Search

A 60‐year‐old man was referred to hospital for loss of consciousness. Her late‐onset Wilson disease was diagnosed with elevated serum bilirubin, hepatic copper concentration, and urinary copper excretion. Zinc sulfate administration decreased the majority of clinical symptoms.

BackgroundCopper associated hepatitis (CAH) has been increasingly recognized in dogs, and speculation exists that hereditary defects in copper metabolism have been exacerbated by increased environmental copper exposure. However, no broad epidemiological investigations have been performed to investigate quantitative hepatic copper concentrations ([Cu]H ) over time in both dogs that are (predisposed breed [PB]), and are not (non-predisposed breed [NPB]), considered at-risk for CAH.ObjectivesTo investigate [Cu]H in dogs and explore temporal, demographic, and histologic associations spanning 34 years.Animals546 archived liver specimens.MethodsRetrospective study. Searches of the Michigan State University Veterinary Diagnostic Laboratory database identified dogs that had undergone hepatic histopathologic assessment. Cases with archived tissue were reviewed and classified by breed, time period, and presence or absence of hepatitis. Inductively coupled plasma mass spectrometry was used to determine [Cu]H .ResultsIn time period 2009-2015, median [Cu]H were 101 μg/g and 313 μg/g greater than median [Cu]H in time period 1982-1988 for NPB and PB dogs, respectively (P < .001 for both comparisons). The proportion of dogs with [CU]H > 300 μg/g increased in NPB (28% to 49%) and PB dogs (48% to 71%) during these periods (P = .002 for both comparisons). Median [Cu]H in dogs with hepatitis increased 3-fold over time in both NPB (P = .004) and PB populations (P < .001).Conclusions and clinical importanceThe frequent recognition of CAH in recent years is likely due to the observed increases in [Cu]H over time. Importantly, effects are not limited to PB dogs.

Introduction. Wilson’s Disease (WD) is an inherited disorder of impaired hepatic copper metabolism that leads to copper accumulation in organs such as the liver and brain. Using transcranial sonography (TCS), we investigated brain changes in WD patients during de-coppering treatment. Methods. Forty-one consecutive treatment-naive WD patients were classified as having hepatic (WDh; n = 20) or neurological WD (WDn; n = 21) based on symptoms at diagnosis; all patients received either D-penicillamine or zinc sulfate and were observed for 24 months. TCS was performed at regular intervals from study entry (month 0) to month 24. Results. At study entry, bilateral lenticular nucleus (LN) hyperechogenicity was found in 18 patients with WDn and in nine with WDh (p = 0.006). Substantia nigra (SN) hyperechogenicity was found in nine patients with WDn) and four with WDh (p = ns). After 24 months of treatment, bilateral LN hyperechogenicity was still present in 17 patients with WDn and 14 with WDh (p = ns). SN hyperechogenicity was present in one patient with WDn and two with WDh (p = ns). The decrease in the number of patients with SN hyperechogenicity was significant in the WDn group (p < 0.05). Conclusions. LN hyperechogenicity is the most common TCS abnormality in WD patients, and was observed despite two years of de-coppering treatment. SN hyperechogenicity was less common, and decreased after treatment introduction.

This study focused on a flock of Dala sheep with recurrent cases of chronic copper (Cu) poisoning. The seasonal variation in hepatic Cu concentration was followed in individual sheep with repeated liver biopsies, four times per year, in two consecutive years. Thirty-six ewes were included, yielding a total of 279 biopsies. Cu concentrations were measured by atomic absorption spectroscopy. Hepatic Cu concentrations remained almost stable from December to March, fell substantially from March to June, and rose sharply during the summer pasture period from June to October. There were large individual differences in hepatic Cu levels. These differences remained stable through the two years. Treatment with ammonium tetrathiomolybdate (3 × 3.4 mg per kg bodyweight (bw) s.c.) in June had only weak and inconsistent effect on hepatic Cu levels in October. The results may partly explain why chronic Cu poisoning in sheep in Norway predominantly occur in the autumn and winter months.

