Zinc-induced copper deficiency in a coin swallower

Nutritional neuropathies

Neuropathies associated with nutritional deficiencies are routinely encountered by the practicing neurologist. Although these neuropathies assume different patterns, most are length-dependent, sensory axonopathies. Cobalamin deficiency neuropathy is the exception, often presenting with a non-length-dependent sensory neuropathy. Patients with cobalamin and copper deficiency neuropathy characteristically have concomitant myelopathy, whereas vitamin E deficiency is uniquely associated with a spinocerebellar syndrome. In contrast to those nutrients for which deficiencies produce neuropathies, pyridoxine toxicity results in a non-length-dependent sensory neuronopathy. Deficiencies occur in the context of malnutrition, malabsorption, increased nutrient loss (such as with dialysis), autoimmune conditions such as pernicious anemia, and with certain drugs that inhibit nutrient absorption. When promptly identified, therapeutic nutrient supplementation may result in stabilization or improvement of these neuropathies.

Pennies for Your Thoughts: A Case Series of Pancytopenia Due to Zinc-induced Copper Deficiency in the Same Patient

A 47-year-old schizophrenic male presented on three separate occasions with pancytopenia and sideroblastic anemia due to copper deficiency from massive zinc penny ingestion. The poisoning was treated differently on each visit: intravenous (IV) copper plus surgical decontamination and chelation with calcium disodium versenate (CaNa2EDTA); IV copper plus whole bowel irrigation; and IV copper with surgical decontamination only. Serum zinc half-lives were 80.0 hours, 233.2 hours, and 83.9 hours, respectively. Importantly, chelation with CaNa2EDTA did not significantly alter the elimination half-life. This is the first reported case of the same patient being treated on three different occasions with three different regimens for this condition.

Nutrients and Neurology

PURPOSE OF REVIEW

This article provides an update on the clinical presentation and management of neurologic disease related to key nutrient deficiencies.

RECENT FINDINGS

Major advances have been made in understanding the pathway related to vitamin B12 absorption and distribution. It is now known that deficiencies of vitamin B12 and copper have similar neurologic manifestations. Bariatric surgery is a risk factor for both. Alcoholism is just one of the many causes of thiamine deficiency. Early neurologic complications following bariatric surgery are often due to thiamine deficiency. Encephalopathy in the setting of alcoholism that persists despite thiamine replacement should prompt consideration of niacin deficiency. Pyridoxine deficiency and toxicity both have neurologic sequelae. Vitamin D deficiency and the risk for multiple sclerosis has been an area of ongoing research.

SUMMARY

Optimal functioning of the nervous system is dependent on a constant supply of certain vitamins and nutrients. This article discusses neurologic manifestations related to deficiency of these key nutrients.

Coin pica-induced gastric perforation resulting from ingestion of 1,894 coins, 8 kg in total: case report and review of published works

Case

Pica is common among patients with psychiatric disorders, but only a few cases regarding coin pica have been reported. A 51-year-old man with depression complaining of fatigue was found to have numerous coins in the esophagus and the stomach on X-rays. He had a peritoneal sign and underwent an emergency laparotomy.

Outcome

The surgical findings showed perforation on the anterior wall of the gastric body and coins in the stomach, which were removed manually, followed by an omental patch. Residual coins in the esophagus were removed by endoscopy. The coins totaled 1,894, weighing 8,076 grams. The patient was then diagnosed as schizophrenic. He was asymptomatic for metal toxicity and was finally transferred to a psychiatric hospital.

Conclusion

This pica case is the first to show coin pica can lead to gastric perforation, and also reports the largest amounts of coins ingested by a person to date.

Neurologic presentations of nutritional deficiencies

Optimal functioning of the central and peripheral nervous system is dependent on a constant supply of appropriate nutrients. The first section of this review discusses neurologic manifestations related to deficiency of key nutrients such as vitamin B(12), folate, copper, vitamin E, thiamine, and others. The second section addresses neurologic complications related to bariatric surgery. The third sections includes neurologic presentations caused by nutrient deficiencies in the setting of alcoholism. The concluding section addresses neurologic deficiency diseases that have a geographic predilection.

