Paralysis Due to Thiamine and Copper Deficiencies Following Sleeve Gastrectomy Complicated by Oral Intolerance With Recurrent Pancreatitis

Abstract

Worsening obesity and widespread availability of laparoscopic surgery has led to an increase in bariatric weight loss procedures with long term consequences including nutritional deficiencies more common after malabsorptive procedures such as gastric bypass and biliopancreatic diversion. This is a case of a restrictive procedure that led to unexpected nutritional deficiencies with lasting disability. A 30 year old woman with a history of vertical sleeve gastrectomy 16 months prior had complications of oral intolerance due to several bouts of pancreatitis with prolonged hospitalization and total parenteral nutrition (TPN). Five weeks after surgery she developed ascending numbness and tingling of the feet leading to falls and inability to walk. She was treated for multiple vitamin deficiencies including Dry Beriberi and had several balloon dilations of her sleeve eventually tolerating enteral feeding again. She was improving with physical therapy but recurrence of oral intolerance led to progression of numbness, tingling, and weakness to include her face, hands, and abdomen causing her to present to the ED. Labs revealed deficiencies of copper and riboflavin with borderline thiamine levels as well as toxic levels of pyridoxine. Exam revealed motor and sensory polyneuropathies with an escutcheon sign to the umbilicus and weakness of lower extremities with loss of vibration and proprioception. Nystagmus and memory loss were consistent with Wernicke's Encephalopathy as well. Endoscopy was unrevealing and gastrointestinal symptoms resolved prior to discharge six days later with improvement of the neuropathy of the hands and face after IV and oral thiamine and copper supplementation. Although not often associated with sleeve gastrectomy, copper deficiency is associated with zinc supplementation and use of TPN as in this case. Currently, the ASMBS (American Society of Metabolic and Bariatric Surgery) only recommends checking levels in patients with suggestive symptoms who have had malabsorptive procedures, but not in restrictive. But in 2017, a small retrospective study of patients with gastric sleeves showed those with neuropathy displayed a pattern of low thiamine, copper, and riboflavin with toxic levels of pyridoxine which also causes neuropathy. Perhaps copper levels should be routine post-operatively in restrictive bariatric procedures. Consistent vitamin toxicities also speaks to the need for reevaluation of vitamin supplementation regimens.