Neurological manifestations in Wilson disease: clinical study and genotype correlations

A doença de Wilson, moléstia hereditária, caracteriza-se pela deficiência de excreção de cobre pelo fígado, originária da mutação do gene ATP7B. As manifestações neurológicas na doença de Wilson são pleomórficas, observando-se distúrbios do movimento com início insidioso e em idade variável - geralmente na segunda ou terceira décadas de vida. Este estudo, dividido em duas partes, descreve as manifestações neurológicas iniciais em 119 pacientes com doença de Wilson (93 casos-índice e 26 familiares acometidos), avaliados entre 1963 e 2004 dos quais 109 foram através de análise retrospectiva dos prontuários médicos, enquanto aos 10 pacientes restantes se dispensou avaliação clínica prospectiva, a partir de 2002. O início dos sintomas ocorreu na média etária dos 19,4 anos (7-37), e o tempo médio do surgimento dos sintomas ao diagnóstico de 1,1 +/- 1,2 anos (0-5 anos). Entre as manifestações neurológicas mais freqüentes, observaram-se: disartria (91%), distúrbios da marcha (75%), risus sardonicus (72%), distonia (69%), rigidez (66%), tremor (60%) e disfagia (50%). A incidência das manifestações coréia e atetose, 16% e 14%, respectivamente, foi baixa. Manifestações atípicas incluíram convulsões (4,2%) e sinais piramidais (3%). A segunda parte do estudo trata da investigação do genótipo ATP7B em 41 pacientes e suas possíveis correlações com o fenótipo neurológico. Encontraram-se 23 mutações distintas, a mais comum das quais (p.A1135fs) com freqüência alélica de 31,7%. Expressiva associação (p<0,05) se deu entre essa mutação e a manifestação disfagia, ainda que limitada por amostra restrita de pacientes. Também sugestiva foi a associação entre a mutação p.A1135fs e quadros neurológicos precoces e graves. Este é o primeiro estudo a comparar o genótipo ATP7B com as manifestações neurológicas na doença de WilsonWilson disease, a rare inborn metabolic error, is characterized by deficient hepatic copper excretion, due to mutations in ATP7B gene. Neurological manifestations may vary, although there is commonly a movement disorder starting in the second or third decade of life. This study is divided in two parts, and it describes the neurological manifestations in 119 patients with Wilson disease (93 index cases and 26 affected family members), which were seen between 1963 and 2004 a retrospective analysis in 109 medical records and prospective clinical evaluation in 10 patients since 2002. The average age of symptoms onset was 19.4 years (ranging from 7 - 37 years), and the mean time between the first symptom and diagnosis was 1, 1 +/- 1, 2 years. The most frequent neurological manifestations observed were: dysarthria (91%), gait disturbance (75%), risus sardonicus (72%), dystonia (69%), rigidity (66%), tremor (60%), and dysphagia (50%). Less frequent manifestations were chorea (16%), and athetosis (14%). Rare neurological presentations were seizures (4,2%), and pyramidal signs (3%). In the second part of this study, we ascertain ATP7B genotype correlations with distinct neurological phenotypes in 41 Wilson disease patients. A total of 23 distinct mutations were detected, and the p.A1135fs frameshift had the highest allelic frequency (31.7%). An association between a p.A1135fs mutation and dysphagia was detected (p<0, 05), but the limited number of patients restricts valuable conclusions. This analysis also suggests an association between this mutation and early and severe neurological presentation. This present study is the first one to evaluate an ATP7B genotype correlation with specific neurological profile in Wilson diseas

Neurological manifestations and ATP7B mutations in Wilson`s disease

Wilson`s disease (WD) is a rare inborn metabolic error characterized by deficient biliary copper excretion secondary to ATP7B gene mutations. Neurological presentations are variable in respect to both pattern and age of onset; commonly a movement disorder presents in the second or third decade. The aim of this study was to ascertain genotype correlations with distinct neurological manifestations in 41 WD patients in a Brazilian center for WD. A total of 23 distinct mutations were detected, and the frameshift 3402de1C had the highest allelic frequency (31.7%). An association between 3402de1C and dysphagia was detected (p = 0.01) but the limited number of patients is insufficient to allow one to draw conclusions. Both clinical studies analyzing larger cohorts and basic research on ATP7B protein function could potentially shed more light on our understanding of WD. (c) 2007 Elsevier Ltd. All rights reserved

Neuropsychological and quality of life assessment in patients with Parkinson's disease submitted to bilateral deep brain stimulation in the subthalamic nucleus

ABSTRACT Deep brain stimulation (DBS) has been widely used to control motor symptoms and improve quality of life in patients with Parkinsons disease (PD). Recently, DBS in the subthalamic nucleus (STN) has become the preferred target for patients with mixed motor symptoms. Despite resultant motor and quality of life improvements, the procedure has been associated with cognitive decline, mainly in language skills, and also with psychiatric symptoms. Objective: To evaluate the influence of DBS in the STN on cognition, mood and quality of life. Methods: We studied 20 patients with PD submitted to DBS in the STN from May 2008 to June 2012 with an extensive battery of cognitive tests including memory, language, praxis, executive functions and attention assessments; the Parkinson's Disease Quality of Life Questionnaire (PDQ-39); and the Hospital Anxiety and Depression Scale (HAD), were applied both before and after the surgery. Data was analyzed using SPSS version 17.0 and results compared using the paired Student's t test. Results: A total of 20 patients with pre and post-operative assessments were included. A statistically significant improvement was found in total score and on subscales of mobility, activities of daily living and emotional well-being from the PDQ-39 (P=0.009, 0.025, 0.001 and 0.034, respectively). No significant difference was found on the cognitive battery or mood scale. Conclusion: DBS in the SNT improved quality of life in PD with no negative impact on cognitive skills and mood

Which factors are associated with global cognitive impairment in Wilson's disease?

ABSTRACT Background: Patients with Wilson's disease (WD) present cognitive impairment, especially in executive functions. Which other factors might be associated with global cognitive decline in these patients remains unclear. Objective: To assess which factors are associated with worse performance on a global cognitive test in patients with WD. Methods: Twenty patients with WD underwent cognitive assessment with the following tests: the Mini-Mental State Examination (MMSE), Dementia Rating Scale (DRS), verbal fluency test, brief cognitive battery, clock drawing test, Frontal Assessment Battery, Stroop test, Wisconsin card sorting test, Hopper test, cubes (WAIS) and the Pfeffer questionnaire. MRI changes were quantified. Patients with poor performance on the DRS were compared to patients with normal performance. Results: Nine patients had a poor performance on the DRS. This group had lower educational level (9.11±3.58 × 12.82±3.06) and a greater number of changes on MRI (9.44±2.74 × 6.27±2.45). The presence of hyperintensity in the globus pallidus on MRI was more frequent in this group (66.6% vs 9.0%), with OR=5.38 (95% CI 0.85-33.86). Conclusion: Global cognitive impairment was prevalent in this sample of patients with WD and was associated with low educational level, number of changes on MRI and MRI hyperintensity in the globus pallidus