525 - Identifying and managing acquired copper deficiency as a treatable cause of myelopathy

The patient is a 61-year-old male with a past medical history of esophageal cancer s/p chest radiation and chemotherapy, peripheral neuropathy, and subacute combined degeneration who presented for evaluation of myelopathy related to copper deficiency. A few weeks after receiving the COVID-19 vaccine, he noted tingling in all fingers and both feet. 2 months later, he endorsed heaviness and a heat-like sensation to both legs, followed by upper limb paraesthesias. Upon evaluation, lab work was notable for decreased copper and ceruloplasmin levels. EMG/NCS revealed electrophysiologic evidence of mild sensorimotor length-dependent axonal polyneuropathy. Imaging of the brain and cervical spine revealed dorsal column tractopathy with intrinsic cord signal change. Overall, the workup was consistent with subacute combined degeneration and myeloneuropathy. Copper levels were normalized with supplementation within the next month.

Discussions:

An acquired copper deficiency is more commonly reported in women and those between the ages of 50 and 70. The most common causes of acquired copper deficiency include gastrointestinal surgeries and excessive zinc ingestion. Although, there is still uncertainty regarding the mechanism associated with neurologic damage in individuals with copper deficiency, it is understood that copper plays a key role in the nervous system in allowing for electron transfer in enzymatic pathways. Some of these pathways involve oxidative phosphorylation, antioxidant defense, melanin synthesis, catecholamine biosynthesis, and many more. Symptoms of copper deficiency may include balance issues, numbness, paraesthesias, and bilateral leg weakness. Physical examination may reveal reduced vibration and proprioception in the legs, spasticity, and hypoesthesia.

Conclusions:

An acquired copper deficiency, which can mimic the presentation of subacute combined degeneration, is now more widely recognized as a treatable cause of myelopathy. This case aims to emphasize the importance of careful consideration and comprehensive laboratory evaluation of copper levels when considering potential causes of myelopathy.