LEARNING OBJECTIVES After participating in this activity, the learner will be better able to: Discuss the histologic presentation of Wilson disease on liver biopsy. Identify indications for copper dry weight, if Wilson disease is suspected. CASE PRESENTATION A 22-year-old female with a history of familial hypercholesterolemia and elevated body mass index (>40 kg/m2) presented to the hospital with 1 month of diffuse abdominal pain, increased abdominal girth, jaundice, and dark urine. Laboratory workup revealed abnormal elevations in liver enzymes with asparte aminotrasnferase 858 U/L (reference: 15–41 U/L), alanine aminotransferase 274 U/L (reference: 14–54 U/L), alkaline phosphatase 112 U/L (reference: 24–110 U/L), total bilirubin 10.8 mg/dL (reference: 0.4–1.5 mg/dL), and coagulopathy with international normalized ratio 2.7 (reference: 0.9–1.1). She was also noted to be mildly anemic with a hemoglobin of 11.4 g/dL (reference: 12–15.5 g/dL), mean corpuscular volume 89 fL (reference: 80–98 fL), and a normal platelet count of 213×109/L (reference: 150–450×109/L). An ultrasound revealed heterogenous liver parenchyma with a nodular liver margin consistent with cirrhosis, moderate ascites, and splenomegaly. There was no family history of liver disease. She reported drinking 1–2 alcoholic beverages occasionally on weekends. Her social history was also notable for lack of health insurance despite having a full-time job. She took fish oil and vitamin D. Of note, she had mildly elevated liver enzyme levels 11 years ago during evaluation for hypercholesterolemia (Table 1). She had not had follow-up testing for this and had not been receiving regular primary care due to lack of insurance. TABLE 1 - Laboratory Values During Hospital Admission 11 years Day 0 Day 3 Day 6 clinic Day 9 Day 14 Day 16 FK started Day 21 Day 25 WD established Day 28 TPE started Day 41 OLT Day 55 discharge Current AST (reference: 15–41 U/L) 53 858 666 856 744 452 455 264 220 162 136 33 17 ALT (reference: 14–54 U/L) 60 274 211 299 325 364 371 232 211 147 86 89 24 Alkaline phosphatase (reference: 24–110 U/L) 201 112 102 103 86 101 103 80 90 84 73 176 73 Total bilirubin (reference: 0.4–1.5 mg/dL) 0.6 10.8 10.6 9.2 9.7 6.4 7.7 9.2 10.3 12.8 21.2 2.0 0.2 Albumin (reference: 3.5–4.8 g/dL) 4.1 2.8 2.4 2.5 3.1 2.6 2.6 4.1 3.5 4.1 3.0 2.4 3.8 Sodium (reference: 135–145 mmol/L) 138 133 134 132 134 133 133 134 133 133 135 137 138 Creatinine (reference: 0.4–1.0 mg/dL) 0.7 0.9 1.0 2.2 1.1 0.8 1.2 1.0 1.6 1.9 1.5 0.6 0.9 Hemoglobin (reference: 12.0–15.5 g/dL) 13.0 11.4 11.7 12.1 9.6 10.8 10.8 10.4 10.4 9.6 7.9 7.8 13.1 Platelets (reference: 150–450×109/L) 330 213 225 274 109 128 127 119 139 83 109 314 253 Prothrombin INR (reference: 0.9–1.1) NA 2.7 2.4 2.3 3.1 2.7 2.8 3.3 3.9 4.1 4.2 1.0 NA This table summarizes our patient’s laboratory testing throughout her entire course. Included are values from 11 years before presenting with liver failure. Notably, the patient had not had any interval labs or checkups before this presentation.Abbreviations: Ab, antibody; ALT, alanine aminotransferase; AMA, antimitochondrial antibody; ANA, antinuclear antibody; ASMA, anti–smooth muscle antibody; AST, asparte aminotrasnferase; FK, tacrolimus; INR, international normalized ratio; NA, not available; TPE, therapeutic plasma exchange; WD, Wilson disease. Serologic evaluation revealed a positive antinuclear antibody with a titer of 1:160, a negative anti–smooth muscle antibody, elevated IgG level of 2160 mg/dL (reference: 588–1572 mg/dL), and a ceruloplasmin level of 22 mg/dL (reference: 20–60 mg/dL). Serologic testing revealed no evidence of hepatitis A, B, or C infection. She was started on oral glucocorticoid therapy for presumed autoimmune hepatitis (AIH). Her liver enzyme levels modestly improved (Table 1). Given clinical stability and a desire to spend time with family over the holidays, she was discharged on prednisone 40 mg daily and spironolactone 50 mg daily with close outpatient liver clinic follow-up and plan for potential biopsy. In clinic, repeat laboratory evaluation showed rising liver enzyme levels, ongoing coagulopathy, and new renal dysfunction (Table 1). Her Model for End-Stage Liver Disease Sodium (MELD-Na) score was 33. She was readmitted to the hospital, started on i.v. methylprednisolone, and underwent liver biopsy with histopathologic findings of cirrhosis and hepatic necrosis seen as described in Figure 1. The biopsy contained abundant Mallory-Denk bodies and prominent neutrophilic satellitosis. The findings of abundant neutrophilic inflammation, Mallory hyaline, and cholestasis were suggestive of a possible drug-related component to the liver injury, possibly concurrent with an AIH not well seen in this biopsy due to steroid therapy. The differential diagnosis for these findings was, however, broad, and other primary processes including biliary, infectious, or metabolic could not be excluded on the basis of these findings. She continued on steroid therapy. Given some improvement in her aminotransferases, stabilization of her coagulopathy, and resolution of the kidney injury on i.v. steroids, tacrolimus (FK) was added due to ongoing suspicion