initial laboratory values were : wbc 2900/l , anc 900/l , hemoglobin 12.0  g / dl , mcv 95  fl , and platelet count of 156,000/l .
creatinine , ast , alt , bilirubin , tsh , iron , total iron binding capacity , ferritin , and vitamin b12 levels were normal .
past medical history was significant for coronary artery disease , ulcerative colitis , and stage ii esophageal adenocarcinoma treated with neoadjuvant concomitant radiation plus carboplatin and paclitaxel followed by ivor - lewis esophagectomy .
postoperative esophagocutaneous fistula formation led to long - term reliance on jejunal feeding for all caloric intake .
his medications were lorazepam , aspirin , amiodarone , lisinopril , balsalazide , metoprolol , and vitamin b12 .
amiodarone was discontinued . a repeat cbc after 1  month showed wbc 2600/l , anc 200/l , hemoglobin 12.7  g / dl , mcv 107  fl , and platelet count of 174,000/l .
a second repeat cbc after 2  months following discontinuation of amiodarone showed : wbc 2900/l , anc 300/l , hemoglobin 11.0  g / dl , mcv 114  fl , and platelets 193,000/l .
examination of a bone marrow aspirate and biopsy specimen revealed nor mocellular bone marrow with progressive trilineage hematopoiesis , mild erythroid hyperplasia , with megaloblastoid features , and vacuolated erythroid cells , highly suspicious for myelodysplastic syndrome ( figs1 and 2 ) .
additional laboratory evaluation included rheumatoid factor 12 , esr 30 , crp 0.4 , serum zinc level 86  g / dl ( 60130 ) and serum copper < 10  g / dl ( 70140 ) .
a cbc after 1  month revealed wbc 7600/l , anc 5400/l , hemoglobin 12.2  g / dl , mcv 120  fl , and platelet count 246,000/l .
ceruloplasmin and cytochrome oxidase are both copper - containing enzymes essential for heme synthesis 3 .
typical morphological findings in peripheral blood and bone marrow aspirate in copper deficiency can mimic myelodysplastic syndrome 1 .
bone marrow aspirate in both conditions may show dysplasia in the erythroid precursors such as large size , nuclear multilobulation , and nuclear budding as well as the presence of ring sideroblasts .
unlike myelodysplastic syndrome , the bone marrow aspirate in copper deficiency characteristically shows cytoplasmic vacuoles within erythroid and myeloid precursors 2 .
furthermore , karyotyping in cases of copper deficiency does not reveal cytogenetic features characteristic of myelodysplastic syndrome .
copper is present in common foods including meat , fish , nuts , seeds , and legumes , and therefore deficiency from dietary inadequacy is rare 4 .
most copper absorption occurs in the stomach and proximal duodenum , although the more distal small intestine can also absorb copper .
problems with copper absorption leading to deficiency should be considered in patients who have history of gastric bypass or gastrectomy , are receiving chronic parenteral nutrition or tube feeding , or on zinc supplementation and develop pancytopenia and/or myeloneuropathy .
however , per the mayo clinic the daily recommended intake for adults is 1.52.5  mg / day .
copper is available in both intravenous ( cupric chloride ) and tablet forms . in this patient , we hypothesize that the long - term use of jejunal feeding led to a nutritional deficiency of copper and consequent pancytopenia .
currently , there is a national shortage of intravenous copper ; therefore we elected to attempt correction of his copper deficiency with higher doses of oral copper .
copper deficiency represents a rare but treatable cause of anemia and neutropenia that may be mistaken for myelodysplastic syndrome .
therefore , patients with a history of abdominal surgery who present with new found anemia and neutropenia with bone marrow biopsy showing dysplastic changes with no cytogenetic abnormalities should have copper levels checked .
recognition of copper deficiency as the cause of these blood abnormalities is critical to appropriately treat this disorder .
 key clinical messagecopper deficiency is a rare cause of pancytopenia that may be mistaken for myelodysplastic syndrome . 
 cytoplasmic vacuolization in erythroid and myeloid precursors is found on bone marrow examination . 
 patients with a history of abdominal surgery who present with anemia and neutropenia with dysplastic changes should have copper levels checked . 
Case Presentation
Discussion
Conflict of Interest