Intended for healthcare professionals

Practice Easily missed?

Copper deficiency

BMJ 2014; 348 doi: (Published 17 June 2014) Cite this as: BMJ 2014;348:g3691
  1. S K Chhetri, specialist registrar in neurology12,
  2. R J Mills, consultant neurologist1,
  3. S Shaunak, consultant neurologist1,
  4. H C A Emsley, consultant neurologist12
  1. 1Department of Neurology, Royal Preston Hospital, Preston PR2 9HT, UK
  2. 2University of Manchester, Manchester M13 9PL, UK
  1. Correspondence to: hedley.emsley{at}
  • Accepted 9 May 2014

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.

T2 weighted sagittal magnetic resonance image of cervical spine showing increased signal intensity (arrowed) involving dorsal columns of the cervical spinal cord

What is hypocupraemia?

Copper is an essential trace element that plays a crucial role in the normal functioning of the neurological, haematological, vascular, skeletal, and antioxidant systems.1 2 Copper is absorbed in the stomach and proximal duodenum, but absorption can be impaired after upper gastrointestinal surgery. Such surgery, although not the sole cause of copper deficiency (hypocupraemia), is increasingly recognised as an important risk factor.3 Copper deficiency leads to several clinical presentations including cytopenia and profound neurological deficits.1 2 3 4

How common is copper deficiency?

Evidence is limited but several reports describe symptomatic copper deficiency.1 2 3 4 5 In a case series of 136 patients with gastric bypass surgery, 9.6% had hypocupraemia.6 Two other case series of 64 and 141 bariatric surgery patients respectively reported substantial hypocupraemia in 23% at 6 months and 70% at 3 years, 7 and a …

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