Objective—To evaluate the accuracy of digitally scanned rhodanine-stained liver biopsy specimens for determination of hepatic copper concentration and compare results with qualitatively assigned histologic copper scores in dogs. Sample—353 liver biopsy specimens from dogs. Procedures—Specimens (n = 139) with quantified copper concentration ranging from 93 to 6,900 μg/g were allocated to group 1 (< 400 μg/g [37]), group 2 (401 to 1,000 μg/g [27]), group 3 (1,001 to 2,000 μg/g [34]), and group 4 (> 2,001 μg/g [41]); stained with rhodanine; and digitally scanned and analyzed with a proprietary positive pixel algorithm. Measured versus calculated copper concentrations were compared, and limits of agreement determined. Influence of nodular remodeling, fibrosis, or parenchymal loss on copper concentration was determined by digitally analyzing selected regions in 17 specimens. After method validation, 214 additional liver specimens underwent digital scanning for copper concentration determination. All sections (n = 353) were then independently scored by 2 naive evaluators with a qualitative scoring schema. Agreement between assigned scores and between assigned scores and tissue copper concentrations was determined. Results—Linear regression was used to develop a formula for calculating hepatic copper concentration ≥ 400 μg/g from scanned sections. Copper concentrations in unremodeled specimens were significantly higher than in remodeled specimens. Qualitative scores widely overlapped among quantitative copper concentration groups. Conclusions and Clinical Relevance—Calculated copper concentrations determined by means of digital scanning of rhodanine-stained liver sections were highly correlated with measured values and more accurate than qualitative copper scores, which should improve diagnostic usefulness of hepatic copper concentrations and assessments in sequential biopsy specimens.

BACKGROUND AND AIMS. Determination of hepatic copper (Cu) concentration is important in Wilson's disease (WD) diagnosis. The aim of this study was to evaluate uneven distribution of liver Cu concentration and the utility of double-sample biopsy in WD diagnosis. METHODS. Thirty-five WD patients (20 male; mean age 41 ± 9 years) were enrolled in the study and double-liver samples for biopsy were obtained. A further 30 WD patients, in whom Cu determination was performed using single-liver samples, were also enrolled as controls. RESULTS. A marked difference in hepatic Cu concentration was observed between the two sample groups (p0.0001). This difference is statistically significant for all levels of liver fibrosis (p0.001) and for the comparison of hepatic and neurological phenotypes (p0.01). The sensitivity of the Cu concentrations obtained from the double-sample biopsies for the conventional cut-off value of 250 mg/g dry weight of tissue was 85.7% compared to 80% in the single-sample biopsies. By lowering the cut-off value from 250 to 50 µg/g of dry weight of tissue, the sensitivity of Cu content to diagnose WD increased to 97% for double-sample liver biopsy compared to 93% for single-sample liver biopsy. CONCLUSIONS. Liver Cu content was unevenly distributed in the WD subjects, irrespective of fibrosis levels and disease phenotypes; hence WD can be misdiagnosed using single-sample liver Cu measurement. Double-sample biopsy sensitivity is greater than that obtained with single-sample biopsy and should therefore be considered to evaluate liver Cu concentration at initial diagnosis in all patients.

In contrast to dogs, the role of copper and iron accumulation in feline hepatic disease remains poorly characterized. Therefore, the objective of the current study was to compare the amount and distribution of copper and iron accumulation for different disease processes in feline liver biopsies. Liver biopsies (from 104 privately owned cats) were categorized by primary histopathologic lesion. Copper (by rubeanic acid) and iron (by Prussian blue) accumulation were graded by amounts (0-3) and location (centrilobular, midzonal, periportal, random). The Kruskal-Wallis test and Pearson chi-square test were used to assess differences in metal grade and location, respectively, between diagnostic categories. Histologic diagnoses were normal (n = 12), congenital (n = 6), neoplastic (n = 16), infectious and/or inflammatory (n = 39), and other (n = 31). Hepatocellular iron staining was negative in 18 samples; remaining samples had grade 1 (n = 38), 2 (n = 40), and 3 (n = 8) accumulation. Ninety-two samples were negative for copper; remaining samples had grade 1 (n = 5), 2 (n = 6), and 3 (n = 1) accumulation. No significant differences were found in the amount of iron or copper accumulation between the different diagnostic categories. Diagnostic category and the location of copper or iron accumulation were not associated. Hepatic iron accumulation was common and not associated with histologic diagnosis. Hepatocellular copper accumulation was more common in cats than previously reported, had a similar pattern of distribution to fibrotic changes, and was not present in histologically normal liver biopsies.

