title: Zinc-induced copper deficiency: a report of three cases initially recognized on bone marrow examination.
abstract: Copper deficiency is a rare cause of sideroblastic anemia and neutropenia that often is not suspected clinically. The morphologic findings in bone marrow, while not pathognomonic, are sufficiently characteristic to suggest the diagnosis, leading to further testing to establish the correct diagnosis. Excess zinc ingestion is among the causes of copper deficiency. We present 3 cases of zinc-induced copper deficiency in which the diagnosis first was suggested on the basis of bone marrow examination. The first patient was a 47-year-old man with a debilitating peripheral neuropathy that had progressed during the previous 18 months, mild anemia, and severe neutropenia. The second was a 21-year-old man receiving zinc supplementation for acrodermatitis enteropathica in whom moderate normocytic anemia and neutropenia developed. The third patient was a 42-year-old man with anemia, severe neutropenia, and a peripheral neuropathy that had progressed during 8 months. The bone marrow findings in all cases suggested copper deficiency, which was confirmed by further laboratory testing and determined to be due to zinc excess. The morphologic features, clinical manifestations, differential diagnosis, and pathogenetic mechanisms are discussed.
authors.affiliation: Department of Pathology, University of Texas Southwestern Medical Center, Dallas 75390-9072, USA.
authors.forename: Monte S
authors.initials: MS
authors.lastname: Willis
authors.forename: Sara A
authors.initials: SA
authors.lastname: Monaghan
authors.forename: Michael L
authors.initials: ML
authors.lastname: Miller
authors.forename: Robert W
authors.initials: RW
authors.lastname: McKenna
authors.forename: Wiley D
authors.initials: WD
authors.lastname: Perkins
authors.forename: Barry S
authors.initials: BS
authors.lastname: Levinson
authors.forename: Vikas
authors.initials: V
authors.lastname: Bhushan
authors.forename: Steven H
authors.initials: SH
authors.lastname: Kroft
mesh_terms: D000328:Adult; D000756:Anemia, Sideroblastic / Q000209:etiology; D001706:Biopsy; D001853:Bone Marrow / Q000473:pathology*; D001856:Bone Marrow Examination; D003300:Copper / Q000172:deficiency* / Q000378:metabolism; D003937:Diagnosis, Differential; D006801:Humans; D008297:Male; D008668:Metallothionein / Q000378:metabolism; D008875:Middle Aged; D009503:Neutropenia / Q000209:etiology; D010523:Peripheral Nervous System Diseases / Q000209:etiology; D015032:Zinc / Q000009:adverse effects* / Q000378:metabolism
chemical_list: D003300:Copper; D008668:Metallothionein; D015032:Zinc