Case History
52-year-old male with anemia and neutropenia.
What nutritional deficiency causes the pictured finding in the bone marrow aspirate?
A. Zinc
B. Folate
C. Copper
D. Vitamin B12
Answer: C. Copper
Discussion:
The erythroid and myeloid precursors show prominent vacuolization, which can be seen in copper deficiency. Copper deficiency demonstrates findings that can mimic myelodysplastic syndrome clinically and histologically. Patients present with anemia and often neutropenia as well. A common way for patients to become copper deficient is from excess zinc ingestion via vitamins and supplements. Zinc interferes with the intestinal absorption of copper, which is essential to red blood cell enzymatic processes.
Under the microscope, the erythroid cells can appear dyserythropoietic, and ring sideroblasts are present. The presence of extensive cytoplasmic vacuolization merits consideration for copper deficiency, and testing for copper levels may be necessary before a diagnosis of myelodysplastic syndrome is rendered, especially if genetic studies are normal.
Case contributed by: Adam Wilberger, M.D., Assistant Professor, Laboratory Medicine, Director, Anesthesia, CICU, CPCC Labs, UAB Pathology