BACKGROUND: Non-Wilsonian hepatic copper toxicosis includes Indian childhood cirrhosis (ICC), endemic Tyrolean infantile cirrhosis (ETIC) and the non-Indian disease known as idiopathic copper toxicosis (ICT). These entities resemble the hepatic copper overload observed in livers of Bedlington terriers with respect to their clinical presentation and biochemical and histological findings. We recently cloned the gene causing copper toxicosis in Bedlington terriers, MURR1, as well as the orthologous human gene on chromosome 2p13-p16.AIM: To study the human orthologue of the canine copper toxicosis gene as a candidate gene for ICC, ETIC, and ICT.METHODS: We sequenced the exons and the intron-exon boundaries of the human MURR1 gene in 12 patients with classical ICC, one patient with ETIC, and 10 patients with ICT to see whether these patients display any mutations in the human orthologue of the canine copper toxicosis gene.RESULTS: No mutations in the MURR1 gene, including the intron-exon boundaries, were identified in a total of 23 patients with non-Wilsonian hepatic copper toxicosis.CONCLUSIONS: Our results demonstrate that copper toxicosis in Bedlington terriers is not an animal model for the non-Wilsonian hepatic copper toxicosis described in this study.

Objective—To determine signalments, clinical features, clinicopathologic variables, imaging findings, treatments, and survival time of cats with presumed primary copper-associated hepatopathy (PCH) and to determine quantitative measures and histologic characteristics of the accumulation and distribution of copper in liver samples of cats with presumed PCH, extrahepatic bile duct obstruction, chronic nonsuppurative cholangitis-cholangiohepatitis, and miscellaneous other hepatobiliary disorders and liver samples of cats without hepatobiliary disease. Design—Retrospective cross-sectional study. Animals—100 cats with hepatobiliary disease (PCH [n = 11], extrahepatic bile duct obstruction [14], cholangitis-cholangiohepatitis [37], and miscellaneous hepatobiliary disorders [38]) and 14 cats without hepatobiliary disease. Procedures—From 1980 to 2013, cats with and without hepatobiliary disease confirmed by liver biopsy and measurement of hepatic copper concentrations were identified. Clinical, clinicopathologic, and imaging data were compared between cats with and without PCH. Results—Cats with PCH were typically young (median age, 2.0 years); clinicopathologic and imaging characteristics were similar to those of cats with other liver disorders. Copper-specific staining patterns and quantification of copper in liver samples confirmed PCH (on the basis of detection of > 700 μg/g of liver sample dry weight). Six cats with PCH underwent successful treatment with chelation (penicillamine; n = 5), antioxidants (5), low doses of elemental zinc (2), and feeding of hepatic support or high-protein, low-carbohydrate diets, and other hepatic support treatments. One cat that received penicillamine developed hemolytic anemia, which resolved after discontinuation of administration. Three cats with high hepatic copper concentrations developed hepatocellular neoplasia. Conclusions and Clinical Relevance—Results suggested that copper accumulates in livers of cats as primary and secondary processes. Long-term management of cats with PCH was possible.

Liver tissue samples were reviewed from 35 Doberman Pinschers with chronic active hepatitis in the precirrhotic stage. Thirty dogs had elevated hepatic copper concentrations, and five had normal liver copper concentrations. The earliest changes were inflammation and scar tissue deposition around the small hepatic vein branches. There was also apoptosis of scattered hepatocytes in zone 3. Inflammation consisted of macrophages, lymphocytes, and plasma cells. As the disease progressed, collagen deposition increased around the hepatic veins; in some liver specimens, thin scar tissue septa radiated from the hepatic vein branches, and inflammation spread to include the portal tracts. The sinusoids adjacent to the scar tissue were converted to endothelial-lined, thin-walled vessels. Chronic active hepatitis (commonly referred to as Doberman hepatitis or chronic active hepatitis of Dobermans) is a progressive fibrosis, inflammation and hepatocyte loss beginning among zone 3 hepatocytes around the terminal hepatic vein branches. The histomorphologic changes were the same among those Dobermans with elevated hepatic copper and those with normal hepatic copper. The cause was not determined, but these morphologic studies support the idea of immune-mediated disease.

