Menkes disease

Last revised by Dr Francis Fortin on 30 Mar 2022

Menkes disease, also known as trichopoliodystrophy or kinky hair kinky vessel syndrome, is an X-linked recessive disorder that results in a derangement in copper handling. It results in low copper levels and subsequently, deficiency in copper-dependent mitochondrial enzymes. 

Menkes disease is rare, occurring in 1 case per 300,000 population.

Signs and symptoms typically appear in infancy.  Hair may be fine, silvery and brittle (kinky hair) and connective tissue disturbances lead to loose skin.

There is progressive neurologic deterioration: seizures usually begin in the first few days or months of life with progressive hypotonia and developmental delay in the first year of life.

Other features include pectus excavatum, failure to thrive/gain weight, and urinary bladder diverticula 8

Menkes disease is a multisystem disorder with an X-linked recessive inheritance, caused by mutation of the gene ATP7A located on Xq13.3. Two-thirds of patients have a positive family history, while the other one-third of patients have spontaneous mutations.

  • metaphyseal widening of the femur and ribs
  • tibial and femoral spurs
  • Wormian bones

Brain manifestations of Menkes syndrome are progressive cerebral and cerebellar atrophy, elongated and tortuous intracranial vessels as well as bilateral subdural collections or bleeds.

At birth, the brain often appears normal on MR images.

During the course of the disease, however, rapidly developing cerebral and cerebellar atrophy and prominent white matter changes can occur 4.

  • T1: can show hyperintensity of the basal ganglia similar to that of chronic hepatic encephalopathy
  • MR angiography: cerebral vessels usually are tortuous and elongated on MR angiograms 4-6

Chronic bilateral subdural hematomas also may be visualized.

The condition is lethal and affected males typically die by age 2-3 years. Pneumonia or respiratory infection is the usual cause of death. Treatment is mainly supportive.

Menkes disease is named after the American physician John H Menkes (1928-2008) 7.

Menkes disease may mimic non-accidental injury (NAI) with retinal hemorrhage and bilateral subdural hematomas. Hence, prudence is advised in always ruling out NAI, particularly when other intracranial signs of Menkes disease are not seen. In a similar manner, the differential diagnosis also includes glutaric aciduria.

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Cases and figures

  • Case 1: with neuroimaging features
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