Copper Deficiency as Cause of Unexplained Hematologic and Neurologic Deficits in Patient with Prior Gastrointestinal Surgery

Abstract

Copper is a trace mineral essential to hematopoiesis and to the structure and function of the nervous system. Copper deficiency is a rare cause of anemia, leukopenia, and myeloneuropathy, but should be considered in the differential diagnosis in a patient with prior gastrointestinal surgery. We report the case of a 51-year-old woman admitted for nonspecific neurologic symptoms ultimately found to be due to copper malabsorption. Case ReportsA 51-year-old female presented to the emergency department complaining of numbness and tingling in her distal lower extremities that had progressively worsened over the previous 4 weeks and had begun to affect her fingers 2 days before presentation. In addition, the patient stated that over the past 2 weeks she had experienced a progressively worsening shortness of breath, generalized weakness, fast heartbeat, and light-headedness.She had undergone a gastrectomy 16 years ago with Roux-en-Y and partial small bowel resection for treatment of Zollinger-Ellison syndrome as well as a Whipple procedure for chronic pancreatitis. Since her surgeries, she received vitamin B12 supplementation intramuscularly and was converted to oral supplementation several months before her presentation in the emergency department.On presentation, the patient's vital signs included a temperature of 36.7°C, blood pressure of 121/84, pulse of 80, respiratory rate of 18, oxygen saturation of 100% on room air, and weight of 43.2 kg. Initial neurological evaluation revealed diminished sensitivity to light touch and vibration and decreased proprioception in her toes and ankles. Her Babinski's reflex was positive bilaterally, and her Romberg was strongly positive. Her patellar and brachioradialis deep tendon reflexes were hyperreflexic bilaterally, but Achilles tendon reflexes were normal. Her cranial nerves were intact, and her sensation of pain and temperature were normal. Her motor strength was normal, but she had significant difficulty walking because of her sensory deficits. The physical examination was otherwise unremarkable.Laboratory tests in the emergency department included a hematocrit of 17% (normal range, 33% to 44.6%) with a mean corpuscular volume (MCV) of 105.9 fL (normal range, 80 to 96 fL). At this point, the patient was admitted for management of anemia and further evaluation of neurologic symptoms. She received a transfusion of 2 units of packed red blood cells, which brought her hematocrit up to 27%. She was also started on 100 mcg of vitamin B12 intramuscularly daily and 1 mg of folate orally daily.The patient's neurological and laboratory findings were initially attributed to vitamin B12 or folate deficiency, given her history of gastrointestinal surgery and recent conversion to oral vitamin B12 supplementation. However, her vitamin B12 and folate levels were available by the third day of hospitalization, with a vitamin B12 level of 738 pg/mL (normal range, 200 to 950 pg/mL) and folate level greater than 24 ng/mL (normal level, Ͼ0.9 ng/mL). Methylmalonic acid was 0.77 mol/L (normal lev...

Assessment of Serum Copper State after Gastrectomy with Roux-en-Y Reconstruction for Gastric Cancer

“…Some investigators have already reported copper deficiency with symptoms after non-bariatric gastrectomy [23][24][25] . Such patients presented with hematological or neurological symptoms, usually many years after the operations (5-21 years).…”

Copper and Lead

“…Relatively few cases of Cu deficiency have been reported (for example [160][161][162]), and these are often accompanied by confounding factors such as malnutrition, malabsorption, excessive gastrointestinal losses [152], and excess dietary zinc [163]. Clinically evident Cu deficiency is a relatively infrequent condition that can result in anaemia, compromised immune response and bone abnormalities (including osteoporosis and fractures) [164][165][166].…”

Microcalorimetric Study of Tetrahymena Growth Affected by Copper(II) Complexes

“…In particular, copper(II) complexes are known to play a significant role either in naturally occurring biological systems or as pharmacological agents [1][2][3][4][5]. As a biological element which always combines with protein (or enzyme) to form copper protein (enzyme), copper plays an important role in the hematopoiesis, the central nervous system, and the bone tissue [6][7][8][9][10][11]. Moreover, due to the ability of copper(II) complexes to cleave DNA, many copper(II) complexes were found to be possible medical uses in the treatment of many diseases including cancer [12].…”