Objective—To evaluate differences in hepatic copper concentrations in Labrador Retrievers with and without chronic hepatitis. Design—Retrospective case-control study. Sample—Liver tissue specimens from 36 Labrador Retrievers with chronic hepatitis and 36 age- and sex-matched Labrador Retrievers without chronic hepatitis (control dogs). Procedures—Liver tissue specimens were obtained during 2 study periods (1980 to 1997 and 1998 to 2010). For each tissue specimen, a histologic score was assigned independently by each of 2 interpreters, and the hepatic copper concentration was qualitatively determined via rhodanine staining and quantitatively determined via atomic absorption spectroscopy. Results—Mean hepatic copper concentration was significantly higher in dogs with chronic hepatitis (614 μg/g of dry weight [range, 104 to 4,234 μg/g of dry weight]), compared with that in control dogs (299 μg/g of dry weight [range, 93 to 3,810 μg/g of dry weight]), and increased significantly over time. A higher proportion of liver tissue specimens collected during the 1998–2010 study period had hepatic copper concentrations > 400 μg/g of dry weight (the upper limit of the reference range), compared with the proportion of liver tissue specimens collected during the 1980–1997 study period. The qualitative copper score did not accurately predict quantitative hepatic copper concentration in 33% of study dogs. Conclusions and Clinical Relevance—Results suggested that the increase in hepatic copper concentrations in Labrador Retrievers with and without chronic hepatitis over time may be the result of increased exposure of dogs to environmental copper, most likely via the diet.

J Vet Intern Med. 2012 Nov;26(6):1274-80. doi: 10.1111/j.1939-1676.2012.01001.x. Epub 2012 Sep 24. Association of dietary copper and zinc levels with hepatic copper and zinc concentration in labrador retrievers. Fieten H, Hooijer-Nouwens BD, Biourge VC, Leegwater PA, Watson AL, van den Ingh TS, Rothuizen J. Source Department of Clinical Sciences of Companion Animals, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands. Abstract BACKGROUND: Copper-associated hepatitis is an inherited disease in the Labrador Retriever. Apart from genetic factors, dietary intake of copper and zinc are suspected to play a role in the pathogenesis. OBJECTIVES: To investigate whether dietary copper and zinc levels of commercially available dry diets are associated with hepatic copper and zinc concentrations in Labrador Retrievers. ANIMALS: Fifty-five Labrador Retrievers that were fed a single brand and type of commercial dry food for at least 1 year. Of these, 44 dogs were family members of Labrador Retrievers with copper-associated hepatitis. METHODS: Liver biopsies, blood samples, and diet samples were obtained. Liver specimens were scored histologically and copper and zinc concentrations were quantified. Dietary concentrations of copper and zinc were measured. The association between dietary intake of copper and zinc and hepatic copper and zinc concentrations was investigated by linear regression analysis. RESULTS: High dietary copper and low dietary zinc levels were significantly associated with high hepatic copper levels. No association between dietary intake and hepatic zinc was present. CONCLUSIONS AND CLINICAL RELEVANCE: Dietary copper and zinc at current levels in commercially available dry dog food can influence hepatic copper and can be a risk factor for the development of copper-associated hepatitis in Labrador Retrievers with a genetic susceptibility to copper. Copyright © 2012 by the American College of Veterinary Internal Medicine. PMID: 22998127 [PubMed - in process]

We studied the Cu-MT present in the hepatic cytosol obtained from 7 patients suffering from conditions associated with hepatic Cu overload (Wilson's disease, biliary atresia, familial cholestatic cirrhosis). Since chromatographic methods appropriate for the isolation of Zn- and Cd-MT were unsuitable for Cu-MT, we developed an indirect procedure for the estimation and resolution of the latter. This procedure involved the preparation of apo-MT and its reconstitution to holo-MT with Zn or Cd. Three predominant isoforms of MT were present in all specimens. Our results indicate that at most 36 +/- 5% of the Cu present in the 10 kDa fraction of cytosol is bound to MT in the liver of patients with hepatic copper overload.

To assess the possibility of iatrogenic hepatic copper overload in adult patients on long-term total parenteral nutrition (TPN).TPN predisposes to hepatic copper accumulation through disturbances of the enterohepatic bile acid pool, but iatrogenic copper overload through TPN solutions may occur as well.Quantitative hepatic copper and multiple clinical, biochemical, and histopathologic parameters were compared between patients with long-term TPN associated liver disease (n = 28) and patients with drug-induced cholestatic liver disease (n = 10).Eighty-nine percent of TPN patients and all controls had mildly elevated hepatic tissue copper, but 29% of TPN patients had levels above the diagnostic threshold for Wilson's disease. Quantitative hepatic copper correlated positively with serum aspartate aminotransferase (P = 0.001, r = 0.59), total bilirubin (P0.001, r = 0.65), and direct bilirubin (P0.001, r = 0.63) in TPN patients, but not in controls. The amount of hepatic copper did not correlate with the duration of TPN (median, 1.9 years; range, 0.3-18.0 years) or serum copper levels. TPN patients with significant cholestasis accumulated more copper than patients with no or only minimal cholestasis (P = 0.002).Significant hepatic copper overload in TPN patients occurs through chronic cholestasis in TPN-associated liver disease and is independent from the total duration of TPN. Iatrogenic copper overload through trace elements in TPN solutions does not seem to be a significant factor.