of AIH because it was felt that the biopsy did not show the typical inflammation from AIH given the degree of necrosis and prior steroid treatment. In addition, ongoing workup for alternative causes was pursued in conjugation with working with hospital and state resources for insurance coverage given her high MELD-Na score. Given the low normal ceruloplasmin in a young patient with acute liver injury, a 24-hour urine copper measurement as performed, which yielded 5327 mcg of copper excreted (normal: 9–71 mcg/24 h). Furthermore, she had a liver copper dry weight of 2445 mcg/g (normal <50 mcg/g), highly suggestive of Wilson disease (WD). Around this time, she was developing worsening anemia and thrombocytopenia with a hemoglobin nadir of 7.7 g/dL and platelet count of 71×109/L. Hematologic evaluation revealed hemolytic anemia, further supporting the diagnosis of WD. Consequently, Immunosuppression therapy was reduced, and she was started on zinc and penicillamine chelation therapy. Unfortunately, this did not have significant effect, and she subsequently underwent plasmapheresis. With successful efforts made to secure insurance coverage, she completed evaluation and was listed for liver transplant with a MELD-Na score of 38. She underwent successful orthotopic liver transplantation. Over 1 year since liver transplant, she is doing well with normal allograft function.FIGURE 1: Initial diagnostic biopsy in this patient revealed cirrhotic morphology with abundant Mallory-Denk bodies (arrowheads) and prominent neutrophilic satellitosis (arrows) throughout the biopsy. Though most commonly associated with alcoholic steatohepatitis, these findings have been reported in cirrhotic liver due to Wilson disease. Notably, the findings were not specific for an etiology for the patient’s fibrosis. The history of steroid therapy was noted. The findings of abundant neutrophilic inflammation, Mallory hyaline, and cholestasis were suggestive of a possible drug-related component to the liver injury, possibly concurrent with an autoimmune hepatitis not well seen in this biopsy due to therapy. The differential diagnosis for these findings was, however, broad, and other primary processes including biliary, infectious or metabolic could not be excluded on the basis of these findings.DISCUSSION In 1912, Sir William Alexander Kinnier Wilson first described hepatolenticular degeneration, linking degenerative neurological changes with liver cirrhosis.1 Named after Sir Wilson, WD is an autosomal recessive mutation in the ATP7B-encoding gene involved in copper metabolism.2,3 ATP7B, predominantly found in hepatocytes, is a copper-transporting ATPase responsible for incorporating copper into ceruloplasmin and its excretion into bile.2,3 ATP7B is absent or dysfunctional in WD patients leading to decreased copper excretion and accumulation in hepatocytes, which eventually exceeds safe storage levels and subsequent hepatocellular injury occurs.3 Copper is subsequently released into circulation and deposited into other organs, most prominently the central nervous system, causing neuropsychiatric disorders and manifestations such as Kayser-Fleischer rings.1–3 Failure to incorporate copper into ceruloplasmin leads to reduced hepatic production and its decreased serum levels found in most WD patients.2 Nevertheless, it is important to note that ceruloplasmin can be an acute phase reactant, and as a result serum levels may be normal. Consequently, as highlighted in this case, ceruloplasmin level is not a reliable indicator of acute on chronic liver failure (ACLF) or acute liver failure (ALF) due to WD given that multiple factors can affect its secretion and serum levels.2,4 Serum copper is usually decreased in WD in conjunction with decreased ceruloplasmin. However, in ACLF or ALF, destruction of hepatocytes leads to an increase free copper; hence, WD patients with liver failure may have normal or elevated total serum copper levels. Studies on diagnostic testing for WD have shown low sensitivity and specificity of ceruloplasmin and serum copper levels in identifying patients with ALF due to WD.4 In the case of our patient, she never developed encephalopathy and as such met criteria for ACLF (bilirubin >5 and international normalized ratio >1.5 complicated within 4 weeks by clinical ascites with or without encephalopathy in a patient with previously diagnosed or undiagnosed cirrhosis or chronic liver disease).5 Acute decompensation of liver function in a patient with WD has been described as a classic example of ACLF.6 The estimated prevalence of WD is 1:30,000–1:50,000, but it is possible that a significant number of WD cases are overlooked with dire consequences.7 Classically, WD patients present between their first and third decades of life with liver injury or failure, a low serum ceruloplasmin, and Kayser-Fleischer rings.2 Patients presenting in their first or second decades of life typically have liver disease whereas those presenting with neuropsychiatric disorders tend to be in their third or later decades of life.3 These criteria alone are not reliable in establishing or eliminating a diagnosis of WD. About 50% of patients