Copper deficiency myelopathy

Nutrition management of a patient following emergent pneumonectomy due to chest wall trauma

Emergent total pneumonectomy is a rare surgical intervention for patients with severe chest trauma. Patients who survive the immediate postoperative period experience prolonged, complex hospitalizations. The purpose of this case study is to review the nutrition care provided to a patient who survived total pneumonectomy and the supporting evidence. John Doe (JD) is a man aged 28 years who presented to a level I trauma center with penetrating chest trauma. He required multiple operative interventions, resulting in a partial right and total left pneumonectomy. JD's hospitalization was complicated by prolonged use of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). His surgical course and gastric feeding intolerance hampered enteral nutrition adequacy, and parenteral nutrition support was initiated on hospital day 17. Tolerance to enteral nutrition improved after jejunal access was obtained, and the patient transitioned to total enteral nutrition support. As a result of inflammatory metabolic changes and nutrition delivery challenges for the first 2 weeks of hospitalization, JD developed malnutrition. His nutrition care was further complicated by copper and carnitine deficiencies, which have been described in patients requiring ECMO and CRRT. Patients who require emergent total pneumonectomy following traumatic chest injuries will likely require complex hospital care, including extracorporeal organ support. These patients present unique nutrition challenges; however, given the relative infrequency of the intervention, there is limited research to guide clinical practice. Additional research on nutrition interventions in this population is warranted.

Neurotoxicity mechanisms and clinical implications of six common recreational drugs

The recreational abuse of addictive drugs poses considerable challenges to public health, leading to widespread neurotoxicity and neurological dysfunction. This review comprehensively examines the neurotoxic mechanisms, clinical manifestations, and treatment strategies associated with six commonly abused substances: methamphetamine, cocaine, synthetic cathinones, ketamine, nitrous oxide and heroin. Despite their diverse pharmacological properties, these drugs converge on shared neurotoxic pathways, including oxidative stress, mitochondrial dysfunction, excitotoxicity, and neuroinflammation. Psychostimulants, such as methamphetamine, cocaine and synthetic cathinones, disrupt monoaminergic neurotransmission, causing cognitive impairment, psychiatric disturbances, and neurovascular damage. Dissociative anesthetics, including ketamine and nitrous oxide, impair glutamatergic transmission and mitochondrial function, thereby exacerbating excitotoxicity and neuronal apoptosis. Opioids, such as heroin, primarily target the brain's reward system and induce oxidative stress, neuroinflammation, and cerebrovascular complications. Treatment strategies remain limited, focusing on symptomatic management, neuroprotective interventions, and behavioral therapies. Emerging approaches, such as antioxidants, NMDA receptor modulators, and cognitive rehabilitation, show promise but require further validation. By highlighting the underlying mechanisms and therapeutic challenges, this review provides a foundation for developing targeted interventions and advancing research on drug-induced neurotoxicity.

Spinal Cord Subacute Combined Degeneration Mimicked by Copper Deficiency: A Case Report

This case report underscores the diagnostic challenge of copper-deficiency myelopathy (CDM) and subacute combined degeneration (SCD) due to their similar clinical presentations. A 32-year-old male farmer initially treated for SCD with normal vitamin B12 levels showed no improvement, leading to a delayed diagnosis of CDM. His symptoms included sensory ataxia, spasticity, and sensory loss in the lower extremities, which resolved with oral copper supplementation. Clinicians should maintain a high index of suspicion for CDM, especially in patients who are unresponsive to B12 therapy. This case also highlights that marginal copper deficiency can cause significant neurological symptoms and that early intervention with copper supplementation can lead to full recovery, preventing irreversible damage. It also emphasizes the need for comprehensive testing, including copper levels, in cases of atypical myelopathy to avoid a delayed diagnosis.

Copper Deficiency: A Frequently Overlooked Complication After MBS-A Systematic Review and Meta-analysis

This study reviews the prevalence of copper (Cu) deficiency in patients for metabolic and bariatric surgery (MBS), as well as the long-term outcomes related to the prevalence of Cu deficiency after undergoing MBS. A systematic literature search and meta-analysis were conducted in PubMed, Web of Science, and Scopus for articles published by August 31, 2024. The search terms included metabolic and bariatric surgery, weight loss surgery, metabolic surgery, obesity surgery, sleeve gastrectomy, gastric banding, gastric bypass, duodenal switch, duodenojejunal bypass, copper, copper deficiency, and hypocuposemia. After PRISMA screening, 43 studies with a total of 49 patients with obesity were included in this meta-analysis. The results demonstrated that the prevalence of Cu deficiency after MBS at 1-, 2-, 3-, and 4-year follow-up was found to be 16%, 28%, 21%, and 16%, respectively. Additionally, hypocuposemia was observed to be more prevalent in patients with BPD compared with other types of surgery. Copper deficiency is frequently observed in patients following MBS, particularly those who have undergone BPD procedures. Therefore, it is imperative for patients to undergo postoperative follow-up and nutritional monitoring, along with targeted interventions.

Clinical Problem Solving: Two Patients With Gait Instability and Difficulty With Hand Coordination

Subacute-to-chronic gait instability has a broad differential diagnosis. The neurological exam can help elucidate the localization and suggest an underlying etiology of the symptomatology, which can lead to a more focused diagnostic approach. Two patients are described - 1 with a month of worsening difficulty with ambulation that evolved to bilateral hand discoordination and another with 18 months of progressive difficulty with ambulation that also then progressed to involve her bilateral hands. These cases highlight an approach to gait dysfunction with hand discoordination secondary to sensory ataxia. The patients were ultimately diagnosed with copper deficiency myelopathy secondary to zinc excess, and different treatment regimens are discussed.

