A 50–year–old female presented to the hematology clinic for evaluation of pancytopenia. Past medical history significant for bariatric surgery performed one year ago. Complete blood counts were normal prior to surgery. Examination was negative for lympadenopathy and organomegaly. Initial labs showed pancytopenia, normal Vitamin b12, folic acid and Iron studies. Bone marrow biopsy showed hypo cellular marrow (10% cellularity) with no obvious myelodysplasia or malignancy, adequate iron stores, normal cytogenetics and flow cytometric analysis. Patient was referred to tertiary care center for further evaluation. Further investigations revealed marked decrease in serum copper and ceruloplasmin levels. Patient was started on intravenous copper chloride infusions once a month, which led to remarkable improvement in complete blood counts.
Copper (Cu) deficiency is an under diagnosed cause of various hematological abnormalities. It manifests as bicytopenia or pancytopenia. Cu is essential for function of numerous enzymes in the body, including ceruloplasmin, cytochrome c oxidase and copper–zinc superoxide dismutase. Patients with history of bariatric surgery, gastrectomy, small bowel resection, celiac disease and prolonged total parenteral nutrition are at risk for Cu deficiency. Myelodysplastic syndrome and other nutritional anemia’s mimic’s presentations of Cu deficiency, crucial part is to identify underlying risk factors. Review of the literature showed only few case series to date. We here report the case of 50–year–old female with pancytopenia and extensive work up finally revealed copper deficiency.
The physiology of Cu absorption is poorly understood in humans. Copper absorption is assumed to take place in stomach and proximal small intestine. Cu deficiency also known as hypocupremia is potentially serious and preventable complication following bariatric surgery. It should be considered in the differential diagnosis of high–risk patients who presents with unexplained cytopenias. With increase in number of bariatric surgeries since last decade, our case report aims to increase awareness among clinicians about the hematological manifestations of copper deficiency. We also emphasize to consider checking serum copper and ceruloplasmin levels during the initial work up for pancytopenia in high–risk patients.