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\begin{document}

\title{A rare case of pancytopenia in a child with cystic fibrosis: Can copper
cure it all?}



\author[1]{Maggie Seblani}%
\author[1]{Susanna McColley}%
\author[1]{Shawn Gong}%
\author[2]{Lee Bass}%
\author[1]{Sherif Badawy}%
\affil[1]{Ann and Robert H Lurie Children's Hospital of Chicago}%
\affil[2]{Northwestern University Feinberg School of Medicine}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\selectlanguage{english}
\begin{abstract}
Nutritional deficiencies such as iron, vitamin B12 and folate are
recognized as etiologies for several cytopenias; although copper's role
in multiple metabolic enzymes is well-established, copper deficiency is
often overlooked as a contributing entity. Frequently diagnosis is
delayed, patients may undergo bone marrow investigations with findings
overlapping a myelodysplastic process, which can lead to further testing
and treatment considerations including hematopoietic stem cell
transplant referral. We present a case of a young boy with cystic
fibrosis with biliary dysplasia corrected with hepato-portoenterostomy
and distal intestinal obstruction syndrome resulting in jejunal
resection, with severe anemia and thrombocytopenia requiring transfusion
support. Initial evaluation had been unremarkable, ongoing pancytopenia
prompted bone marrow studies, which revealed vacuolated granulocytic and
erythroid precursors and ring sideroblasts, suggestive of copper
deficiency. Serum copper and ceruloplasmin were consistent with severe
deficiency, attributed to insufficient absorption intestinal resection,
chronic parenteral nutrition and prior zinc supplementation. Following
enteral copper supplementation, anemia, leukopenia and thrombocytopenia
significantly improved, however upon cessation, counts again worsened
and has since been maintained on daily copper supplementation without
further transfusion needs. Our experience exemplifies the importance of
early consideration for copper deficiency in children with cytopenias,
especially within context of intestinal malabsorption or inadequate
nutritional intake which often occurs in children with cystic fibrosis.%
\end{abstract}%



\sloppy


\textbf{Title Page}

\textbf{Title} : A rare case of pancytopenia in a child with cystic
fibrosis: Can copper cure it all?

\textbf{Authors} : Maggie D. Seblani\textsuperscript{1,2}; Susanna A.
McColley\textsuperscript{2,3,4}; Shunyou Gong\textsuperscript{5}; Lee M.
Bass\textsuperscript{2,6}; Sherif M. Badawy\textsuperscript{1,2}

\textbf{Affiliations} : \textsuperscript{1} Division of Hematology,
Oncology and Stem Cell Transplant, Ann \& Robert H. Lurie Children's
Hospital of Chicago, Chicago, IL, USA; \textsuperscript{2} Department of
Pediatrics, Northwestern University Feinberg School of Medicine,
Chicago, IL, USA; \textsuperscript{3} Division of Pulmonary and Sleep
Medicine, Ann \& Robert H. Lurie Children's Hospital of Chicago,
Chicago, IL, USA; \textsuperscript{4} Stanley Manne Children's Research
Institute, Ann \& Robert H. Lurie Children's Hospital of Chicago,
Chicago, Illinois, USA; \textsuperscript{5} Division of Pediatric
Pathology, Ann \& Robert H. Lurie Children's Hospital of Chicago,
Chicago, IL; \textsuperscript{6} Division of Gastroenterology,
Hepatology and Nutrition, Ann \& Robert H. Lurie Children's Hospital of
Chicago, Chicago, IL.

\textbf{Correspondence:} Sherif M. Badawy, MD, MS, MBBCh, 225 E. Chicago
Ave., Box \#30, Chicago, IL, 60611, office: 312-227-4836, fax:
312-227-9376, e-mail: sbadawy@luriechildrens.org

\textbf{Word count:} 998

\textbf{Number of Tables, Figures, and Supplemental files} : 1

\textbf{Keywords:} pancytopenia, anemia, leukopenia, neutropenia,
thrombocytopenia, copper deficiency, ring sideroblasts, copper
supplement, cystic fibrosis, malabsorption