Copper status and its relation to abdominal obesity indices and liver function in non-alcoholic fatty liver disease: a case-control study

OBJECTIVE

This study investigated copper (Cu) status in relation to abdominal obesity indices and liver function in patients with non-alcoholic fatty liver disease (NAFLD). This case-control study was carried out on 80 overweight/obese patients with NAFLD and 80 apparently healthy age, sex, and body mass index (BMI)-matched controls. A validated and reliable 168-item semi-quantitative food frequency questionnaire was completed for each subject and fasting serum levels of liver aminotransferases, ferritin, Cu and ceruloplasmin were assessed.

RESULTS

Mean intakes of energy and carbophydrate were significantly lower in patients with NAFLD than the control group while mean protein intake was highre (p < 0.05). Although mean Cu intake was greater in cases than controls, low dietary intake of Cu was found in 7.5% and 32.5% of the cases and controls, respectively. Apart from serum levels of liver aminotransferases (p < 0.001) and ferritin (p = 0.010), no significant differences were found in serum levels of Cu and ceruloplasmin. Serum and dietary Cu were positively correlated with obesity indices and serum ceruloplasmin was correlated with waist to height ratio and ferritin only in cases (p < 0.05). Low Cu intake (< 0.95 mg/day) was more likely to increase the odds of NAFLD (p for trend = 0.002), after adjusting for potential confounders.

Use of natural history museum ungulate specimen hair as biomarkers for environmental trace element contamination

This study reports the first use of natural history museum ungulate specimens' (common fallow deer, bontebok, Arabian oryx, impala, Dall's sheep, water buffalo, and yak) hair as biomarkers for the determination of environmental trace element contamination and public exposure risk factor assessment. Morphological characteristics of the hair, like diameter and protein structure, were determined using optical microscopy and FTIR spectroscopy, respectively. The levels of thirty-nine (39) elements, sixteen (16) rare earth elements (REEs), and selected isotope ratios (52Cr/53Cr, 144Nd/146Nd, 147Sm/149Sm, 173Yb/172Yb, 206Pb/207Pb, and 206Pb/208Pb) in the hair samples were determined by ICP-MS analysis. A NIST 1643e standard reference material was analyzed for method validation to determine the accuracy of the developed elemental analysis method. The average hair diameter found in samples obtained from common fallow deer (193 ± 72 µm), bontebok (148 ± 48 µm), Arabian oryx (194 ± 40 µm), impala (88 ± 20 µm), Dall's sheep (240 ± 68 µm), water buffalo (139 ± 17 µm), and yak (139 ± 16 µm) were recorded. 27Al (1642 ± 1551 mg·kg-1), 44Ca (506 ± 272 mg·kg-1), 56Fe (730 ± 1391 mg·kg-1), 24 Mg (108 ± 57 mg·kg-1), 39 K (720 ± 1591 mg·kg-1), 28Si (1125 ± 1163 mg·kg-1), 23Na (10,223 ± 9824 mg·kg-1), and 66Zn (33 ± 25 mg·kg-1) have the highest concentrations detected in the hair samples. Potentially toxic elements and REEs have the lowest concentration in the hair samples. The detection of low concentrations of 75As, 111Cd, 59Co, 52Cr, 53Cr, 60Ni, Pb isotopes, and REEs in all hair samples suggests heavy metal contamination. The plausible sources of the detected elements in ungulate animal hair are likely due to dietary intake, anthropogenic activities, environmental contamination, specimens' preservation practices, or a combination of those sources. The figures of merit highlighted by a high correlation coefficient (R2 ≥ 0.9990), low limit of detection (as low as 1.00 × 10-7 mg·kg-1 for 140Ce), and high average percent recoveries (97.0 ± 11.5) of the NIST 1643e standard reference material analyses demonstrate the linearity, high sensitivity, and accuracy of the ICP-MS technique for elemental and isotopic analysis of hair samples.

Treating osteoporosis in patients with atypical femoral fracture

Patients who have suffered an atypical femoral fracture while on bisphosphonates or denosumab may continue to be at risk for typical osteoporotic fractures. There are no studies to provide guidance on safe treatment for such patients. Instead, using an illustrative case, 5 principles of management are provided that may lead to decreased osteoporotic fracture risk. The first principle is to discontinue the anti-resorptive medications, which may be challenging for the patient on denosumab because of rebound vertebral fractures reported in patients stopping denosumab. The second principle is to maximize non-pharmacologic management to reduce falls and fractures. Home safety, other methods of fall risk reduction, adequate nutrition, and an exercise prescription should help reduce fracture risk. Investigating potential secondary causes of osteoporosis, particularly if the original workup was not comprehensive, is the third principle because treatment of some specific causes may lower fracture risk. Reviewing the medication list is the fourth principle, with the goal of eliminating drugs that may increase fracture risk, and considering thiazides for some patients, which may lower fracture risk. Finally, some patients may benefit from anabolic therapy. One potential (but not FDA-approved) method is to use long-term cyclic teriparatide or abaloparatide on a 3-mo on, 3-mo off schedule. Tailoring the approach to each patient is important, based on the 5 clinical principles, in the absence of evidence-based management recommendations.

Copper and Melanoma Risk: Results from NHANES 2007-2018 and Mendelian Randomization Analyses

