Copper deficiency anemia after bariatric surgery

Copper is a trace mineral essential to hematopoiesis and to the structure and function of the nervous system. Copper acts as a ligand to ferroxidase II, which oxidizes iron, allowing it to be mobilized and transported from the hepatic stores to the bone marrow to be used in erythropoiesis..Copper deficiency is a rare cause of anemia, leukopenia, and myeloneuropathy. In this report we describe a case of a 49 year-old overweight Caucasian woman who was referred June 2008 to the Obesity Outpatient Clinic at UNIFESP for evaluation of muscular pain and weakness in both legs, fatigue and chronic anemia. The past medical history included Scopinaro Surgery for severe obesity in November 2004 when her weight was approximately 180 Kg (BMI 68.6 kg/m2). She lost considerable weight after surgery, with her weight being stable around 80 kg (BMI 30). Because of clinical manifestations of sub nutrition, protein and vitamin deficiencies and severe anemia, which lead to several hospital admissions, in February 2008 she was submitted to another surgery from conversion of the gastrointestinal surgical Scopinaro procedure to that performed by Capella. She also had a history of hypothyroidism, hyperuricemia and panic syndrome, requiring specific medications, beyond parenteral iron and B12 vitamin therapies for anemia. Physical examination revealed a bilateral edema and no other abnormality. Laboratory tests revealed hypoalbuminemia and hypochromic megaloblastic anemia with normal serum levels of B12 vitamin, iron and ferritin. Due to the persistence of the neurologic symptoms and anemia in spite of adequate iron and B12 vitamin therapies, the hypothesis of copper deficiency was considered and a low serum level of 40μg/dl was found. An oral supplementation with high doses of copper resulted in evident clinical and laboratorial improvements after eight weeks of therapy. The diagnosis of copper deficiency has to be part of the differential diagnosis in patients with unexplained neurologic symptoms, anemia, and leukopenia, especially in those who underwent to previous gastrointestinal surgery