with liver disease do not meet 2 of the 3 above-stated criteria.2–4 If WD is not actively pursued, delays or failure of diagnosis can lead to poor outcomes.3,7,8 In this case, WD was initially dismissed in favor of AIH given the normal ceruloplasmin level, positive autoimmune markers, and absence of neuropsychiatric findings. There are a few cases in the literature of WD resembling AIH with patients having elevated titers of autoimmune antibodies and IgG.8,9 Similar to our case, these patients failed to respond to IS and did not improve until the diagnosis of WD was made and appropriate therapy was initiated.8,9 Given these diagnostic challenges, the Leipzig score, a WD scoring system with good diagnostic accuracy, was developed by a group of experts in 2001 and included in European societal practice guidelines in 201210 (Figure 2). Although well validated, this scoring system is not without limitations as it does not guide clinicians through an algorithmic approach to testing. If cases involve no neuropsychiatric findings and a normal ceruloplasmin, liver biopsy with copper quantification would be required to cross the 4-point Leipzig score threshold for diagnosing WD. Of note, in the setting of fibrosis the usefulness of Orcein copper staining is limited, and copper dry weight is more reliable.FIGURE 2: This is the diagnostic criteria for Wilson disease, which was developed at an international meeting in 2001 in Liepzig, Germany. This table is adapted from the EASL guidelines on the diagnosis and management of Wilson disease from 2012.10 Reproduced with permission from the publisher.About 5% of WD patients present with ALF and often have normal or low serum alkaline phosphatase, modest elevations in serum aminotransferases, coagulopathy unresponsive to vitamin K therapy, Coombs-negative hemolytic anemia with acute intravascular hemolysis, and female-to-male ratio of 2:1.2,3,10 These patients tend to present in their second or third decade of life and have previously unobserved advanced fibrosis or cirrhosis.3,11 Moreover, while current data is sparse, there is emerging evidence that ACLF in WD patients carries an overall 3-month mortality as high as 75.4% in the absence of encephalopathy and 96% if encephalopathy is present.6 As such, the timely diagnosis and immediate evaluation for liver transplantation in WD patients with ALF or ACLF are essential given the almost certain progression of liver failure and death in the absence of therapy. Lifelong pharmacological copper chelation therapy is the mainstay treatment for WD (Figure 3).2,10 The goal of therapy is preventing progression of liver disease, neurological symptoms, and organ failure. This is particularly important in asymptomatic patients without any disease manifestations. Societal guidelines recommend molecular testing, if available, to screen for WD in first-degree relatives of a patient with a secure diagnosis of WD.2,10 If molecular screening is unavailable, blood and urine testing can be performed, and if normal should be repeated in 2–5 years.2 In our patient’s case, her siblings were referred to a genetic counselor for molecular screening. For WD patients with progressive symptoms and severe liver dysfunction or liver failure, liver transplant is the only option and is curative. When temporary barriers to transplant exist—such as lack of insurance as in this case—and the patient shows signs of anemia, renal dysfunction, and coagulopathy, therapeutic plasma exchange can be an effective adjunctive treatment.12 Therapeutic plasma exchange quickly removes albumin-bound copper and stabilizes hemolytic anemia and coagulopathy, thus potentially allowing for time until transplantation is possible.12FIGURE 3: This is a summary of the available pharmacological chelation therapies available to treat Wilson disease. This table is adapted from the AASLD guidance on the diagnosis and management of Wilson disease.2 Reproduced with permission from the publisher.Finally, this case highlights the importance of evaluating social barriers to transplant and the need for program-level operational planning to address these barriers to transplant listing as highlighted by a 2011 study evaluating this issue across 61 of 104 US adult liver transplant programs.13 As described in this case, our young patient found herself in a race against time as she clinically deteriorated and was unable to be evaluated or listed for transplant until emergency health insurance was secured. It was found that 68.9% of the transplant programs surveyed cited inadequate or unstable health insurance as the social barrier to liver transplant listing.13 The vast majority of adult liver transplant centers in the US do not initiate a formal transplant evaluation at all if social barriers are present.13 KEY POINTS A normal ceruloplasmin level does not exclude a diagnosis of Wilson disease. The histologic presentation of Wilson disease on liver biopsy is variable, and therefore, copper dry weight should be requested if Wilson disease is suspected. Management of Wilson disease in patients presenting with features of ALF or ACLF should undergo prompt evaluation for liver transplantation.