Copper is an essential trace element obtained from food. There is a paucity of observational or prospective studies that have investigated the relationship between copper and melanoma risk. Copper serves as a cofactor for pivotal enzymes involved in mitochondrial respiration, antioxidant defense, and neurotransmitter synthesis. Undoubtedly, copper plays an indispensable role in the initiation and progression of tumors, particularly melanoma; however, further investigations are warranted to elucidate the underlying mechanisms linking copper and melanoma risk. Given the availability of dietary copper and serum copper data in the NHANES database, we conducted an investigation into the association between dietary copper intake and serum copper levels with melanoma risk. We enrolled 26,401 individuals with dietary copper data in the 2007-2018 NHANES database. To mitigate confounding variables, a propensity score matching (PSM) was performed. To assess the association between dietary copper intake and melanoma risk, we employed a multivariate logistic regression analysis before and after PSM. The restricted cubic spline analysis was utilized to determine whether there is a non-linear relationship between dietary copper intake and melanoma risk, with subgroup analysis conducted to determine beneficiaries. Then, those with blood copper data from the enrolled population with dietary copper intake were screened out, and subsequently, multivariate logistic regression models were subsequently constructed to investigate the association between serum copper levels and melanoma risk after PSM. Mendelian analysis was further utilized to validate the results of the NHANES database using serum copper as the exposure factor and melanoma as the outcome variable. The study found that melanoma risk was associated with dietary copper intake before and after PSM, demonstrated by multiple logistic regression. The relationship between dietary copper intake and melanoma risk was non-linear, with a reduced risk observed above approximately 2.5 mg/day, as shown by the RCS. The evidence suggests that an increased intake of copper is linked to a decreased risk of melanoma. To clarify the mechanism behind the increased risk of melanoma due to higher dietary copper intake, we analyzed the population data from the NHANES database on serum copper and dietary copper intake. Our results indicated that there is no causal relationship between serum copper and melanoma risk. Mendelian randomization analysis of multi-database data sources confirmed the conclusion of the NHANES database analysis. Dietary copper is a protective factor against melanoma, and serum copper or blood copper is not associated with melanoma risk. This suggests that serum or blood copper is not responsible for the protective effect of dietary copper intake on melanoma risk, and the mechanisms need to be further investigated.

Copper deficiency myelopathy mimicking cervical spondylitic myelopathy: a systematic review of the literature with case report

BACKGROUND AND CONTEXT

Copper deficiency myelopathy (CDM) is a rare disease that can present with spastic quadriparesis and sensory ataxia. As a result, it can precisely mimic cervical spondylitic myelopathy (CSM). Copper deficiency may be seen following gastric bypass surgery, malabsorption syndromes such as celiac disease, and with excessive exogenous zinc intake. We present a systematic review of the literature for CDM and an illustrative case.

PURPOSE

Provide a systematic review of CDM to highlight the importance of recognizing the consideration of CDM in patients presenting to a spine surgeon with myelopathy that progress despite adequate surgical decompression, or myelopathy concomitant with cytopenia, thus requiring further workup.

STUDY DESIGN/SETTING

Retrospective medical record review and systematic review of the literature.

PATIENT SAMPLE

PubMed and Ovid-Embase database search was conducted in July 2022.

OUTCOME MEASURES

Self-reported measures include PRISMA flow diagram for retrospective review; Physiological measures include retrospective review of MRI imaging of cervical spine; alternate demographic and laboratory value data extracted via literature review.

METHODS

A PubMed and Ovid-Embase database search was conducted in July 2022 searching for "copper deficiency myelopathy (MeSH)" from 2000 to 2022 via PRISMA guidelines. Following title and abstract review, the following data was extracted from full text: age, sex, etiology, hematological values upon presentation (mean corpuscular volume, white blood count, platelet count, and hemoglobin level), metal serum studies (serum copper, ceruloplasmin, and zinc), 24-hour collection of copper and zinc, and distinct radiographic findings on MRI.

RESULTS

A total of 116 studies were included in this review which contained 198 cases of copper deficiency myelopathy. The mean age was 53.57±14.14 years, with the majority being females (63.8%). The most common etiology was prior gastric surgery (n=55, 36.2 %) followed by excessive zinc consumption from the use of zinc denture cream (n=39, 19.9%). The mean serum copper was 15.67±17.84 (normal=80.0-155.0) mcg/dL and mean ceruloplasmin was 6.43±5.25 (normal=16-45) mg/dL. In spite of appropriate treatment with copper supplementation, only 47 cases (24%) reported improvement in neurological status, and only 10 (5.1%) recovered to baseline. A hyperintense T2 signal abnormality resembling an inverted "v" in the dorsal columns was the most common radiographic abnormality.

CONCLUSION

Pertinent risk factors for copper deficiency myelopathy include prior upper gastrointestinal surgery, zinc excess, and malabsorption. Characteristic laboratory and imaging findings include cytopenia, low serum copper and ceruloplasmin, and distinct inverted "v" T2 signal hyperintensity in the dorsal columns. The neurologic deterioration with copper deficiency will progress in spite of decompressive surgery, and can be devastating and irreversible even with copper supplementation, reinforcing the importance of early detection. We thus recommend patients with myelopathy presenting with a history of gastric bypass, malabsorption syndromes, excessive zinc exposure, cytopenia, or imaging resembling an inverted "v" shaped hyperintense T2 MRI signal in the dorsal columns, should first undergo blood tests for copper, ceruloplasmin, and B12 levels prior to surgical consideration.

Neurodegeneration in a domestic rabbit with severe malnourishment and low hepatic copper

Copper is a trace element that plays an essential role in neurodevelopment and neurologic function. Acquired copper deficiency has a range of neurologic manifestations, with myelopathy being the most common association. We describe here the clinical, radiologic, histopathologic, and toxicologic findings of a rabbit with malnutrition, neurodegeneration, and suspected copper deficiency. A stray, adult female dwarf rabbit cross (Oryctolagus cuniculus) in poor body condition developed ataxia and pelvic limb weakness progressing to lateral recumbency and urine retention. The clinical findings suggested multifocal brainstem disease with right-sided central vestibular involvement; however, microscopic examination identified thoracic and lumbosacral spinal cord myelopathy. Differentials for the spinal cord changes included neurodegenerative disease, nutritional deficiency, neurotoxin, trauma to the lumbosacral region, and ischemia. Hepatic copper levels were suboptimal at 18 ppm dry weight (RI: 24-150 ppm dry weight). While speculative, copper-deficiency myelopathy is a treatable cause of non-compressive myelopathy that may occur in this species.

