Anemia is the hematological hallmark of copper deficiency; however, the infrequency with which it is encountered makes copper deficiency a formidable diagnostic challenge. We present the case of a 71-year-old woman who is a Jehovah's Witness with a history of cardiomyopathy, end-stage renal disease on peritoneal dialysis, prior gastric bypass surgery, and chronic anemia, who presented with generalized weakness. She was initially diagnosed with anemia in 2003, with a hemoglobin level of 10 g/dL. Her anemia progressively worsened over time, prompting a thorough gastroenterology evaluation with no abnormalities and eventually requiring aggressive treatment with oral and parenteral iron. However, she remained persistently anemic, causing a rapid deterioration in her functional status with hemoglobin worsening to 6 g/dL. An extensive diagnostic workup, inclusive of iron studies, B12 levels, and hemolytic panel was unremarkable. Despite receiving 20,000 units of epoetin alfa three times weekly and intravenous iron supplementation, her hemoglobin level failed to improve. Eventually, hematology was consulted, and a copper level was checked, which was significantly low at 38 μg/dL. Her functional status dramatically improved following intravenous copper replenishment, and her hemoglobin increased from 6 g/dL on admission to 10 g/dL in four weeks. This case illustrates the importance of thinking about copper deficiency in a patient with a history of gastric bypass. It could be lifesaving for a patient who is a Jehovah's Witness.
Ami J Patel (Sat,) studied this question.