NORD gratefully acknowledges George J. Brewer, MD, Morton S. and Henrietta K. Sellner Emeritus Professor of Human Genetics, Emeritus Professor of Internal Medicine, Departments of Human Genetics and Internal Medicine, University of Michigan Medical School, for assistance in the preparation of this report.
Wilson disease is a rare genetic disorder characterized by excess copper stored in various body tissues, particularly the liver, brain, and corneas of the eyes. The disease is progressive and, if left untreated, it may cause liver (hepatic) disease, central nervous system dysfunction, and death. Early diagnosis and treatment may prevent serious long-term disability and life threatening complications. Treatment is aimed at reducing the amount of copper that has accumulated in the body and maintaining normal copper levels thereafter.
Wilson disease is a rare genetic disorder beginning with liver dysfunction where damage begins by six years of age, but usually presents clinically in teenage years or early twenties. Common signs of associated liver disease include a yellow discoloration (jaundice) of the skin, mucous membranes and the membranes (sclera) that line the eye, swelling (edema) of the legs and abdomen (ascites) due to abnormal retention of fluid, presence of abnormal blood vessels in the esophagus that may bleed (esophageal varices), a tendency for bruising and prolonged bleeding, and excessive tiredness (fatigue). Some individuals with Wilson disease may have only abnormalities of liver function test and may show no other symptoms until many years later.
A minority of affected individuals may experience severe liver failure. This happens most frequently in people with Wilson’s disease during adolescence and more commonly in women. These individuals may rapidly develop signs and symptoms of liver disease, often associated with anemia due to breakdown of red blood cells (hemolysis) and mental confusion. In these young patients, the characteristic rusty-brown deposits in the corneas of the eyes (Kayser-Fleischer rings) may not yet be present.
In some patients, liver disease does not reveal itself, and the patient develops neurologic (brain-related) symptoms. Common neurological symptoms of Wilson disease that may appear and progress with time include tremor, involuntary movements, difficulty swallowing (dysphagia), difficulty speaking and poor articulation (dysarthria), lack of coordination, spasticity, dystonic postures, and muscle rigidity. Almost all affected individuals with the neurological symptoms of Wilson’s disease have Kayser-Fleischer rings in their eyes that can be identified by an ophthalmologist.
The psychiatric manifestations of Wilson disease may vary widely from patient to patient. These symptoms may be confused with other disorders ranging from depression to schizophrenia, and are often misdiagnosed as substance abuse. Changes in personality or behavior may occur. Most affected individuals with psychiatric symptoms also have neurologic symptoms concurrently or will develop them within about three years and Kayser-Fleischer rings in the corneas of their eyes.
In young females, menstruation may not begin or ceases, until disease is treated. This is due to general disturbances in hormone metabolism due to the liver disease caused by Wilson’s disease. Menstrual irregularity, loss of menstruation (ammenorrhea), miscarriages and infertility are also common.
Other signs and symptoms of Wilson disease may include kidney stones and renal tubular damage, premature arthritis, and other joint and bone involvement including thinning of the bones (osteoporosis) and the appearance of bony outgrowths (osteophytes) at large joints. There may also be reduced spinal and extremity joint spaces.
Wilson disease is inherited as an autosomal recessive trait. Genetic diseases are determined by two genes, one received from the father and one from the mother.
Recessive genetic disorders occur when an individual inherits two copies of an abnormal gene for the same trait, one from each parent. If an individual inherits one normal gene and one gene for the disease, the person will be a carrier for the disease but usually will not show symptoms. The risk for two carrier parents to both pass the altered gene and have an affected child is 25% with each pregnancy. The risk to have a child who is a carrier like the parents is 50% with each pregnancy. The chance for a child to receive normal genes from both parents is 25%. The risk is the same for males and females.
Parents who are close relatives (consanguineous) have a higher chance than unrelated parents to both carry the same abnormal gene, which increases the risk to have children with a recessive genetic disorder.
Researchers have determined that Wilson disease is caused by disruption or changes (mutations) of the ATP7B gene, which plays an important role in the movement of excess copper from the liver to the bile to eventually be excreted from the body through the intestines. More than 300 different mutations of the ATP7B gene have been identified.
Wilson disease is a rare disorder that affects males and females in equal numbers. The disease is found in all races and ethnic groups. Although estimates vary, it is believed that Wilson’s disease occurs in approximately one in 30,000 to 40,000 people worldwide. Approximately one in 90 people may be carriers of the disease gene. Although only about 2,000-3,000 cases have been diagnosed in the United States, other affected individuals may be misdiagnosed with other neurological, liver or psychiatric disorders. According to one estimate, there may actually be 9,000 people affected by Wilson’s disease in the United States.