Research Division for Higher Education Center for Research and Development in Higher Education Hokkaido University Sapporo 060-0809 Japan Department of Environmental Medicine and Informatics Graduate School of Environmental Earth Science Hokkaido University Sapporo 060-0811 Japan Department of Public Health Asahikawa Medical School Asahikawa 078-8510 Japan Department of Pediatrics Kumamoto University School of Medicine Kumamoto 860 Japan Terumo Corporation Research and Development Center Terumo Corporation Kanagawa 259-01 Japan Department of Hygiene and Preventive Medicine Hokkaido University School of medicine Sapporo 060-8638 Japan

Wilson's disease is effectively treated by zinc administration which, in vitro, increases metallothionein concentrations. To ascertain whether the latter also occurs in humans we measured metallothionein and trace element concentrations in the duodenal mucosa of 15 Wilson's disease patients: 12 treated with zinc sulphate, two treated with penicillamine, and one not yet on treatment. The control group consisted of 17 patients with dyspepsia, who underwent the same study protocol.Metallothionein and trace element concentrations were measured in duodenal mucosa biopsies according to the silver-saturation hemolysate method and atomic absorption spectrophotometry.Metallothionein concentrations increased by 1500% after zinc and 150% after penicillamine in Wilson's disease patients, with respect to controls who had negative endoscopy and Wilson's disease patients who were not treated. A significant correlation was found between metallothionein and duodenal zinc concentrations. Mucosal iron concentration increased in Wilson's disease patients whether they were treated with zinc or penicillamine. Duodenum with duodenitis also had significantly increased iron levels compared with normal duodenum.Zinc administration increases intestinal metallothionein in Wilson's disease patients. The blockade of copper absorption and its elimination in the stools on desquamation of the intestinal cells probably explains one of the mechanisms underlying the effect of zinc treatment. Despite normal endoscopy, Wilson's disease patients present increased mucosal iron concentrations similar to those in controls with duodenitis. Metallothionein may therefore prevent oxidative damage caused by metal toxicity.

Indian Childhood Cirrhosis (ICC) (Tanner 1997) and Tyrolean Childhood Cirrhosis (TCC) (Muller et al 1996) have both now virtually disappeared. In ICC, and putatively in TCC, greatly increased levels of ingested dietary copper in infancy were associated with greatly increased hepatic copper concentrations and, hence, cirrhosis. Cessation of this feeding habit has been associated with disappearance of the disease in each case.

In previous studies, the majority of patients with the cholestatic liver diseases, primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC), had increased hepatic copper (Cu) levels even in early stages of disease. We prospectively measured hepatic copper content by atomic absorption spectrophotometry in 55 patients with PBC, 6 patients with PSC, and 29 patients with other chronic noncholestatic liver diseases. Hepatic Cu content was normal in 22/61 (36%) of patients with PBC or PSC; 18 of the 22 did not have cirrhosis (82%). Hepatic Cu content increased with increasing stage of disease (r = 0.61, P0.001) and was positively correlated with serum total bilirubin (r = 0.6, P0.0001) and alkaline phosphatase (r = 0.5, P0.001). All patients with stage I and II disease had hepatic Cu150 micrograms/g dry weight, and all patients with hepatic Cu150 micrograms/g dry weight had stage III and IV disease. Hepatic Cu content is normal in early PBC and PSC. Copper accumulation in the liver in these cholestatic liver diseases is secondary to cholestasis rather than a primary phenomenon.

Indian childhood cirrhosis is generally believed to be caused by toxic excesses of hepatic copper derived from milk boiled in copper vessels. Sporadic cases of a disorder indistinguishable from Indian childhood cirrhosis have appeared in other countries where the toxic hepatic copper has been thought to be derived from drinking water. In published reports of seven 2-year-old or younger infants with non-Indian childhood cirrhosis (five of whom died), the copper content of their drinking water--which the authors considered the essential, if not the sole, aetiological factor--ranged from 0.05 to 6.8 mg Cu/L. We identified three Massachusetts towns in which between 1969 and 1991 there were 64,124 child-years of exposure of children under the age of 6 years to drinking water that contained between 8.5 and 8.8 mg Cu/L. Data from the Massachusetts Department of Public Health showed that there were 135 deaths among these children, but no deaths from cirrhosis or any form of liver disease. These data, and evidence of a genetic aetiology in three of the seven infants reported previously, suggest that non-Indian childhood cirrhosis is an inherited disorder.

