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Case 132 - Discussion

Uploaded: 2010-08-06, Updated: 2010-08-06


Copper Deficiency Induced Anemia

  • Causes:

    • Gastrointestinal malabsorption syndromes

    • GI surgery: gastrectomy, bariatric surgery, and intestinal resection

    • Long-term parenteral nutrition lack of copper

    • Excessive amounts of zinc-containing supplements that compete with copper absorption

  • Clinical presentations:

    • Neurologic manifestations

    • Anemia with or without leukopenia, rarely thrombocytopenia

  • CBC and peripheral blood smear

    • RBC: anemia, microcytic, normocytic or macrocytic

    • WBC: leukopenic or neutropenic in 2/3 patients, moderate to severe

    • Platelets: usually normal, rarely thrombocytopenia

  • Bone marrow morphology:

    • Often hypocellular

    • Granulocytic hypoplasia, relative erythroid hyperplasia, preserved megakaryopoiesis

    • Vacuolization in erythroid and granulocytic precursors

    • Increased stainable iron within macrophages and plasma cells

    • Erythroid dysplasia and occasional myeloid dysplasia

    • Occasional ringed sideroblasts

  • Serum chemistry:

    • Low serum copper and ceruloplasmin

    • Increased or normal zinc level

  • DDX:

    • MDS: pancytopenia, no vacuolations. Copper deficiency shows normal platelet count and vacuolation in erythroid and myeloid precursors.

    • Vitamin B12 deficiency: also presents with both neurologic and hematologic symptoms, but typically reveals macrocytic anemia and hypersegemented neutrophils, no vacuolation in erythroid or myeloid precursors

    • Vacuolation associated with acute alcohol ingestion and drug-induced damage: usually in myeloid precursors, not erythroid precursors.


  • Halfdanarson TR, Kumar N, Li CY, Phyliky RL, Hogan WJ. Hematological manifestations of copper deficiency: a retrospective review. Eur J Haematol. 2008 Jun;80(6):523-31

  • AFIP, Non-Neoplastic Disorders of the Bone Marrow, series 4