The physiological and pathophysiological roles of copper in the nervous system

Copper is a critical trace element in biological systems due the vast number of essential enzymes that require the metal as a cofactor, including cytochrome c oxidase, superoxide dismutase and dopamine-β-hydroxylase. Due its key role in oxidative metabolism, antioxidant defence and neurotransmitter synthesis, copper is particularly important for neuronal development and proper neuronal function. Moreover, increasing evidence suggests that copper also serves important functions in synaptic and network activity, the regulation of circadian rhythms, and arousal. However, it is important to note that because of copper's ability to redox cycle and generate reactive species, cellular levels of the metal must be tightly regulated to meet cellular needs while avoiding copper-induced oxidative stress. Therefore, it is essential that the intricate system of copper transporters, exporters, copper chaperones and copper trafficking proteins function properly and in coordinate fashion. Indeed, disorders of copper metabolism such as Menkes disease and Wilson disease, as well as diseases linked to dysfunction of copper-requiring enzymes, such as SOD1-linked amyotrophic lateral sclerosis, demonstrate the dramatic neurological consequences of altered copper homeostasis. In this review, we explore the physiological importance of copper in the nervous system as well as pathologies related to improper copper handling.

Progress in copper-based materials for wound healing

Chronic wounds have become the leading cause of death, particularly among diabetic patients. Chronic wounds affect ~6.5 million patients each year, according to statistics, and wound care and management incur significant financial costs. The rising prevalence of chronic wounds, combined with the limitations of current treatments, necessitates the development of new and innovative approaches to accelerate wound healing. Copper has been extensively studied for its antibacterial and anti-inflammatory activities. Copper in its nanoparticle form could have better biological properties and many applications in health care.

Current state of research on copper complexes in the treatment of breast cancer

Breast cancer, a malignancy originating from the epithelium or ductal epithelium of the breast, is not only highly prevalent in women but is also the leading cause of cancer-related deaths in women worldwide. Research has indicated that breast cancer incidence is increasing in younger women, prompting significant interest from scientists actively researching breast cancer treatment. Copper is highly accumulated in breast cancer cells, leading to the development of copper complexes that cause immunogenic cell death, apoptosis, oxidative stress, redox-mediated cell death, and autophagy by regulating the expression of key cell death proteins or assisting in the onset of cell death. However, they have not yet been applied to clinical therapy due to their solubility in physiological buffers and their different and unpredictable mechanisms of action. Herein, we review existing relevant studies, summarize the detailed mechanisms by which they exert anti-breast cancer effects, and propose a potential mechanism by which copper complexes may exert antitumor effects by causing copper death in breast cancer cells. Since copper death in breast cancer is closely related to prognosis and immune infiltration, further copper complex research may provide an opportunity to mitigate the high incidence and mortality rates associated with breast cancer.

Neurological complications due to copper deficiency in the context of Wilson disease treatment: a case report with long-term follow-up and review of the literature

The objective is to investigate the presentation, complications, management, and outcomes of copper deficiency-induced neurological pathologies due to Wilson disease (WD) overtreatment. We examined the case of a WD patient who developed a low thoracic dorsal myelopathy due to chronic hypocupremia from excessive zinc therapy. A comprehensive literature review was conducted to identify similar cases. Ten additional cases of neurological pathology resulting from copper deficiency in the context of WD over-treatment were identified, all occurring during therapy with zinc salts. Myelopathy and peripheral neuropathy were the most common complications, while two additional groups reported leukoencephalopathy. Early cytopenia was often associated with copper deficiency-related neurological pathology appearing early in the context of copper deficiency. WD patients undergoing treatment, especially with zinc salts, should be closely monitored to prevent over-treatment and the consequent copper deficiency. Regular complete blood counts could provide early detection of copper deficiency, avoiding irreversible neurological damage. Swift recognition of new neurological signs not consistent with WD and timely discontinuation of the decoppering therapy are critical for improving outcomes. The optimal management, including the potential benefit of copper supplementation in patients with WD and subsequent therapy adjustments, remains unclear and necessitates further investigation. Despite the general poor functional neurological outcomes, there were some exceptions that warrant further exploration.

It Looks Like a Spinal Cord Tumor but It Is Not

Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.

Metabolic and Toxic Myelopathies

OBJECTIVE

This article reviews the clinical presentation, diagnostic evaluation, and treatment of metabolic and toxic myelopathies resulting from nutritional deficiencies, environmental and dietary toxins, drugs of abuse, systemic medical illnesses, and oncologic treatments.

LATEST DEVELOPMENTS

Increased use of bariatric surgery for obesity has led to higher incidences of deficiencies in nutrients such as vitamin B12 and copper, which can cause subacute combined degeneration. Myelopathies secondary to dietary toxins including konzo and lathyrism are likely to become more prevalent in the setting of climate change leading to drought and flooding. Although modern advances in radiation therapy techniques have reduced the incidence of radiation myelopathy, patients with cancer are living longer due to improved treatments and may require reirradiation that can increase the risk of this condition. Immune checkpoint inhibitors are increasingly used for the treatment of cancer and are associated with a wide variety of immune-mediated neurologic syndromes including myelitis.

ESSENTIAL POINTS

Metabolic and toxic causes should be considered in the diagnosis of myelopathy in patients with particular clinical syndromes, risk factors, and neuroimaging findings. Some of these conditions may be reversible if identified and treated early, requiring careful history, examination, and laboratory and radiologic evaluation for prompt diagnosis.