\textbf{Running title:} Pancytopenia and copper deficiency in a child
with CF

\textbf{To the Editor}

We present a nine-year-old boy with cystic fibrosis, biliary dysplasia
corrected with hepato-portoenterostomy, and distal intestinal
obstruction syndrome resulting in jejunal resection with intermittent
cytopenias since two years of age. Namely, a macrocytic anemia with mean
corpuscular volume (MCV) 87--109 fL, leukopenia below 3 thou/uL,
neutropenia 0.035--0.705 thou/uL and mild to moderate thrombocytopenia
of 48--147 thou/uL. He had frequent episodes of culture-negative sepsis
syndrome requiring intensive care stays ever 2-3 months, during which he
required frequent transfusions with packed red cells, often once
hemoglobin reached below 7 g/dL, as well as intermittent platelet
transfusions.

Our patient presented to general hematology with pancytopenia at 3
years. Initial evaluation included negative Coombs and anti-neutrophil
antibody with normal folate, vitamin B12, methylmalonic acid (MMA),
vitamin E, iron studies and soluble transferrin receptor. Peripheral
smear revealed no morphologic abnormalities. His physical exam was
notable for pallor, lower extremity weakness and mild
hepatosplenomegaly. Initially, anemia and thrombocytopenia were
attributed to hypersplenism; however, with persistent pancytopenia, bone
marrow evaluation was performed. Marrow studies showed progressive
myelopoiesis without evidence of dysplasia or malignancy, but the
presence of vacuolated granulocytic and erythroid precursors and ring
sideroblasts prompted evaluation of a potential copper deficiency. A
serum copper level of \textless{}5 (reference range 117-181 mcg/dL) and
serum ceruloplasmin level of \textless{}3 (reference range for male 7-9
is 25-52 mg/dL) confirmed his severe copper deficiency.

Our patient's copper deficiency was attributed to poor absorption
secondary to his cystic fibrosis and gut resection. In addition, prior
zinc supplementation, used to promote growth in CF, was thought to
compound deficiency due to zinc's interference with copper
metabolism.\textsuperscript{1} After two months of enteral
supplementation with copper gluconate at 2 mg daily, serum copper and
ceruloplasmin levels normalized (\textbf{Figure 1} ). There was
significant improvement in hematological parameters: normalization of
hemoglobin, MCV, WBCs and neutrophils, and as stabilization of his
platelet count (\textbf{Figure 1} ). Given his response, supplementation
was suspended for some time; however, later resumed upon recurrence of
pancytopenia.

\textbf{Discussion}

Copper is a trace element serving as a cofactor for enzymes involved in
respiratory oxidation, iron transport and metabolism and
neurotransmitter synthesis, also known as
cuproenzymes.\textsuperscript{1-2} Copper homeostasis regulates
absorption and distribution, with mechanisms to limit free radical
production and copper overload.\textsuperscript{1-2} Dietary copper
content drives intestinal absorption, which occurs primarily through the
proximal small intestine, to a lesser degree the
stomach.\textsuperscript{1} The recommended dietary allowance for copper
increases from infancy through adolescence and adulthood, up to 1000
\selectlanguage{greek}µ\selectlanguage{english}g/day in the United States and Canada.\textsuperscript{1}

Up to 70\% of dietary copper is absorbed enterally; deficiency may occur
secondary to states of malabsorption (e.g., celiac disease and small
bowel Crohn's disease) as well as chronic inflammatory conditions.
Acquired deficiency may be a complication following surgical resection,
seen in short gut syndrome, gastrectomy and gastric bypass
surgery.\textsuperscript{3} Additionally, prolonged parenteral nutrition
without copper supplementation and excessive zinc intake lead to
deficiency. Zinc and copper are described to have an antagonistic
relationship, with excessive zinc intake interfering with copper
absorption due to zinc-induced synthesis of a copper-binding ligand
leading to sequestration within intestinal cells preventing entry into
circulation.\textsuperscript{2}

