the initial manifestations are neurologic in 40% of patients , hepatic in 40% and psychiatric in 15% of patients .
wd is an autosomal recessive condition characterized by inability of the liver to transport and store normally absorbed dietary copper , resulting in abnormal deposition of copper in the basal ganglia , eyes , liver and other tissues . in 1912 ,
kinnier wilson published a description of 12 patients who presented with extrapyramidal motor disease and , on autopsy , demonstrated softening of the lenticular nucleus and cirrhosis of the liver .
he further noted that these patients exhibited  emotionalism  , and 2 of his 12 patients presented with schizophrenic - like psychoses .
scheinberg and sternlieb wrote that 1025% of patients with wd initially present with psychiatric symptoms .
psychiatric symptoms in wd may range from major depression , mania , and anti - social behavior to psychosis .
g. d. , a 32-year - old unmarried gentleman born of non - consanguineous parents , presented with personality change and behavioral disturbances since the last 6 months .
the behavioral disturbances were in the form of emotional liability , aggressiveness and disinhibition and delusions .
he had past history of jaundice at 18 years of age which resolved in 3 months .
physical examination at the time of the admission revealed a kf ring obvious on naked eye examination and risus sardonicus .
higher mental function examination revealed impaired attention span  7 days of week forward and 2 days of a week backward , and he was able to comprehend two - stage axial commands .
he lost three points in orientation to time , two points in orientation to place , five points for calculation , one point in construction and one point in recall .
he had impaired abstract thinking and could not explain the meaning of a given proverb .
complete blood count ( cbc ) was normal ; total bilirubin : 0.6 mg% ; direct bilirubin : 0.15 mg / dl ; total protein : 8.2 g / dl ; albumin : 4.8 g / dl ; globulin : 3.4 g / dl ; serum glutamic oxaloacetic transaminase ( sgot ) : 35 iu ; serum glutamic pyruvic transaminase ( sgpt ) : 22 iu ; alkaline phosphatase : 84
the 24-hour urinary copper was significantly elevated , i.e. 635.52 g / day ( normal 32 - 64 g / day ) .
usg abdomen revealed liver parenchymal disease with minimal free fluid in the abdomen along with splenomegaly .
for the severe agitation and restlessness , he was given injection haloperidol 5 mg i m in bid doses for 2 days
haloperidol was replaced with quetiapine 25 mg tablet which was increased to bid over the next 2 weeks .
after 2 weeks of inpatient treatment with antipsychotics and sedatives , his behavior was controlled .
the patient was started on penicillamine 250 mg daily which was gradually increased to 250 mg five times a day supplemented with pyridoxine 40 mg daily .
wd is an autosomal recessive disease characterized by inability of the liver to transport and store normally absorbed dietary copper , resulting in abnormal deposition of copper in the basal ganglia , eyes , liver and other tissues .
he had emotional lability , disinhibition and was severely agitated , restless with delusional thoughts .
since the psychiatric symptoms in wd are generally mild , patients may not present with these symptoms .
of the 108 patients , only 9 ( 8.3% ) manifested severe psychiatric symptoms that required admission . among these patients , only one patient developed bipolar disorder that began some months before the onset of neurologic disorder .
our patient presented with severe neuropsychiatric symptoms and had tremors on examination which were present since 5 years .
a high degree of suspicion and early detection of wd is critical because early initiation of chelation therapy can prevent a catastrophic outcome .
 wilson 's disease ( wd ) is a relatively rare disease of copper metabolism . 
 the diagnosis is often missed initially . 
 the presentation is usually neurologic or hepatic , seen in 40% of patients . 
 psychiatric presentation of wd is reported in only 15% of patients . 
 we present a 32-year - old patient with severe psychiatric manifestations . on examination , he had mild rest and postural tremors and a kf ring was seen . 
 serum ceruloplasmin was low and 24-hour urinary copper was elevated . 
 the patient responded to penicillamine , lorazepam and quetiapine , and is being followed up . 
INTRODUCTION
CASE REPORT
DISCUSSION