Category: Clinical Sciences/Health Conditions
A 67-year-old female presented with complaints of bilateral paresthesias of her hands and legs, gait instability and falls, and urinary incontinence. The patient has a significant history of malabsorption and malnutrition related to a 40-yr prior jejunoileal bypass (JIB) and abnormal MRI in the dorsal columns in the upper cervical cord. The patient was found to have ongoing incomplete copper deficiency (hypocupraemia), and a similar case presentation a year prior which was only treated with IV and PO copper repletion.
The most common cause of copper deficiency is previous upper gastrointestinal surgery (47% of cases). JIB was a popular weight loss surgery in the 1960-70’s, which is now rare and no longer viable due to its short and long-term complications. Hypocupraemia can manifest in a variety of ways included central nervous system (CNS) demyelination, optic neuritis, anemia, leukopenia, peripheral polyneuropathy, and motor neuron disease. Copper deficiency can present indistinguishable to B12 deficiency, making diagnosis and treatment difficult.
The patient returned after one year with continuing bilateral paresthesias and gait instability, indicating that PO and IV Copper repletion was insufficient as a solitary therapy. In conjunction with repletion, the patient began intensive PT and OT 5-7 times/week for 180 minutes. She was able to regain independence, return home, and improved activities of daily living with increased functional mobility.
It is important to recognize the related metabolic consequences of micronutrient deficiencies and their potential for myelopathy. The significant impact that intensive PT/OT regimens may have in addition to micronutrient repletion may be necessary to improve overall function. The patient ultimately underwent reversal of the JIB. This case highlights the importance of continued monitoring of patients with older/rare surgical interventions, and the importance of more holistic and targeted (combination nutrient repletion, PT/OT, and surgical reversal) approaches compared to singular symptomatic treatments.