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A 38-year-old woman presented to the emergency department because of increasing fatigue and shortness of breath, worsening during the past 2 months. At the time of presentation, even minimal exertion caused her to become short of breath. She denied chest pain, cough, expectoration, orthopnea, paroxysmal nocturnal dyspnea, recent fevers, or chills. Her medical history was remarkable for a Roux-en-Y gastric bypass procedure 16 years earlier for morbid obesity. Her weight before surgery was approximately 100 kg (220 pounds), but she had lost considerable weight after surgery, with her recent weight being stable at around 57 kg (125 pounds). She had a history of frequent upper respiratory tract infections, urinary tract infections, and yeast infections since her obesity surgery.
Physical examination revealed a pale woman who appeared malnourished and in mild distress. She was afebrile. The patient's vital signs were as follows: pulse rate, 110 beats/min; respiration rate, 16 breaths/min; and blood pressure, 110/70 mm Hg. Her pulse oximetry revealed normal oxygen saturation while breathing room air. A grade 2/6 systolic ejection murmur was heard over the left sternal border. Her chest was clear to auscultation bilaterally. Examination or her ear, nose, and throat was remarkable for cheilitis and glossitis.
A complete blood cell count yielded the following results (reference ranges shown parenthetically): hemoglobin, 6.1 g/dL (12.0-15.5 g/dL); hematocrit, 18.1% (34.9%-44.5%); mean corpuscular volume, 104 fL (81.6-98.3 fL); white blood cell count, 1.1 × 109/L (3.5-10.5 × 109/L); and platelet count, 254 × 109/L (150-450 × 109/L). She had a blood urea nitrogen level of 17 mg/dL (6-21 mg/dL), a creatinine level of 0.7 mg/dL (0.6-0.9 mg/dL), and a reticulocyte count of 2.11% (0.60%-1.83%). A differential white blood cell count revealed 66% lymphocytes (16%-52%), 19% monocytes (1%-11%), and 11% neutrophils (42%-75%). A peripheral smear revealed mostly macrocytes, few hypochromic microcytes, and dacrocytes, with no schistocytes or spherocytes.
Bariatric surgical procedures cause weight loss through restrictive or malabsorptive processes or a combination of the two. Although low macronutrient and micronutrient levels are common after bariatric surgery, consensus has not been reached regarding supplementation. These patients require close follow-up with attention to individual signs and symptoms to avoid serious morbidity from nutrient deficiencies.14
Once a rare entity, acquired copper deficiency is becoming more recognized with the increase in gastric bypass procedures. Exogenous zinc ingestion, malnutrition, parenteral alimentation, and malabsorption are also recognized risk factors for copper deficiency. Copper deficiency has multiple clinical consequences because copper is an essential metal for the development and function of the bone marrow as well as the nervous system. Microcytic hypochromic anemia is most commonly seen with hypocupremia, but sideroblastic and macrocytic anemias have also been reported. Copper supplementation promptly resolves the anemia and neutropenia.9
Hypocupremia can present with many neurologic manifestations, including sensory ataxia, proprioceptive deficits, and paresthesias. The sensory ataxia is secondary to dorsal column dysfunction and often leads to gait difficulties. Clinical and neuroimaging findings closely resemble those for subacute combined degeneration seen in patients with vitamin B12 deficiency. Copper supplementation may prevent further neurologic deterioration in these patients, but it may not reverse them.9,15
Copper deficiency should be considered in patients who have undergone gastric bypass surgery and who develop unexplained anemia and neurologic symptoms. Copper deficiency can mimic vitamin B12 deficiency. However, in copper deficiency, symptoms continue to progress despite adequate vitmain B12 supplementation and normal vitamin B12 levels. Treatment of copper deficiency quickly reverses the hematologic symptoms and may prevent further neurologic disease progression.
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Correct answers: 1. e, 2. a, 3. e, 4. b, 5. d