Since the hepatitis in LEC rats is controlled by a single autosomal recessive gene [1], a genetic metabolic disorder is likely to be the cause of the hepatitis. Although interesting biochemical changes associated with the development of the hepatitis have been reported [2–4], they have been unable to provide any direct evidence about the pathogenesis of the rats.

Unfortunately, these three genetic diseases have yet to contribute to our understanding of copper transport the revelations that we geneticists expect from “experiments of nature”. Nonetheless, I still have faith that the resolution of the basic defects in these conditions will eventually play a critical role in giving us a complete understanding of this process. Therefore we battle on.

A 10-year-old Italian boy with chronic liver disease and copper overload is described. Biological and histopathological findings are similar to those described in children with Indian childhood cirrhosis. This report suggests that a disease akin to Indian childhood cirrhosis but different from Wilson disease can be found in non-Indian children probably representing a new, possibly inherited, disease of copper metabolism leading to copper overload in the liver.

In an autopsy study, hepatic copper (Cu) concentrations in primary biliary cirrhosis were compared with those in normal organs, two other forms of cirrhosis, and extrahepatic obstruction. Cu tissue stores in other major organs were also assessed in primary biliary cirrhosis and in normal organs. The mean hepatic Cu level in primary biliary cirrhosis was significantly greater than that in normal groups and in both groups with cirrhosis (P

Forty-three liver biopsies histologically diagnosed as Indian childhood cirrhosis were studied with the object of investigating accumulation of copper and copper-associated protein in the hepatocytes as demonstrated by the rhodanine and orcein stains respectively. The findings reveal that, in almost all cases, there was an increased accumulation of copper and copper-associated protein, accompanied by the presence of numerous Mallory bodies. It is postulated that the accumulation of copper in the hepatocytes might be the result of a metabolic defect and might be aetiologically related to the liver cell injury and the subsequent development of Indian childhood cirrhosis.

We studied the clinical histories of four white American siblings who died at 41/2 to six years of age of an unknown form of cirrhosis, in an effort to identify the etiologic factors in this familial syndrome. The family history disclosed no Indian heritage or parental consanguinity. The children were born and raised in New Jersey. Each had been well until progressive lethargy, abdominal swelling, jaundice, and fever developed four to seven months before death. The liver histopathology in each case closely resembled that of Indian childhood cirrhosis and included severe panlobular liver-cell swelling with Mallory body formation, prominent pericellular fibrosis, "micro-micronodular" cirrhosis, and marked deposits of copper and copper-binding protein. Hepatic copper levels were as high as 2083 microgram per gram of tissue (normal, less than 50 microgram). A number of features distinguish this syndrome from Wilson's disease and familial cholestatic disorders of childhood. A genetically determined disturbance in copper metabolism appears to be the most likely cause.

One hundred prospectively studied children with Indian childhood cirrhosis (ICC) in Pune District, India, differed from 100 matched controls with respect to feeding history. Animal milk was used in all ICC cases but not in 27 controls. It had been started by 3 months in 63 cases and by 6 months in 82 cases of ICC, as compared with 15 and 25 controls. Twenty-four ICC cases received no breast feeding, and 45 and 60 were breast fed for less than 3 and less than 6 months, respectively; only 10 control children were breast fed for less than 6 months. All ICC children's feeds had been in contact with brass vessels. Copper vessels were used for water carriage with equal frequency in cases and controls. Girls predominated amongst healthy older siblings of cases. Ninety-one healthy siblings of cases had been fed similarly to controls. Three pairs of twins with similar feeding histories died with ICC, whereas two pairs were discordant for feeding and outcome. Hepatic copper loading in ICC is attributable to copper contamination of early animal milk feeds.

