Question of the Week # 434

434) A 44 year old woman is evaluated in your office for one month history of worsening fatigue. She also reports tingling and numbness in bilateral lower extremities. Her past medical history is significant for morbid obesity for which she underwent gastric bypass surgery four years ago. She has lost about 80lbs weight since her surgery. Her medications include oral ferrous sulfate, folic acid and vitamin b-complex. Physical examination reveals absent ankle jerks. Laboratory Studies reveal WBC 5400/µl HGB: 9.8 gm%, MCV 74 fl, Platelets : 300k/µl, Serum ferritin 280ng/ml, Transferrin saturation 26% . A bone marrow aspirate smear is shown below :

Archer USMLE

Which of the following is the most likely cause of patient’s presentation?

A) Iron deficiency

B) Copper deficiency

C) Vitamin B12 deficiency

D) Zinc deficiency

E) Pure red cell aplasia

35 Responses

  1. Answer …. BB

  2. vit b12 defficiency……gastric bypass surgery caused its deficiency and it menifestated as bilateral tingling n numbness of the feet..

  3. Mcv 74 ,,, so it cant be b12 def…the bone morrow aspirate showing ring sideroblast.
    S.ferritin 280 , so more than 100 which r/o ida
    Copper def. which can also be caused by zinc toxicity like in the case with oral denture who got similar symptoms to this pt., but here the problem is gastric bypass surgery which is the most common cause of copper def….. Copper def. gives both hematological & neurological symptoms…. & the ring sideroblast which caused by abormal clumping of iron in the mitochondria is one of the features of the copper def.

    Hyperzincemia is a cause of copper def. ….. While zinc def. should cause different symptoms,,,, diarrhea, cognitive changes, anorexia,…

  4. D

  5. Subacute combined degeneration of spinal chord…due to vit B12 deficiency..

  6. Deficiencia vitamina b12

  7. Option C that is. vit b12

  8. C, b12 def

  9. c

  10. Not B12 because the MCV is less than 100. Also it can’t be B12 because the blood smear does not show a Macro-ovalocyte or hyper-segmented PMNs. I agree with acer’s explanation.

  11. i think it is copper def

  12. Is for the vitamin b12 deficiency

  13. copper deficiency

  14. B….common from gastric bypass, and you see the ring sideroblast on smear…and Cu can cause neurological complications…

  15. B…Copper involved in cytochrome c oxidase in complex IV in the mitochondrial electron transport chain, ceruloplasmin, Cu/Zn superoxide dismutase, amine oxidases

    SALT HI…is a mnemonic I came up with a while ago for most of the common anemias associated with a MCV 100…

    B12…get neuropathy, dementia

  16. sorry people…what ever i am typing in is not coming right

  17. c) vitamin B12 deficiency

  18. c)vitamin B12 deficiency

  19. Copper Deficiency. anemia, microcytic with normal ferritin, with ring sideroblast. He may have myelopathy. bariatric surgery is commom cause of copper def.

  20. And is B: Copper Def

  21. Vit b deficiency

  22. C

  23. Answer. B – Copper deficiency. Let us start with anemia here which is microcytic. Some of the commonest causes of microcytic anemia are Iron deficiency, Sideroblastic anemia and AOCD. Bone marrow biopsy clearly shows a ringewd sideroblast which are seen often in sideroblastic anemia or myelodysplastic syndrome. Copper deficiency is a common cause of sideroblastic anemia. Copper deficiency can also cause neurological symptoms such as neuropathy mentioned in the question. Causes of copper deficiency includes malabsorption ( in this case, from gastric bypass) , Zinc toxicity. Patients with zinc containing dentures are predisposed to Zinc toxicity and consequently, copper deficiency.

    Zinc deficiency (Choice D) causes gastrointestinal symptoms, neurological changes but usually, no anemia.

    Choice A is incorrect because serum ferritin and transferrin saturation are normal and sideroblasts are not a feature of iron deficiency.

    Choice C is incorrect because Vit B12 DEFICIENCY can cause similar neuropathic symptoms but it would cause macrocytosis not microcytosis.

    Choice E is incorrect. Pure red cell aplasia is associated much severe anemia and does not show sideroblasts.

  24. Good explanation thank you

  25. E,,pure red aplasia

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