Hypocupraemia-related drug-refractory seizures in Wilson disease

Wilson disease is an inherited disorder of copper metabolism caused by an ATP7B gene mutation, which encodes a protein responsible for excreting excess copper into bile and plasma. The excess copper deposits in the liver, brain and cornea. Copper deposition in the brain causes neuronal loss, gliosis and cavitation in the cortex/basal ganglia/brainstem. Cortical lesions increase patients' liability to seizures. Other causes of seizures in Wilson disease include acute copper shifts and pyridoxine deficiency produced by copper chelating drugs and hepatic encephalopathy. Copper-free diets and copper chelating drugs sometimes cause copper deficiency, resulting in anaemia, thrombocytopenia, neuropathy and myeloneuropathy. Hypocupraemia may rarely cause seizures. We describe a patient with Wilson disease who developed refractory focal seizures with impaired awareness that were resistant to multiple antiseizure medications, midazolam, intravenous methylprednisolone (given in view of recent new-onset refractory status epilepticus), parenteral pyridoxine and the treatment for hepatic encephalopathy. His seizures improved promptly with copper supplementation.