 mm and 10-12 mm mid stroma and the 2-6 mm, 6-10 mm, and 10-12 mm posterior corneal densitometry values in group II were significantly higher than those in groups I and III (for all values, P <  0.05). However, the 10-12 mm posterior corneal densitometry values in group I were also significantly higher than those in group III (P = 0.038). The central corneal thickness (CCT), thinnest corneal thickness (tCT), and corneal volume (CV) values in groups I and II were significantly lower than those in group III (for CCT values, P = 0.011 and P = 0.009; for tCT values, P = 0.010 and P = 0.005; for CV values, P = 0.043 and P = 0.029).

CONCLUSION

In WD patients with a KF-r, corneal transparency decreased in the peripheral posterior and mid stromal corneal layers; for these patients, corneal transparency may be impaired not only in the peripheral cornea but also in the paracentral cornea.

Kayser-Fleischer ring with keratoconus: a coincidence? A case report

Background

It is rare for hepatolenticular degeneration [Wilson’s disease (WD)] to occur along with keratoconus (KC). In our report, a teenager was diagnosed with WD because of the discovery of Kayser–Fleischer (KF) ring in the cornea, and concomitant KC was found.

Case presentation

A 19-year-old male was diagnosed with KC due to a rapid decline in visual acuity within a short period of time. Ocular examination revealed the presence of ring-shaped, dense, brown sediment at the Descemet membrane of the bilateral limbus cornea, exhibiting characteristics similar to those of KF ring. Then, the patient was referred to the Department of Neurology and diagnosed with asymptomatic WD. During the next 5 years of follow-up, the patient has worn RGP lenses, routinely taken drugs that inhibit copper absorption and promote copper excretion, and maintained a low-copper diet. He has never exhibited obvious systemic symptoms associated with WD, such as neurological, mental, or hepatic dysfunction, and the color of the KF ring has grown obviously lighter. Moreover, the morphology of the cornea has stabilized.

Conclusion

Only one report of WD combined with KC was found in the literature. So far, there is no evidence of a correlation between the occurrence of the two diseases. However, a low-copper diet and active copper-reducing therapy may have played a role in stabilizing the patient’s condition in this case.

[Diagnosis and treatment of Wilson disease in Japan]

Wilson disease is an autosomal recessive disorder based on inborn error of copper metabolism. The copper accumulates in the liver, brain, cornea, kidney, and other organs. This disease should be considered any individual with liver abnormality except infant, any patient older than teenage with neurological (especially for extra pyramidal signs) or neuropsychiatric disorder with or without liver disease and sibling of Wilson disease patient. Typically, a combination of low serum ceruloplasmine levels and high levels of urinary copper contents is sufficient to establish a diagnosis. As other diagnostic tests, measurement of hepatic copper content and ATP7B gene analysis are available. The key strategy of treatment is to reduce the amount of copper in the liver and other tissues by administering both copper-chelating agents, such as D-penicillamine or Trientine, and/or zinc acetate. The author recommend zinc acetate monotherapy for mild to moderate hepatic disorder, Trientine mono therapy for mild to moderate neurologic disorder and combination therapy of Trientine and zinc acetate for sever hepatic or neurologic disorder.

Anterior segment optical coherence tomography (AS-OCT) as a new method of detecting copper deposits forming the Kayser-Fleischer ring in patients with Wilson disease

PURPOSE

Kayser-Fleischer ring pathognomonic for Wilson disease (WD) is formed of corneal copper deposits present predominantly within the anterior chamber angle at the Schwalbe's line. The slit-lamp assessment commonly used as a standard of care cannot detect them early enough, as the angle view is obscured by the corneal limbus. The aim of the research was to evaluate the anterior segment optical coherence tomography (AS-OCT), as objective diagnostic assessment of copper deposits forming KF ring in patients with WD.

METHODS

Twenty-nine subjects (17 women) and twenty-nine controls (14 women) were enrolled and underwent slit lamp and AS-OCT assessment.

RESULTS

Kayser-Fleischer ring was not detected - either with a slit lamp or with AS-OCT - in any of the controls. Fifteen subjects presenting without KF ring at a slit-lamp examination were found to have a KF ring when examined with AS-OCT (p < 0.001), which confirms improved accuracy of AS-OCT, as compared to the slit-lamp examination.

CONCLUSION

Our results support AS-OCT as a diagnostic procedure to offer better objectivity and accuracy as compared to a slit-lamp examination, both at the diagnostic stage and when monitoring changes in KF ring during medical therapy to assess its efficacy and patient compliance.

Ocular manifestations of monoclonal copper-binding immunoglobulin

The dense accumulation of copper in Descemet membrane and lens capsule is the characteristic manifestation of a circulating monoclonal antibody with strong affinity for copper. The overproduction of this monoclonal immunoglobulin may be associated with either multiple myeloma or a benign monoclonal gammopathy. Despite prolonged exposure to elevated serum copper, no other tissues in the body are adversely affected by this redox metal. We describe the clinical and pathological findings in a 46-year-old woman with this disorder.