Sideroblastic anemia secondary to zinc toxicity

Abstract

Sideroblastic anemia secondary to zinc toxicity A 52-year-old African-American woman with a history of allergic rhinitis and alcohol abuse presented with a presyncope. The following levels were found: hemoglobin, 3.7 g/dL; mean cell volume, 82 fL; white blood cell count, 9.2 3 10 3 /mL; and platelets, 168 3 10 3 /mL. The workup was negative for hemolysis or bleeding. Her blood alcohol level was normal. B 12 and folate levels were normal. A peripheral smear showed dimorphic red blood cells with Pappenheimer bodies (panel A). A bone marrow biopsy showed slightly hypercellular marrow with intact trilineage hematopoiesis and mild erythroid dyspoiesis. An iron stain showed adequate iron content and occasional ring sideroblasts (panel B). Marrow morphology and cytogenetic analysis did not support a myelodysplastic syndrome. Copper and ceruloplasmin levels were low at 515 mg/L and 16 mg/ dL (normal ranges, 810-1990 mg/L and 20-60 mg/dL), respectively. The zinc level was elevated at 186 mg/dL (normal range, 60-130 mg/dL). The patient admitted to self-treating her chronic cough with zinc lozenges for the last 4 months.Our impression was that sideroblastic anemia caused by copper deficiency induced by zinc lozenge use was a significant component of the severe anemia. Zinc lozenges were discontinued, and copper supplements were initiated, with complete hematologic recovery in 4 weeks. For additional images, visit the ASH IMAGE BANK, a reference and teaching tool that is continually updated with new atlas and case study images. For more information visit http://imagebank.hematology.org.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

“…Special attention should be made to avoid oversupplementation during this period, which could be a result of faulty a priori decision‐making, various mutations/polymorphisms, altered physiology, especially decreased binding proteins, confounded or unnecessary biochemical testing, and indiscriminate/inappropriate continuation that induces other metabolic derangements . This includes, but is not limited to, iron , zinc , and vitamin D . With respect to routine vitamin D supplementation, patients who have had an SG or RYGB had comparable 12‐month safety and effectiveness with early postoperative individualized dosing starting with only 800 IU/d and uptitrated based on serum levels or a fixed high dose with 2,000 IU/d .…”

The Implications of Zinc Therapy in Combating the COVID-19 Global Pandemic

“…At the same time, chronic overdose manifests as sideroblastic anemia, neurological disorders, granulocytopenia, myelodysplastic syndrome, and copper deficiency. [183][184][185] Furthermore, there have been no reports of deaths or significant life-threatening adverse drug reactions related to zinc supplementation. 186 Therefore, both preventive and therapeutic doses should be determined for COVID-19 patients considering age, gender, and comorbidity to avoid further consequences.…”

Absorption Mechanisms of Iron, Copper, and Zinc: An Overview

“…Unintended imbalance in the concentrations of these metals can lead to deficiency or overload disorders as described above, which may cause some diseases. For example, excess zinc is known to induce copper deficiency, leading to reduction of iron absorption, which eventually results in anemia (80,81). Moreover, intricate interactions between iron, copper, and zinc have been found, although the molecular mechanisms underlying these interactions are not yet known (11).…”