Host-guest interactions of coumarin-based 1,2-pyrazole using analytical and computational methods: Paper strip-based detection, live cell imaging, logic gates and keypad lock applications

A novel Coumarin-based 1,2-pyrazole, HCPyTSC is synthesised and characterized. The chemosensor has been shown to have efficient colourimetric and fluorescence sensing capabilities for the quick and selective detection of fluoride and copper ions. At 376 and 430 nm, the HCPyTSC exhibits selective sensing for Cu2+ and F- ions. By examining the natural bond orbital (NBO) analysis and the potential energy curve (PES) of the ground state for the function of the C-H bond, it has been determined from the theoretical study at hand that the deprotonation was taken from the 'CH' proton of the pyrazole ring. For F- and Cu2+, the HCPyTSC detection limits were 4.62 nM and 15.36 nM, respectively. Similarly, the binding constants (Kb) for F- and Cu2+ ions in acetonitrile medium were found to be 2.06 × 105 M-1 and 1.88 × 105 M-1. Chemosensor HCPyTSC with and without F- and Cu2+ ions have an emission and absorption response that can imitate a variety of logic gates, including the AND, XOR, and OR gates. Additionally, a paper-based sensor strip with the HCPyTSC was created for use in practical, flexible F- sensing applications. The paper-based sensor was more effective in detecting F- than other anions. The effectiveness of HCPyTSC for the selective detection of F- in living cells as well as its cell permeability were examined using live-cell imaging in T24 cells.

Evidence for decreased copper associated with demyelination in the corpus callosum of cuprizone-treated mice

Demyelination within the central nervous system (CNS) is a significant feature of debilitating neurological diseases such as multiple sclerosis and administering the copper-selective chelatorcuprizone to mice is widely used to model demyelination in vivo. Conspicuous demyelination within the corpus callosum is generally attributed to cuprizone's ability to restrict copper availability in this vulnerable brain region. However, the small number of studies that have assessed copper in brain tissue from cuprizone-treated mice have produced seemingly conflicting outcomes, leaving the role of CNS copper availability in demyelination unresolved. Herein we describe our assessment of copper concentrations in brain samples from mice treated with cuprizone for 40 d. Importantly, we applied an inductively coupled plasma mass spectrometry methodology that enabled assessment of copper partitioned into soluble and insoluble fractions within distinct brain regions, including the corpus callosum. Our results show that cuprizone-induced demyelination in the corpus callosum was associated with decreased soluble copper in this brain region. Insoluble copper in the corpus callosum was unaffected, as were pools of soluble and insoluble copper in other brain regions. Treatment with the blood-brain barrier permeant copper compound CuII(atsm) increased brain copper levels and this was most pronounced in the soluble fraction of the corpus callosum. This effect was associated with significant mitigation of cuprizone-induced demyelination. These results provide support for the involvement of decreased CNS copper availability in demyelination in the cuprizone model. Relevance to human demyelinating disease is discussed.

Subacute Combined Degeneration of the Spinal Cord Induced by Nitrous Oxide Abuse: A Rare Patient Presentation to a Spine Surgery Clinic: Illustrative Case

Subacute combined degeneration (SCD) of the spinal cord is a disease involving the lateral and posterior columns of the spinal cord that can manifest in patients with vitamin B12 deficiency. Nitrous oxide (N2O)-induced SCD of the spinal cord is a result of N2O interfering with the metabolism of vitamin B12 and results in nervous system demyelination. This is an infrequent complication of N2O anesthesia; however, cases are rising with recreational N2O use. This case report describes a patient with SCD of the spinal cord induced by recreational N2O abuse. The patient presented to a spine surgery clinic with a 3-week history of progressive global weakness and paresthesias. After a detailed history and physical examination, the diagnosis was made and supported by various tests and imaging findings. Despite marked neurologic deficits, the patient's symptoms improved markedly with therapy and vitamin B12 supplementation. Spine surgery clinicians may be confronted with these cases and should be aware of this atypical presentation of SCD. As in our case, patients may present with neurologic deficits of unclear etiology. Neurologic dysfunction may be irreversible; therefore, accurate diagnosis, medical treatment, and complete neurologic evaluation are of the utmost importance to prevent additional progression.

Association Between Serum Copper Levels and Urinary Incontinence in Adult Men

Urinary incontinence (UI) is a major health burden to aging patients. The function of the trace element copper in male UI is unclear. To elaborate on the impact of serum copper levels on UI, we investigated the association between serum copper levels and UI using data from the National Health and Nutrition Examination Survey (NHANES), a cross-sectional survey of male participants aged 20 years old and older in the United States from 2011 to 2016. We performed weighted multivariable logistic and linear regression models to evaluate the association between serum copper levels and UI. Compared with serum copper levels in quartile 1 (Q1), serum copper levels in Q2 and Q3 were associated with stress urinary incontinence (SUI) after adjusting for all potential confounders (Q2, odds ratio [OR] = 0.292, 95% confidence interval [CI] = 0.093-0.920, P = 0.047; Q3, OR = 0.326, 95% CI = 0.113-0.937, P = 0.049). No significance was found between serum copper levels and other types of UI. Our findings revealed that the serum copper levels were inversely related to SUI in adult males. Race and education level might modulate this relationship. Further studies are warranted for validation.

Acute copper deficiency myelopathy after single-anastomosis gastric bypass

Bariatric surgery is a well-established treatment for morbid obesity, combining both restrictive and malabsorptive mechanisms to achieve weight loss. Macro and micronutrient deficiencies are some of the most common complications of these operations, which in rare occasions can be unexpected, severe, and difficult to manage. We present a case of severe copper deficiency related myelopathy in a patient post single anastomosis gastric bypass, requiring parenteral copper replacement and eventual reversal. She presented with ascending lower limb paraesthesia and weakness, with copper levels on admission of 4 μmol/l, and ceruloplasmin 94 mg/l. She continued to have progressive neuropathy and visual deterioration, despite IV and enteral replacement, and eventually underwent reversal of her bypass, with normalization in her copper levels and incomplete improvement in symptoms. Copper deficiency myelopathy is a rare and severe complication of bariatric surgery. Early identification is key, as neurological symptoms are often not reversible.

Copper Deficiency: An Overlooked Diagnosis

Copper deficiency may often be overlooked due to physicians' poor awareness of the disease. Delayed diagnosis and therapy may lead to poor prognosis of neurological function. Here, we present a 68-year-old male with an approximately one-year history of unsteady feet who had visited several clinical departments and was finally diagnosed with copper deficiency. In the present case, it took approximately one year to diagnose the condition, and the therapy of copper supplementation led to only slight improvement in subjective symptoms. Physicians should be more aware of this condition for a good prognosis of the disease.