In a retrospective study of forty patients with copper deficiency and
hematologic abnormalities, thirty-nine had isolated anemia or anemia
with other cytopenias.\textsuperscript{4} Copper deficiency anemia can
range from microcytic to macrocytic, with severity correlating to extent
of deficiency.\textsuperscript{3} The pathophysiology of anemia is
theorized to derive from copper's role in proteins involved in iron
homeostasis and transport. Reduced transport of iron across intestinal
cells leads to impaired conversion of iron by ceruloplasmin and
hephaestin (a copper-dependent ferroxidase), needed for loading onto
transferrin and incorporation into
protoporyphrin.\textsuperscript{3}With incomplete hemoglobin synthesis
ring sideroblasts form and red cell membrane defects occur from
decreased activity of copper superoxide dismutase against free radicals,
leading to a shortened red cell lifespan.\textsuperscript{3}

Leukopenia of copper deficiency primarily consists of neutropenia.
Proposed hypotheses include impaired maturation and increased
destruction of precursors within the marrow, in addition to limited
neutrophil migration from marrow and increased clearance from
circulation.\textsuperscript{3,5} Thrombocytopenia is a less frequent
consequence and rarely copper deficiency presents as isolated
thrombocytopenia. In the previously described cohort, thrombocytopenia
was only noted in combination with anemia in two of forty
patients.\textsuperscript{4} In copper deficiency, the bone marrow is
typically hypercellular and with characteristic findings of cytoplasmic
vacuolization of both erythroid and myeloid precursor
cells.\textsuperscript{3} Iron stores are also increased with a
prominence of ring sideroblasts.\textsuperscript{3} The constellation of
all these findings is often misdiagnosed or mistaken for myelodysplastic
syndrome (MDS) and with reports of copper deficiency identified upon
referral for hematopoietic stem cell
transplant.\textsuperscript{3}Timely diagnosis allows for appropriate
intervention; of the previously described patients with available
response to therapy follow up, 16 of 28 (57\%) had complete
normalization of cytopenias, nine with partial response and three with
no response.\textsuperscript{4} This response underlies the importance
of early consideration of copper deficiency in a differential for
cytopenias.

Neurologic changes can frequently accompany hematologic findings and
encompass a spectrum of disorders. This includes isolated peripheral
neuropathy or polyneuropathy, motor neuron disease, myopathy, cerebral
demyelination, cognitive dysfunction, optic neuropathy and myelopathy.
In copper deficiency myelopathy, common presenting symptoms are gait
difficulties secondary to sensory ataxia and dorsal column dysfunction
with associated extremity paresthesias.\textsuperscript{5} In a review
of 55 cases of patients with copper deficiency and neurologic symptoms,
copper supplementation led to improvement in about half of patients with
reported outcomes and stabilization of symptoms in the
remainder.\textsuperscript{5}

\textbf{Conclusion}

Our patient exemplifies the potential delay in identifying copper
deficiency as an etiology for pancytopenia. Copper deficiency should be
a consideration in the initial evaluation of children with restricted
diets or concerns for malabsorption. Low levels of serum copper and
ceruloplasmin are uniformly seen in all patients and essential to
establish the diagnosis. Patient with copper deficiency could be
misdiagnosed or mistaken for MDS and some patients identified only when
referred for hematopoietic stem cell transplant. Enteral copper
supplementation is feasible and effective in addressing these
cytopenias, eliminating the need for transfusion support as well as
improving patients' quality of life and neurological function.

\textbf{Conflict of Interest:} Author has no conflicts of interest to
disclose.

\textbf{Figure Legend:}

\textbf{Figure 1} : Trend in various hematologic indices following
initiation of copper supplementation: (A) Total White Blood Cell Count,
(B) Absolute Neutrophil Count, (C) Hemoglobin, and (D) Platelet Count.
Changes in serum copper level (blue line) and time of initiation of
copper supplementation (black arrow).

\textbf{References}

1. Wapnir RA. Copper absorption and bioavailability. Am J Clin Nutr.
1998;67(5 Suppl):1054s-60s

2. van den Berghe PV, Klomp LW. New developments in the regulation of
intestinal copper absorption. Nutr Rev. 2009;67(11):658-72

3. Lazarchick J. Update on anemia and neutropenia in copper deficiency.
Curr Opin Hematol. 2012;19(1):58-60

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

5. Jaiser SR, Winston GP. Copper deficiency myelopathy. J Neurol.
2010;257(6):869-81\selectlanguage{english}
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