Abstract
Copper is an essential cofactor in many enzymatic reactions vital to the normal function of the hematologic, vascular, skeletal, antioxidant, and neurologic systems. Parenteral nutrition and chronic tube feeding are used in various mal-absorptive syndromes, including following gastrectomy and gastric bypass surgery. Features of copper deficiency include hematologic abnormalities (anemia, neutropenia, and leukopenia) and myeloneuropathy; the latter is a rarer and often unrecognized complication of copper deficiency.
We describe a 36 -year-old Emirati woman who was referred to endocrinology service because of generalized body weakness and fatigue post bariatric surgery. The patient initially noted a lower extremity swelling in feet bilaterally that worsened in severity over time and progressed up to knees. Over a 3 month period, her ability to ambulate gradually deteriorated. She also noticed maculopapular skin rash over both shins. Patient had Sleeve Gastrectomy in 2011. Followed by conversion of sleeve to RYGB surgery in 2018 due weight loss failure. Patient is known to have well controlled hypothyroidism on thyroxine. She was prescribed vitamin D, neurobion, iron and multivitamins tablets post surgery but never been compliant. The patient was admitted with severe malnutrition due to poor oral intake over the last 5 months prior to admission. Her total weight loss was 34.5 kg (32% weight change, BMI 28 .52kg/m2) in less than 9 months post surgery. Initial labs revealed severe hypoalbuminemia, normochromic anemia and neutropenia. Iron, folate, thiamine, and vitamin B12 levels were normal. Vitamin B6 level was normal at 11 mcg/L (normal = 5-50 mcg/L). The serum copper level was low at 310 µg/l (normal = 794-2023µg/l). Zinc level was low at 447 µg/l (normal = 551-925µg/l). Nutritional needs were estimated using the following formulas; 22-25 kcal/kg ideal body weight (IBW)/d and 1.5-2.0 g protein/kg IBW/d, 30-35 ml IVF/kg /d. The patient’s input/output, body weight, and clinical status were monitored. Parenteral nutrition additive copper 0.3 mg/day and oral copper 8 mg daily, resulted in the rapid correction of hematologic indices over one week. Combined multivitamins supplementation and oral copper supplements alone normalized serum copper levels over 4 weeks and resulted in resolution of weakness and body edema.
This report serves to alert physicians of the association between bariatric surgeries and subsequent severe copper deficiency in order to avoid diagnostic delays and to improve treatment outcomes.
Severe malnutrition after bariatric surgery and clinic manifestations of infection