[Cervical myelopathy due to copper deficiency secondary to dental zinc overload: A case report]

We present the case of a 68-year-old man with progressive brachial and crural hypoaesthesia with gait ataxia suggesting subacute myelopathy of the posterior cords, demonstrated by MRI. After blood tests, a diagnosis of copper deficiency was made following zinc intoxication, secondary to the use of denture glue containing zinc. Treatment was started with copper and the dental glue was removed. Rehabilitation treatment was started with physiotherapy, hydrotherapy and occupational therapy. Functional improvement was achieved, going from an ASIAD level C4 to an ASIAD level C7 spinal cord injury. Copper levels should be studied in all non-compressive myelopathies of subacute onset if there is clear involvement of the posterior cords. Copper deficiency in analysis would establish the diagnosis. Rehabilitative treatment, supplementary copper supplementation and zinc withdrawal are essential to prevent irreversible neurological damage.

Imaging Aspects of Toxic and Metabolic Myelopathies

Metabolic and toxic myelopathies usually occurs due to several different causes. Metabolic myelopathy usually occurs due to deficiency of a nutrient, such as vitamin B12. Toxic myelopathy occurs secondary to the exposure to an external toxic agent. Although they may have a difficult diagnosis, determination of the specific cause of myelopathy is of utmost importance, because many causes are amenable to treatment. Although they have many clinical, electrophysiologic, and neuropathologic similarities, imaging may aid in the suspicion of toxic or metabolic myelopathy. The aim of this article, is to review the imaging features of the main toxic and metabolic myelopathies.

Can Patients with Wilson's Disease Develop Copper Deficiency?

Background

Wilson's disease (WD) is a rare genetic condition characterized by a copper overload in organs secondary to mutation in ATP7B gene. Lifelong decoppering treatments are the keystone of the treatment but must be regularly adapted to obtain a correct copper balance and could lead to copper deficiency (CD).

Objectives

Study the characteristics of CD in WD patients.

Methods

CD cases from our cohort of 338 WD patients have been investigated. CD was defined by the association of serum copper, exchangeable copper and urinary copper excretion assays less than two standard deviations from the mean with cytopenia and/or neurological damage of spinal cord origin. A systematic review of literature about cases of CD in WD patient was performed in PubMed database according to PRISMA guidelines.

Results

Three WD patients were diagnosed with CD in our cohort. Review of the literature found 17 other patients. Most of the patients had anemia and neutropenia associated with neurological symptoms (especially progressive posterior cord syndrome). All the patients were treated with Zinc salts and the symptoms occurred more than a decade after the initiation of treatment. The adaptation of the treatment allowed a correction of the cytopenia but only a partial improvement of the neurological symptoms.

Conclusions

WD patients can develop CD after many years of zinc therapy. Anemia and neutropenia are red flags that should evoke CD.

Copper Deficiency as Wilson's Disease Overtreatment: A Systematic Review

BACKGROUND

Treatment of Wilson's disease (WD), an inherited disease characterized by copper overload, is lifelong and there is the possibility that copper deficiency (CD) may occur. We systematically reviewed the literature to describe treatment patterns, symptoms and outcomes associated with CD.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, the PubMed database was searched up to 6 April 2023.

RESULTS

Across 17 articles, 20 cases of CD were described, most commonly (15 cases) in WD patients treated with zinc salts (ZS), less often on combined chelator and ZS therapy (3 cases), molybdate salts plus ZS (1), or molybdate alone (1). CD symptoms occurred insidiously, including sideroblastic anemia, neutropenia, axonal sensory neuropathy, posterior cord myelopathy and increased ratio of epileptic seizures (or epilepsy). CD diagnosis was based on symptoms and severely reduced urinary copper excretion (<20 µg/24 h [<0.3 µmol/24 h] on ZS, or <100 µg/24 h [<1.6 µmol/24 h] on chelators) with low total serum copper and ceruloplasmin.

CONCLUSIONS

Awareness of CD and regular monitoring of copper metabolism is needed during WD treatment. Temporary cessation of anti-copper treatment usually reverses serum copper reductions as well as pancytopenia; however, some symptoms, especially neuropathy and myelopathy, may persist.

A Case Series of Patients With Polyneuropathy Due to Copper Deficiency

We are presenting six cases of patients with peripheral polyneuropathy due to malnutrition in settings of prior history of gastric bypass surgery, zinc-based dentures usage, or long-standing alcohol abuse. The clinical presentation in all six patients included sensory, motor, or combined peripheral polyneuropathy and gait instability due to imbalance. All patients included in this case series were found to have low copper levels. Electromyography (EMG) with nerve conduction study (NCS) showed predominantly axonal and length dependent sensory or sensory-motor polyneuropathies. Patients were treated with copper supplements with reportable improvement in their presenting symptoms.

High Prevalence of Malnutrition and Micronutrient Deficiencies in Patients With Inflammatory Bowel Disease Early in Disease Course

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at an increased risk of malnutrition. The goal of this study was to define the prevalence of malnutrition and micronutrient deficiencies in recently diagnosed IBD patients and to compare the performance of existing malnutrition screening tools in identifying IBD patients at increased risk for malnutrition.

METHODS

This was a retrospective cohort study of adult patients with recently diagnosed IBD (≤18 months disease duration). A diagnosis of malnutrition was made utilizing the European Society for Clinical Nutrition and Metabolism malnutrition criteria. Serum micronutrient levels were included. The sensitivity of 5 malnutrition screening tools in identifying patients at moderate-high risk of malnutrition was determined based on the European Society for Clinical Nutrition and Metabolism malnutrition definition. Descriptive statistics summarized the data and univariate analyses tested associations.

