to the editor: In a society where obesity has taken on epidemic proportions, several therapeutic modalities have been developed to control this phenomenon. Bariatric surgery, the most aggressive and invasive treatment for obesity, has been shown to be effective in promoting weight loss. As Drs. Virji and Murr noted in their article on bariatric surgery, postoperative complications occur frequently. Metabolic disturbances are more common following surgeries that tend to produce more alteration in the gastrointestinal anatomy.¹ For example, vitamin B₁₂ and thiamine deficiencies are common after gastric bypass surgery. However, more rare metabolic deficiencies may arise as more of these surgeries are performed. One of these conditions is copper deficiency, also known as hypocupremia.

Copper is available in various food products including crab meat, fresh vegetables, fruits, nuts, seeds, and legumes.² It is absorbed in the upper gastrointestinal tract through the duodenum and proximal jejunum.³ Copper is essential for hemoglobin synthesis, the development of connective tissue and bone, and neurologic function. Deficiency in copper may lead to vitamin B₁₂ deficiency-like symptoms⁴; anemia and leukopenia with myelodysplastic manifestations; growth retardation; defective keratinization and pigmentation of the hair; neurodegenerative syndrome; mental deterioration; and scurvy-like changes in the skeleton. Symptoms may vary from mild and vague (e.g., fatigue, dizziness, nausea, shortness of breath) to more pronounced and serious (e.g., ataxia with severe gait disturbance, mental deterioration, respiratory arrest).

Treatment of hypocupremia consists of the prompt reversal of the deficiency with intravenous copper infusion, oral supplementation of copper, or both, depending on the severity of the condition. Although the hematologic manifestations, including pancytopenia and myelodysplasia, promptly improve with copper therapy,⁵ the neurologic improvement may show varying degrees of response depending on the duration and severity of the condition.⁶

Family physicians are expected to care for a growing number of patients after gastric bypass, and will likely encounter an increasing number of patients with hypocupremia. Prompt recognition and treatment of this condition is essential to prevent the development of permanent neurologic deficits.^4,6