Excessive hepatic copper accumulation occurs in long-lasting cholestatic liver disorders especially in primary biliary cirrhosis. As in Wilson's disease, penicillamine has recently been introduced for the treatment of primary biliary cirrhosis. In Wilson's disease there is decreased biliary excretion of copper. The present study shows that as compared with controls the biliary excretion of copper is not decreased in primary biliary cirrhosis; instead it may be increased in some patients. However, when compared with high hepatic copper concentration biliary copper excretion was low. In contrast with copper, biliary secretion of bile acids was decreased in eight of the 17 patients. Treatment with oral penicillamine (600 mg/day) for one year resulted in a significant decrease of hepatic copper concentration, but had no consistent effect on the biliary excretion of copper or on the amount of histologically stainable orcein-positive copper-binding protein. The results suggest that excessive hepatic copper accumulation in primary biliary cirrhosis may not be primarily caused by a decreased biliary excretion, or that a new equilibrium is achieved in advanced primary biliary cirrhosis. D-penicillamine appears to improve significantly the biliary excretion of bile acids.

A longitudinal study was carried out for evaluating the effect of D-penicillamine in the treatment of 85 biopsy proven cases of Indian childhood cirrhosis. The drug significantly (P< 0.002) reduced the serum and hepatic copper content and simultaneously there was improvement in clinical and symptomatic aspects. This therapy was compared with the conventional corticosteroid therapy. The D-penicillamine therapy was found to be superior (P< 0.002).

Copper (6 ppm) was administered to pregnant heterozygous brindled and normal mice from 13 to 18 days gestation. The copper and zinc concentrations in the cerebrum, cerebellum, liver, and kidneys of mothers and their fetuses were determined. The placental concentrations in fetuses of heterozygous mothers administered copper were also determined. The heterozygous mothers had smaller numbers of live fetuses than the normal mothers, but had the same number as normal mothers when copper was administered. The hepatic copper concentration in the heterozygous mothers was lower than that in the normal mothers and was not increased by the administration. The body and tissue wet weights of all fetuses were unaffected by the maternal genotype or drinking fluid. The cerebral copper concentrations in hemizygous and heterozygous fetuses were increased by the copper administration but did not reach normal levels. The hepatic and renal concentrations remained unchanged. The cerebral copper concentrations in normal fetuses of both heterozygous and normal mothers were increased by the copper administration. The copper administration increased the copper concentrations in liver of normal fetuses of heterozygous mothers and in kidneys of normal fetuses of normal mothers. The placental copper concentration in hemizygous fetuses was higher than those in heterozygous and normal fetuses. These results suggested that oral copper administration to pregnant females could improve an abnormal copper distribution in hemizygous and heterozygous fetuses without affecting fetal growth.

BR was referred to us at the age of 13 years because of slowly progressing neurological signs that had started two years earlier. Symptoms had been dyspnoea, sialorrhoea, ataxic unco-ordinated movements and choreic head and arm tremors. The child appeared excessively emotional. The intelligence quotient was good. Slight hepatomegaly and Kayser-Fleisher rings were found. Wilson disease was suggested by clinical findings and laboratory test results (cupraemia 46 µg dL−1 (normal range 65–165); cupruria 348 µg day−1 (normal

Forty-three patients were examined with computed tomography of the liver and liver biopsies with measurement of hepatic copper content. All recorded liver attenuation values were within normal range, even in patients with markedly elevated hepatic copper content. No statistically significant correlation between the liver attenuation values and the copper concentrations in liver tissue was demonstrated. At present, therefore, computed tomography has no place in monitoring the development of copper accumulation.

19 Indian children with liver disease were studied. 5 in whom a clinical and histological diagnosis of Indian Childhood Cirrhosis was made had massive orcein-staining deposits in liver cells. The hepatic copper content in these 5 cases was strikingly high (1389 microgram/g dry tissue, range 1045--2303) the normal range being 15--55 microgram/g. Of the other 14 cases, only 2 had hepatic copper levels above normal (170 and 262 microgram/g.) This high hepatic copper concentration may be caused by excessive copper ingestion or an abnormality of copper metabolism.