Hematological manifestations of copper deficiency: a retrospective review

Copper deficiency is an established cause of hematological abnormalities but is frequently misdiagnosed. Copper deficiency can present as a combination of hematological and neurological abnormalities and it may masquerade as a myelodysplastic syndrome. We reviewed the records of patients with hypocupremia and hematologic abnormalities identified between 1970 and 2005. Patients with hypocupremia unrelated to copper deficiency (e.g. Wilson's disease) were excluded. Forty patients with copper deficiency and hematological abnormalities were identified. Ten patients (25%) had undergone bariatric (weight reduction) surgery and an additional 14 patients (35%) had undergone surgery on the gastrointestinal tract, most commonly gastric resection. In 12 cases, no cause for copper deficiency was identified. Anemia and neutropenia were the most common hematologic abnormalities identified and the majority of the patients also had neurologic findings, most commonly due to myeloneuropathy. Abnormalities observed on bone marrow examination including vacuoles in myeloid precursors, iron-containing plasma cells, a decrease in granulocyte precursors and ring sideroblasts may be valuable clues to the diagnosis. Copper deficiency is an uncommon but very treatable cause of hematologic abnormalities.

In vitro study of ingested coins: leave them or retrieve them?

BACKGROUND

Objects and notably coins are frequently swallowed by children 3 to 5 years old. Precisely how they should be managed after passing the gastroesophageal junction without causing symptoms remains controversial. This study was performed to assess dissolution of specific metals from coins immersed in simulated gastric juice.

METHODS

Four types of euro and US coins were immersed in simulated gastric juice for 4, 24, 72, and 120 hours. Six metals were evaluated by inductively coupled plasma-atomic emission spectrometry. Weight loss and corrosive behavior were also determined.

RESULTS

After only 4 hours, metals had dissolved from euro (Cu, 2.86-7.85 mg; Ni, 0.23-0.52 mg; Zn, 0.09-0.99 mg; Al, 0.24 mg; Sn, 0.02 mg) and US (Cu, 1.45-6.65 mg; Ni, 0-0.62 mg; Zn, 0-0.14 mg) coins. Their concentrations in simulated gastric juice peaked after 24 to 72 hours (milligrams/hours) in euro (Cu, 218/48; Ni, 82.50/72; Zn, 83.00/72; Al, 14.65/72; Sn, 0.66/72) and US (Cu, 126.50/24; Ni, 88.00/72; Zn, 149.00/24) coins. All coins underwent corrosion and weight loss (by 2.56%-4.8%).

CONCLUSIONS

Coins retained in the stomach will release a number of heavy metals well known to cause dose-dependent poisoning. Studies to evaluate their toxicity and absorption are needed to optimize treatment.

Gastric bezoar in anorexia nervosa

OBJECTIVE

To report the case of a gastric bezoar in a patient with anorexia nervosa (AN).

METHOD

Case report of a bezoar of the stomach occurring in AN and a review of the literature relating to bezoars and AN from PubMed.

RESULTS

A 19 year-old female presented with a 2-year history of AN binge-purge subtype. After 7 days of complete adherence to diet and no purging in hospital, she complained of increased nausea. She vomited up a cylindrical mass that was sent for pathology. A literature search yielded only one report of a bezoar in AN.

DISCUSSION

Bezoars are agglomerations of food or foreign material in the intestine. They usually present with abdominal pain, intestinal obstruction, weight loss, poor appetite, or vomiting. The CT scan of the abdomen is the preferred method of diagnosis. Clinicians should consider the diagnosis of a bezoar in AN if there is concomitant pica, trichotillomania, or a change in gastrointestinal symptomatology.

Zinc intoxication in dogs: 19 cases (1991–2003)

OBJECTIVE

To determine physical examination findings, clinicopathologic changes, and prognosis in dogs with zinc toxicosis.

DESIGN

Retrospective case series.

ANIMALS

19 dogs with zinc toxicosis.

PROCEDURES

Medical records from 1991 through 2003 were searched for animals with a diagnosis of zinc toxicosis. Information concerning signalment, body weight, historical findings, initial owner complaints, physical examination findings, clinicopathologic findings, blood zinc concentrations, source of zinc, treatments given, duration of hospital stay, and outcome was collected.

