Hematogone hyperplasia in copper deficiency

Causes and Pathophysiology of Acquired Sideroblastic Anemia

The sideroblastic anemias are a heterogeneous group of inherited and acquired disorders characterized by anemia and the presence of ring sideroblasts in the bone marrow. Ring sideroblasts are abnormal erythroblasts with iron-loaded mitochondria that are visualized by Prussian blue staining as a perinuclear ring of green-blue granules. The mechanisms that lead to the ring sideroblast formation are heterogeneous, but in all of them, there is an abnormal deposition of iron in the mitochondria of erythroblasts. Congenital sideroblastic anemias include nonsyndromic and syndromic disorders. Acquired sideroblastic anemias include conditions that range from clonal disorders (myeloid neoplasms as myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms with ring sideroblasts) to toxic or metabolic reversible sideroblastic anemia. In the last 30 years, due to the advances in genomic techniques, a deep knowledge of the pathophysiological mechanisms has been accomplished and the bases for possible targeted treatments have been established. The distinction between the different forms of sideroblastic anemia is based on the study of the characteristics of the anemia, age of diagnosis, clinical manifestations, and the performance of laboratory analysis involving genetic testing in many cases. This review focuses on the differential diagnosis of acquired disorders associated with ring sideroblasts.

Copper and Zinc Feud: Is This Myelodysplasia or Myelodysplastic Syndrome?

We report a case of a 59-year-old male who developed pancytopenia and multiorgan failure attributed to copper deficiency from exogenous consumption of zinc tablets. During the six months preceding his presentation, he had experienced increasing shortness of breath, lightheadedness, and fatigue. Laboratory studies revealed pancytopenia with profound anemia (hemoglobin level 2.8 g/dL) along with evidence of acute kidney injury and acute heart failure; the patient was presumed to have multiorgan failure due to profound anemia. Bone marrow biopsy revealed dyspoiesis suggestive of myelodysplastic syndrome (MDS). There were no cytogenetic abnormalities observed. However, the blood workup analysis found low copper and ceruloplasmin levels, whereas zinc levels were excessively elevated (257 mg/dL). Upon inquiry, the patient reported taking an over-the-counter zinc supplement of an unknown quantity for over a year. After two months of copper treatment, his blood count returned to normal. This case highlights a rare presentation of zinc-induced copper deficiency resulting in pancytopenia and severe anemia-related multiorgan failure. A growing number of hematological disorders are being linked to copper deficiency. Copper deficiency pancytopenia is a reversible condition that often goes unnoticed and can be misdiagnosed as MDS because it has similar hematological characteristics.

Hematogone Hyperplasia Masquerading as Acute Lymphoblastic Leukemia With Concurrent Hypercupremia

Alterations in copper homeostasis is an uncommon cause for hematologic alterations frequently presenting with dysplastic features in the bone marrow. Most of these alterations have been documented in adult patients with copper deficiency. Rare cases show hematogone hyperplasia in these patients. Effects of mild copper excess have not been documented in literature. We are describing a pediatric patient who presented with pancytopenia associated with hypercupraemia (excess of copper). Bone marrow examination showed hematogone hyperplasia. Interestingly, correction of serum copper levels with zinc therapy lead to complete improvement in pancytopenia. Hematogones had also reduced in subsequent marrow biopsy after therapy.

The Role of Fe, Zn, and Cu in Pregnancy

Iron (Fe), copper (Cu), and zinc (Zn) are microelements essential for the proper functioning of living organisms. These elements participatein many processes, including cellular metabolism and antioxidant and anti-inflammatory defenses, and also influence enzyme activity, regulate gene expression, and take part in protein synthesis. Fe, Cu, and Zn have a significant impact on the health of pregnant women and in the development of the fetus, as well as on the health of the newborn. A proper concentration of these elements in the body of women during pregnancy reduces the risk of complications such as anemia, induced hypertension, low birth weight, preeclampsia, and postnatal complications. The interactions between Fe, Cu, and Zn influence their availability due to their similar physicochemical properties. This most often occurs during intestinal absorption, where metal ions compete for binding sites with transport compounds. Additionally, the relationships between these ions have a great influence on the course of reactions in the tissues, as well as on their excretion, which can be stimulated or delayed. This review aims to summarize reports on the influence of Fe, Cu, and Zn on the course of single and multiple pregnancies, and to discuss the interdependencies and mechanisms occurring between Fe, Cu, and Zn.