RESULTS

A total of 182 patients were included for analysis; 65 (36%) met criteria for malnutrition. A total of 135 (74%) patients had ≥1 micronutrient level checked and 105 (78%) had ≥1 deficiency. Patients with prior surgery (odds ratio [OR], 4.5; P = .004), active Crohn's disease (OR, 2.8; P = .03), and diarrhea (OR, 2.1; P = .02) were more likely to be malnourished. The Malnutrition Universal Screening Tool and Saskatchewan IBD Nutrition Risk Tool had the highest sensitivity (100%) in predicting those at moderate-high risk of malnutrition at the time of screening.

CONCLUSIONS

Patients with recently diagnosed IBD have a high prevalence of malnutrition and micronutrient deficiencies. Both the Malnutrition Universal Screening Tool and Saskatchewan IBD Nutrition Risk Tool can be used to identify those at increased risk of malnutrition. Future studies and screening tool development are necessary to identify those at risk of developing malnutrition to facilitate timely referral for nutritional evaluation and prevent disease related complications.

In Vivo and In Vitro Biocompatibility Study of CuS Nanoparticles: Photosensitizer for Glioblastoma Photothermal Therapy

Although photothermal treatment (PTT) has made significant progress in the fight against cancer, certain types of malignant tumors are still difficult to eradicate. PTT uses photothermal transforming agents to absorb NIR light and convert it to thermal energy, causing cancer cell death. In this study, we synthesized alginate (Alg)-coated CuS nanoparticles (CuS@Alg) as photothermal transforming agents to kill glioblastoma cancer cells. Nanoparticles were synthesized via a facile method, then, were characterized with different techniques such as ultraviolet-visible spectroscopy (UV-Vis), Fourier transform infrared (FTIR), X-ray diffraction analysis (XRD), transmission electron microscopy (TEM), and dynamic light scattering (DLS). Nanoparticles show high stability, and are monodisperse. CuS@Alg was discovered to have a spherical shape, a hydrodynamic size of about 19.93 nm, and a zeta potential of - 9.74 mV. CuS@Alg is able to increase temperature of medium under NIR light. Importantly, in vitro investigations show that PTT based on CuS@Alg has a strong theraputic impact, resulting in much high effectiveness. The LD50 and histopathology assays were used to confirm the NPs' non-toxicity in vivo. Results from an in vivo subacute toxicity investigation showed that the fabricated NPs were perfectly safe to biomedical usage.

Sub-acute combined degeneration of the spinal cord as first presentation of coeliac disease in a Sudanese child

The prevalence of coeliac disease (CD) is rapidly rising in both developed and underdeveloped countries. CD classically presents with gastrointestinal manifestations, but it is now increasingly considered as a multisystem disease mostly affecting the central nervous system. Recently, a non-biopsy approach for the diagnosis of CD has been recommended by the European Society for paediatric gastroentrology, hepatology and nutrition. Here, we are reporting a 12-year-old Sudanese boy who presented with chronic diarrhoea and weight loss and lower limbs weakness. His examinations showed emaciation, pallor and weakness of both lower limbs and mixed upper and lower motor neuron signs and peripheral neuropathy, suggestive of sub-acute combined degeneration of the spinal cord (SACDSC). His initial investigations showed microcytic hypochromic anaemia with hypokalaemia and hypocalcaemia and very high titer of the IgA class of tissue transglutaminase (28× upper limit normal ) with a positive anti-endomeseal IgA antibodies. He was diagnosed with acute coeliac crisis with SACDSC, most likely due to Vitamin B12 deficiency. Although his initial cobalamine level was normal, he later developed macrocytosis and his neurological signs improved rapidly with injectable B12. We reported a rare neurological presentation of CD and we highlighted the non-biopsy approach for the diagnosis of CD in children.

Magnetic resonance imaging negative myelopathy in Leber's hereditary optic neuropathy: a case report

BACKGROUND

Leber's hereditary optic neuropathy (LHON) is a common form of mitochondrial disease. The typical clinical presentation of LHON is subacute, painless loss of vision resulting from bilateral optic nerve atrophy. Moreover, extra-ocular manifestations such as cardiac conduction abnormalities and neurological manifestations such as multiple sclerosis (MS) like disease or parkinsonism are encountered in some patients. Abnormal findings in spinal cord MR imaging or in the cerebrospinal fluid (CSF) have been observed in previous cases of LHON-associated myelopathy.

CASE PRESENTATION

We report a male patient with LHON who developed symptoms of myelopathy including gait unsteadiness, enhanced deep tendon reflexes and sensory loss of the lower extremities. Imaging of the brain and spinal cord, CSF analysis, as well as neurography and electromyography did not disclose any abnormalities. The somatosensory evoked potential (SEP) findings were suggestive of dorsal column dysfunction.

CONCLUSIONS

The patient case demonstrates that myelopathy associated with LHON can present without abnormal findings in central nervous system MR imaging or in the CSF, and without evidence suggestive of multiple sclerosis or MS-like disease. The dorsal column seems to be particularly vulnerable to myelopathy changes in LHON. Evoked potential investigations may assist in confirming the diagnosis, when clinical features are in line with myelopathy but findings in CSF analysis and central nervous system imaging are normal.

A Diagnostic Approach to Spastic ataxia Syndromes

Spastic ataxia is characterized by the combination of cerebellar ataxia with spasticity and other pyramidal features. It is the hallmark of some hereditary ataxias, but it can also occur in some spastic paraplegias and acquired conditions. It often presents with heterogenous clinical features with other neurologic and non-neurological symptoms, resulting in complex phenotypes. In this review, the differential diagnosis of spastic ataxias are discussed and classified in accordance with inheritance. Establishing an organized classification method based on mode inheritance is fundamental for the approach to patients with these syndromes. For each differential, the clinical features, neuroimaging and genetic aspects are reviewed. A diagnostic approach for spastic ataxias is then proposed.