Wilson disease may be diagnosed based upon a thorough clinical evaluation, a complete patient history, and specialized tests. Such tests may include slit-lamp examination of the eyes that reveals the presence of Kayser-Fleischer rings; tests of the fluid portion of the blood (serum) that demonstrate low levels of ceruloplasmin, a copper protein; and tests that reveal abnormally high levels of copper excreted in the urine. In some patients, a liver biopsy for copper analysis may be necessary to confirm a diagnosis of Wilson disease. Molecular genetic studies that use DNA from blood cells to search for patterns of differences or similarities, a procedure called haplotype analysis may establish whether a full sibling of an affected patient has Wilson disease, is a carrier of the Wilson disease gene, or is not a carrier. This analysis is available for family members of individuals identified as having Wilson disease. DNA analysis may also be used for diagnosing affected patients. In over half of patients, DNA analysis will reveal mutations that cause Wilson’s disease.
It is important to diagnose Wilson disease as early as possible. Permanent neurologic dysfunction and serious liver disease may be avoided with early diagnosis and treatment.
Treatment for Wilson disease is life-long and aimed at lowering copper levels to nontoxic levels, and at preventing the progression of the disease and trying to reverse any signs and symptoms that have appeared because of copper accumulation in the body. Treatment may be divided into three parts: first, treatment of symptomatic patients, second, maintenance therapy after copper has been reduced in affected tissues, and third, in asymptomatic patients, maintenance therapy may be used from the beginning.
Treatment for Wilson disease includes three types of medications. First those that remove (chelate) copper from the body by urinary excretion such as penicillamine (Cuprimine) and trientine dihydrochloride (Syprine), second, zinc salts to prevent the gut from absorbing copper from the diet, and third, tetrathiomolybdate which both prevents absorbing copper and binds up toxic copper in the blood making it nontoxic.
Patients who present symptomatically with mild to moderate liver failure can be effectively treated with a combination of trientine and zinc for 4-6 months, and then go on maintenance therapy with zinc or trientine alone. A second choice would be penicillamine and zinc, but penicillamine has more side effects than zinc. Patients with severe liver failure may require liver transplantation. Patients who present neurologically can best be treated with tetrathiomolybdate, but it is not commercially available as yet. The second choice is zinc alone. Zinc is rather slow acting but doesn’t cause the drug catalyzed worsening so common with trientine and penicillamine. Trientine and penicillamine are poor choices to treat neurologically presenting patients because of the high frequency of neurological worsening, from which many patients never recover.
Zinc Acetate (Galzin) has been approved for the maintenance treatment for patients.
For affected individuals without symptoms (asymptomatic) or for individuals initially treated with chelating agents, zinc acetate (Galzin manufactured by the Gate division of Teva Pharmaceuticals) is used to prevent copper absorption from the gut. Zinc therapy is often preferred in children and pregnant women because of limited side effects. For some patients intolerant of zinc due to gastric irritation, maintenance therapy with trientine may be preferable.
Monitoring of chronic drug therapy includes follow-up physical examinations, measurement of copper (and zinc for those on zinc therapy) in 24-hour urine collection, blood tests to determine the amount of copper not bound to ceruloplasmin (free copper), periodic measurement of liver functions, and blood counts. For those on chelating agents, periodic urinalysis should also be done to look for the presence of cells or protein in the urine. Repeat liver biopsies are usually not necessary to follow the progress of drug therapy.
Discontinuation of medication for Wilson disease may cause rapid build-up of copper and life threatening events. It is important that patients taking zinc acetate use the prescription version of this drug (Galzin) because nutritional supplements may not be bioequivalent and may be ineffective.
Liver transplantation may be lifesaving for individuals presenting with severe liver failure.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website:
For information about clinical trials sponsored by private sources, contact:
For information about clinical trials conducted in Europe, contact:
Researchers at the University of Michigan are currently looking into several treatment options for Wilson’s disease. The University has been designated a Wilson Disease Center of Excellence by the Wilson’s Disease Association. For information about studies being conducted there, contact:
George J. Brewer, MD
Emeritus Professor of Human Genetics and Internal Medicine
Department of Human Genetics
University of Michigan
Ann Arbor, Michigan 48109-5720
Phone: 734-761-7970 or 734-395-1070
Email: [email protected]
Frederick Askari, MD, PhD
Associate Professor of Medicine
University of Michigan
3912 Taubman Center
Ann Arbor, MI 48109-0362
Email: [email protected]
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