Copper Deficiency Secondary to Bariatric Surgery Mimicking Myelodysplasia.

Introduction: Bariatric Surgery is promoted as a successful method for weight loss and is performed with increasing frequency. The benefits and the short term risks of the surgical procedure are well understood. However, its long term pathophysiological consequences are still for the most part unknown. They may include metabolic changes that result in malnourishment and malabsorption. Deficiency disorders of iron, B-12 and folate are commonly encountered. However hematological problems from copper deficiency due to malabsorption have not been well studied.

Background: Copper and Iron are essential trace elements through their functions as co-factors in numerous biochemical reactions. Hephaestin, a transmembrane copper-dependent ferroxidase, is necessary for effective iron transport from intestinal enterocyte into the circulation. Copper is hence required for iron absorption. Copper enzymes such as superoxide dismutase and cytochrome oxidase have an essential role in red cell development and heme maturation.

Patients and Method: We present data on five patients referred for treatment of myelodysplasia whose evaluation revealed copper deficiency and low ceruloplasmin level. All five patients were female and had undergone gastric bypass surgery for weight reduction. The hematological features included pancytopenia, erythroid hyperplasia and dysplasia with increased blasts mimicking erythroleukemia, multilineage dysplasia with ring sideroblasts, bilineage megakaryocytic and erythroid dysplasia. One patient presented with neutropenia and anemia with a normal bone marrow; she was found to have copper deficiency. No cytogenetic abnormalities were observed and the patients had normal B-12 and folate. Copper gluconate was started at 20 mg/day by mouth, with weekly monitoring, till normal levels were reached. Patients were subsequently maintained at 5–10 mg/day with regular monitoring. Upon repletion of copper, all the patients recovered with normalization of the bone marrow and peripheral counts.

Discussion: We conclude that Gastric bypass especially Roux-en-Y gives rise to copper deficiency due to malabsorption in the duodenum and can present as pseudomyelodysplasia. We consider measurement of copper and ceruloplasmin levels an important component of the evaluation of patients presenting with myelodysplasia with normal cytogenetics, especially after gastric bypass.