Copper deficiency, a rare but correctable cause of pancytopenia: a review of literature

INTRODUCTION

Copper is increasingly being recognized as a vital mineral required by both animals and humans. It plays a vital role in many metabolic processes such as cellular respiration, iron oxidation, and hemoglobin synthesis. Copper deficiency, which can be hereditary or acquired, can lead to a wide spectrum of disease processes such as ringed sideroblastic anemia, myelodysplasia, and pancytopenia. Timely identification and management of copper deficiency is necessary to prevent irreversible complications.

AREAS COVERED

Our study focuses on prevalence, etiology, pathophysiology, complications, and treatment of copper deficiency.

EXPERT OPINION

Copper deficiency is frequently underrecognized as the cause of anemia, neutropenia, and bone marrow dysplasia. As it is potentially treatable, it should always be kept in the differentials when patients present with neurological and hematological abnormalities.

Gastrointestinal digestibility insights of different levels of coated complex trace minerals supplementation on growth performance of yellow-feathered broilers

This study was designed to evaluate the optimum additional level of coated complex trace minerals (TMs) and its impacts on the growth performance of broilers through measurement of digestibility of nutrients and intestinal development. In a 56-day trial, a total of 360 one-day-old male yellow-feathered broilers were randomly divided into six dietary treatment groups. Each treatment contained six replicates, with 10 birds. The control group was supplemented with 1,000 mg/kg of uncoated complex TMs in the basal diet (UCCTM1000). The remaining 5 treatments were degressively supplemented with coated complex TMs from 1,000 to 200 mg/kg in the basal diet, which were considered as (CCTM1000), (CCTM800), (CCTM600), (CCTM400), (CCTM200), respectively. Results: On comparing the UCCTM1000 supplementation, the CCTM1000 supplementation decreased the feed to gain ratio (F/G) (P < 0.05), increased digestibility of crude protein (CP) (P < 0.05), crude fat (CF) (P < 0.05), villus height (VH) of duodenum (P < 0.05), and the mRNA expression level of occludin in jejunal mucosa (P < 0.05). In addition, the F/G was lower in the CCTE600 group than that in the CCTE200 group (P < 0.05). The VH to crypt depth (CD) ratio (V/C) of jejunum and ileum in the CCTM400 and CCTM600 groups was higher (P < 0.05) than that in the CCTM1000 group. The serum endotoxin and D-lactate level and CP digestibility were increased by dietary coated complex TMs addition level. The mRNA expression levels of claudin-1 and ZO-1 in the CCTM600 group were higher (P < 0.05) than that in the CCTM1000 group. In conclusion, adding 600 mg/kg of coated complex TMs showed the minimum F/G and the maximum crude protein digestibility and intestine development of yellow-feathered broilers compared with other treatments. This supplementation level of coated complex TMs could totally replace 1,000 mg/kg of uncoated complex TMs to further decrease the dose of TMs and raise economic benefit.

Copper Deficiency and Polyneuropathy: A Case Report

Although copper plays a pivotal role in numerous physiological processes, its deficiency is virtually indistinguishable from subacute combined degeneration due to cobalamin deficiency. Moreover, the co-occurrence of deficiencies in other micronutrients and vitamins is common, making the diagnosis even more challenging. Here, we describe a case of copper deficiency in a 50-year-old woman who presented with altered mental status and bilateral upper and lower extremity weakness, numbness, and paresthesia. She was treated for cirrhosis and hepatic encephalopathy secondary to hepatic injury. While her mental symptoms improved, her physical symptoms continued to worsen, and she was transferred for further evaluation. The neurologic examination was positive for sensory neuropathy including decreased vibration/proprioception and ataxia in arms and legs; complete blood count showed pancytopenia; but infectious workup, cerebrospinal fluid analysis, autoimmune studies, and brain/spine magnetic resonance imaging were normal. A nerve conduction study showed generalized, axonal sensorimotor polyneuropathy. Micronutrient/trace element deficiency was suspected in the setting of gastric bypass surgery, and supplementation was successfully initiated. Though uncommon, clinical copper deficiency is increasingly frequently recognized in the inpatient setting, and permanent neurological damage can occur prior to diagnosis and treatment. Physicians should have an elevated clinical suspicion of copper deficiency in cases of polyneuropathy and pancytopenia in patients with a history of bariatric surgery.

Update in autoimmune and paraneoplastic myelopathies: Newly described antigen targets and antibody testing

Myelopathy is an increasingly recognized presentation of many antibody-mediated neuroinflammatory disorders. While specific features of certain autoimmune myelopathies such as aquaporin-4 antibody associated neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein associated disorder (MOGAD) are well-characterized, other less commonly seen antibody-associated myelopathies are not as well-defined. These include but are not limited to, Hu/ANNA1, anti-glial fibrillary acidic protein (GFAP), anti-CV2/collapsin response mediator protein (CRMP5), and amphiphysin. Here, we review the mentioned more common antibody mediated myelopathies as well those that as less common, followed by a review of differentials that may mimic these disorders.

Copper Deficiency-Induced Neuropathy After Bariatric Surgery Disguised as Demyelinating Disease: A Case Report

Neuropathy may arise from many different etiologies - from diabetes and nerve compression to viral infections and chemotherapy side effects; many patients suffer from neuropathic symptoms. While some etiologies produce irreversible neuropathy, others, such as vitamin and mineral deficiencies, lead to a possibly reversible disease process once treated. General clinicians should strive for early and prompt diagnosis of copper deficiency neuropathy whenever possible, especially in patients with normal vitamin B12 levels who present with a subacute gait disorder or prominent sensory ataxia. We present a case of a 73-year-old female with a surgical history of Roux-en-Y gastric bypass (RYGB) 20 years prior, who presented with difficulty with ambulation due to sensory ataxia and bilateral, ascending, sensory neuropathy, who was diagnosed with acquired copper deficiency-induced myeloneuropathy.