Hematogones Detected by Flow Cytometry in a Child with Vitamin B12 Deficiency

Vitamin B12 deficiency is a known cause of megaloblastic anemia and bone marrow failure. Bone marrow biopsies are not frequently performed as part of the diagnostic workup and can demonstrate morphologic features that overlap with myelodysplastic syndrome (MDS) and acute leukemia. We describe a case of a dysplastic bone marrow with increased bone marrow hematogones detected by flow cytometry in a child with vitamin B12 deficiency. Hematogones are normal B cell precursors, and hyperplasia has been described in a variety of often reactive conditions and also disease. Hematogones are not typically seen in MDS. The presence of hematogones may help differentiate the dysplastic changes seen in vitamin B12 deficiency from MDS.

Idiopathic hyperzincemia with associated copper deficiency anemia: a diagnostic dilemma

Prompt serum copper and zinc in addition to vitamin B12 levels should be measured in patients suffering from refractory anemia with neurological symptoms. A timely copper supplementation can help revert the hematological and possibly the neurological manifestations.

Copper deficiency (hypocupremia) and pancytopenia late after gastric bypass surgery

Hypocupremia, or copper deficiency, is a rare and underrecognized cause of bone marrow dysplasia. Most cases of copper deficiency in adults occurred historically in patients receiving total parenteral hyperalimentation or total parental nutrition. More recently, with the obesity epidemic and the prevalence of gastric bypass, cases of malabsorption-related copper deficiency have occurred. Copper deficiency can lead to significant cytopenias and possible neurologic sequelae, which can be misdiagnosed and mismanaged. Unfortunately, a delay in diagnosis and appropriate treatment may lead to permanent neurologic damage. We describe a woman with previous gastric bypass surgery who presented with pancytopenia and bone marrow biopsy findings consistent with a myelodysplastic syndrome with excess blasts. She was found to be significantly copper deficient. With replacement copper therapy, her cytopenias quickly resolved. We discuss the distinctive clinical and hematologic features of this rare cause of significant cytopenias and provide recommendations for monitoring and treatment of such patients. Moreover, this case is an important reminder that bariatric patients should have routine follow-ups after surgery and continue dietary supplements indefinitely.

Update on anemia and neutropenia in copper deficiency

PURPOSE OF REVIEW

Copper deficiency is an under-recognized cause of reversible refractory anemia and leukopenia, particularly neutropenia, often misdiagnosed as myelodysplastic syndrome (MDS). Clinicians and hematopathologists need to be aware of distinct morphologic findings to distinguish these entities including cytoplasmic vacuolization of both erythroid and myeloid precursors, excess iron stores, ringed sideroblasts, iron incorporation in plasma cells, and variable marrow cellularity. In contrast, the findings in MDS do not include myeloid lineage vacuolization, abnormal nuclear lobulation of both erythroid and myeloid precursors, nuclear/cytoplasmic dyssynchrony, or dysmegakaryopoiesis with abnormalities of nuclear lobulation and size.

RECENT FINDINGS

The mechanism of neutropenia remains unknown; however, the study by Peled and coworkers suggests that copper deficiency results in the inhibition of differentiation and self-renewal of CD34(+) hematopoietic progenitor cells. A number of recent studies have reported on the association of copper deficiency with the development of concomitant neurologic deficits manifested as peripheral neuropathies and myeloneuropathy indistinguishable from the findings seen in vitamin B12 deficiency.

SUMMARY

Patients presenting with refractory anemia and leukopenia with or without associated neurologic deficits should have copper and ceruloplasmin levels measured as part of their diagnostic evaluation.

Significant CD5 expression on normal stage 3 hematogones and mature B Lymphocytes in bone marrow

B-cell maturation from hematogones to mature B cells in bone marrow exhibits a consistent, complex spectrum of sequential antigen expression. CD5 expression, however, has not been characterized. We studied the dynamics of CD5 expression on developing B cells by 4-color flow cytometry in 32 patients, aged 9 months to 63 years, with hematogone hyperplasia (>3.5% of total events). The mean percentage of hematogones was 8.1%. We demonstrate consistent CD5 expression on normal, polytypic B cells in a continuum, predominantly at later stages of maturation, specifically on stage 3 hematogones and mature B cells. Awareness of this normal pattern of CD5 expression on B-cell subsets has implications in the analysis of minimal residual disease of CD5+ B-lineage non-Hodgkin lymphomas.