Rapid development of severe copper deficiency in a patient with Crohn's disease receiving parenteral nutrition

A 32-year-old man with active Crohn's disease and recurrent small bowel str ictures underwent abdominal surgery and was subsequently given total parent eral nutrition (TPN). Severe cholestasis developed and copper was removed f rom the TPN. Although serum ceruloplasmin levels were within normal limits, 8 weeks after copper removal, he developed pancytopenia. Serum copper leve ls were severely depressed. Bone marrow biopsy was consistent with copper d eficiency; cytoplasmic vacuolization of bath myeloid and erythroid precurso rs, megaloblastic erthropoiesis, and marked hypocellularity were observed. IV replacement with copper sulfate resulted in improvement in the patients anemia, neutropenia, and thrombocytopenia, but the patient died suddenly fr om cardiac tamponade. Postmortem examination revealed fibrinous and hemorrh agic pericarditis. Despite the rare occurrence of overt copper deficiency, this case emphasizes the need to recognize copper deficiency as an importan t etiology of iron-resistant anemia in patients receiving TPN. Furthermore, the relative rapidity with which our patient developed pancytopenia sugges ts that, in view of the established recommendation that copper be removed f rom TPN in cholestatic conditions, serum copper levels must be measured per iodically.