Hypocupremia

Abstract

Purpose: With the mounting number of gastric bypass surgeries for the treatment of morbid obesity, complications of nutritional deficiencies must be recognized. A rare nutritional deficiency after gastrojejunal bypass is hypocupremia, which is clinically indistinguishable from the neurologic deficits of vitamin B12 deficiency. In addition, hypocupremia has been implicated in hematologic abnormalities of anemia and neutropenia. We describe a case with the rare combination of neurologic and hematologic abnormalities secondary to gastric bypass-associated hypocupremia. Methods: Case Report Results: A 45 year old white female underwent a Roux-en-Y gastric bypass for morbid obesity six years prior to presentation and complained of 15 months of progressive symptoms of lower extremity paresthesias, dysesthesias, and weakness. She had no other significant past medical or surgical history. On neurologic examination, the patient demonstrated a wide-based gait and a decreased tandem walk. Examination of her lower extremities demonstrated a bilateral absence of vibratory perception, decreased pin-prick to her ankles, strength of +1 and spastic quadriceps muscle stretch reflexes. A serum copper of 24 ug/dL (normal 80–155) and ceruloplasmin of 9 mg/dL (normal 22–58) were demonstrated. Concurrent with her neurologic deficits, the patient had episodes of anemia and neutropenia, which, at their nadirs, were 9.2 g/dL (normal 12–15) and 4.1 K/cumm (normal 4.5–11), respectively. Homocysteine, vitamin B12, ferritin and methylmalonic acid levels were normal. Upper endoscopy identified no abnormalities and biopsies of the small intestine were negative for celiac sprue. A thoracic spine MRI demonstrated a minimally increased focus of T2 signal intensity in the central spinal canal from T4 through T7. The patient was treated with an oral preparation of elemental copper at 2 mg/day, which halted the progression of the patient's neurologic symptoms and resulted in the complete resolution of her anemia and neutropenia within 2 months. She remains stable after 9 months follow-up. Conclusion: Copper is absorbed in the stomach and proximal small intestine; as a result, gastrojejunal bypass predisposes patients to copper deficiency. Since the recognition of hypocupremia after gastric bypass as a cause of myeloneuropathy, 15 cases have been reported in the literature with a further smaller proportion of patients demonstrating concomitant hematologic disturbances. The aim of this report is to raise the index of suspicion for hypocupremia in post-gastric bypass patients, who present with either neurologic or hematologic abnormalities related to copper deficiency.