Low alkaline phosphatase levels: a potential indicator of Wilson's disease

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Abstract
A young adult female patient presented with complaints of jaundice, intermittent vomiting, and weight loss. Upon examination, pedal oedema and abdominal distension were observed. Laboratory investigations indicated macrocytic anaemia, hemolysis, prolonged prothrombin time, mixed hyperbilirubinemia, elevated aspartate/alanine transaminase (AST/ALT), and a normal alkaline phosphatase (ALP). The investigations repeated showed an increase in bilirubin, AST, and ALT. However, the levels of ALP and the ALP: total bilirubin ratio (ALP:TB ratio) were found to be very low. This raised the suspicion of Wilson disease, and further laboratory workup was initiated. Urine (24-hour) and serum copper levels were elevated, while serum ceruloplasmin levels were lower. Based on this, the diagnosis of acute on chronic liver failure (ACLF) related to Wilson disease was made. The levels of ALP and the ALP:TB ratio remained low until the sixth day. This report demonstrates the clinical relevance of low levels of ALP and ALP: TB ratio and its diagnostic utility in establishing the diagnosis of Wilson disease.

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