A patient with cryptogenic cirrhosis was found to have corneal pigmentation rings indistinguishable from Kayser-Fleischer rings on slit-lamp examination. Although she had hepatic encephalopathy that included confusion, tremor, and slurred speech, diagnosis of Wilson's disease was ruled out because urinary cooper excretion and hepatic copper concentrations were below the range found in symptomatic Wilson's disease. The exact nature of these rings could not be determined, and they were considered as Kayser-Fleischer-like rings. ( Arch Intern Med 138:1857-1858, 1978)

To the Editor. —It has been brought to our attention that there is incorrect information about Wilson's disease in the new 15th edition of The Merck Manual (pp 947 to 949), particularly regarding diagnosis and treatment. Wilson's disease, transmitted in an autosomal recessive fashion, is always fatal unless it is diagnosed and an appropriate lifelong therapeutic regimen instituted before progressive and irreversible pathology of the liver or brain develops. 1 Concerning diagnosis, a normal ceruloplasmin level is 200 to 500 mg/L (20 to 50 mg/dL) , not 150 to 400 mg/L (15 to 40 mg/dL). A concentration of hepatic copper greater than 250 μg/g dry weight (not >250 μg/g wet weight) is absolutely diagnostic if, and only if, the serum ceruloplasmin concentration is less than 200 mg/L ( 20 mg/dL). Diagnosing Wilson's disease in these patients

Previous results regarding the two metalloforms of MT which accumulate in chick liver following the parenteral administration (ip) of copper were discussed. One metalloform, which is exclusively zinc, was suggested to reflect the marked accumulation of hepatic zinc following copper injection. The present report shows that there is a marked difference in hepatic zinc accumulation if copper is administered iv. Under these conditions there is virtually no change in hepatic zinc and thus MT produced under these conditions appears to contain only copper. We suggest the the changes in zinc metabolism as effected by copper when given intraperitoneally reflect a secondary response analogous to that observed when iron is similarly administered.

New observations are described in a case of congenital hepatic fibrosis. Histochemical stains of liver tissue for copper (rhodanine) and copper associated protein (orcein) were positive and hepatic copper concentration, measured by atomic absorption spectroscopy, was markedly elevated being 550 micrograms/g dry weight (NR less than 30 micrograms/g dry weight). Mallory bodies were observed in several areas in liver sections. These observations have not been previously recorded in congenital hepatic fibrosis. Increased hepatic copper concentration in this case may have contributed to the production of liver damage. Hepatic copper concentration should be specifically measured in other patients with congenital hepatic fibrosis.

A method using nuclear resonant scattering of gamma-rays from a vapour phase 65ZnI2 source is described. A NaI:Tl crystal detector coupled to a photomultiplier is used and the output is amplified and the signals analysed in a 512 channel multichannel analyser.

SUMMARY Chronic hepatitis and increased hepatic copper concentrations, from 1,600 to 6,361 fig/g dry tissue were found in 4 related, Australian-bred Bedlington terriers. Two dogs were asymptomatic and 2 were clinically ill with signs referable to liver dysfunction. Two dogs were treated with d-penicillamine. After one year there was no improvement in the histopathological liver changes in either dog or significant lowering of hepatic copper level in one dog.

The authors established the diagnosis of hepatolenticular degeneration (HLD, Wilson's disease) in eight out of nine asymptomatic subjects suspected of being destined to develop the disease because of the finding of decreased serum ceruloplasmin concentration. Deficiency or absence of ceruloplasmin (less than 20 mg/ 100 ml of serum) is a necessary condition, and elevation of hepatic copper concentration above 100 μg/gm of dry weight is a sufficient condition, for a diagnosis of HLD in asymptomatic persons. The finding of nonspecific histologic changes in the livers of the eight subjects serves to confirm the presence of the disease. If the diagnosis is made, prompt adoption of an "anticopper" therapeutic regimen is recommended.

Wilson disease is an autosomal recessive disorder of hepatic copper metabolism with consequent copper accumulation and toxicity in many tissues and consequent hepatic, neurologic and psychiatric disorders. We report a case of Wilson disease with chronic liver disease; moreover, in our patient, presenting also with high levels of state anxiety without depression 99mTc-ECD-SPECT showed cortical hypoperfusion in frontal lobes, more marked on the left frontal lobe. During the follow-up of our patient, penicillamine was interrupted after the appearance of a lichenoid dermatitis, and zinc acetate permitted to continue the successful treatment of the patient without side-effects. In our case the therapy with zinc acetate represented an effective treatment for a Wilson disease patient in which penicillamine-related side effects appeared. The safety of the zinc acetate allowed us to avoid other potentially toxic chelating drugs; this observation is in line with the growing evidence on the efficacy of the drug in the treatment of Wilson disease. Since most of Wilson disease penicillamine-treated patients do not seem to develop this skin lesion, it could be conceivable that a specific genetic factor is involved in drug response. Further studies are needed for a better clarification of Wilson disease therapy, and in particular to differentiate specific therapies for different Wilson disease phenotypes.