Copper deficiency

A 73 year old man with treated pernicious anaemia and partial gastrectomy 30 years earlier consulted his GP with a 12 month history of progressive numbness of his feet and hands. A haematology opinion for normocytic anaemia, neutropenia, and lymphopenia led to an unremarkable bone marrow biopsy. Increasing unsteadiness and falls prompted neurology referral. He was found to have sensory ataxia with clinical, radiological (figure⇓), and neurophysiological evidence of myelopathy and peripheral neuropathy. Vitamin B₁₂ level was high, consistent with ongoing replacement. Low serum copper confirmed hypocupraemic myeloneuropathy. Copper replacement achieved resolution of the cytopenia within four weeks, and slow but minimal neurological improvement was seen over more than nine months of follow-up.