RESULTS

Records of 19 dogs with zinc toxicosis were reviewed. The most common historical findings were vomiting (n = 14) and pigmenturia (12). The most common clinicopathologic findings were anemia (n = 19) and hyperbilirubinemia (12). Median age was 1.3 years, and median weight was 5.6 kg (12.3 lb). The prognosis was favorable, with 17 dogs surviving after a median hospital stay of 2 days.

CONCLUSIONS AND CLINICAL RELEVANCE

Hemolytic anemia as a result of zinc toxicosis appeared to affect young small-breed dogs more frequently than older large-breed dogs. The prognosis with treatment is good, and most affected dogs had a short hospital stay.

Copper deficiency myelopathy (human swayback)

The hematologic manifestations of copper deficiency are well known and include anemia and neutropenia. In the past few years, the neurological manifestations of acquired copper deficiency in humans has been recognized, the most common being a myelopathy presenting with a spastic gait and prominent sensory ataxia. The known causes of acquired copper deficiency include prior gastric surgery, excessive zinc ingestion, and malabsorption; however, often the cause is unclear. Hyperzincemia may be present even in the absence of exogenous zinc ingestion. The clinical features and neuroimaging findings are similar to the subacute combined degeneration seen in patients with vitamin B12 deficiency. Copper and vitamin B12 deficiency may coexist. The neurological syndrome may be present without the hematologic manifestations. Copper supplementation resolves the anemia and neutropenia promptly and completely and may prevent the neurological deterioration. Improvement, when it occurs, is often subjective and preferentially involves sensory symptoms. This article describes patients with copper deficiency myelopathy seen at the Mayo Clinic in Rochester, Minn, and reviews the literature on neurological manifestations of acquired copper deficiency in humans.

Effects of gastric acid on euro coins: chemical reaction and radiographic appearance after ingestion by infants and children

OBJECTIVES

This study investigated whether coins of the new European currency (euro) corrode when they are exposed to gastric acid, and whether this change can be detected radiographically.

METHODS

The eight different denominations of coins were immersed for seven days in 0.15 N hydrochloride acid (HCl), which corresponds to the level of post-prandial gastric acid. A Swedish crown coin and three different Austrian schilling coins were used as controls. The coins were weighed and radiographed daily to evaluate visible corrosions and HCl was analysed daily for possible dissolved substances.

RESULTS

All coins lost weight within 24 hours after exposure to HCl. The 1, 2, and 5 euro cent coins developed changes that were visible on radiographs. The weights of all coins decreased by 0.43% to 11.30% during one week. The dissolved substances measured in the HCl corresponded to the different metals and alloys of the coins, except for copper, which does not dissolve in HCl. The highest absolute weight loss was observed in the Swedish crown coin (0.67 g), and the highest relative weight loss in the 1 Austrian schilling coin (11.30%). The two coins that showed the highest absolute and relative weight losses were the 2 euro (0.54 g or 6.35%) and the 1 euro (0.48 g or 6.39%) coin.

CONCLUSIONS

A higher rate of toxicity for the new European coins compared with coins of other currencies is not expected, unless a massive coin ingestion occurs.

Zinc-induced copper deficiency: a report of three cases initially recognized on bone marrow examination

Copper deficiency is a rare cause of sideroblastic anemia and neutropenia that often is not suspected clinically. The morphologic findings in bone marrow, while not pathognomonic, are sufficiently characteristic to suggest the diagnosis, leading to further testing to establish the correct diagnosis. Excess zinc ingestion is among the causes of copper deficiency. We present 3 cases of zinc-induced copper deficiency in which the diagnosis first was suggested on the basis of bone marrow examination. The first patient was a 47-year-old man with a debilitating peripheral neuropathy that had progressed during the previous 18 months, mild anemia, and severe neutropenia. The second was a 21-year-old man receiving zinc supplementation for acrodermatitis enteropathica in whom moderate normocytic anemia and neutropenia developed. The third patient was a 42-year-old man with anemia, severe neutropenia, and a peripheral neuropathy that had progressed during 8 months. The bone marrow findings in all cases suggested copper deficiency, which was confirmed by further laboratory testing and determined to be due to zinc excess. The morphologic features, clinical manifestations, differential diagnosis, and pathogenetic mechanisms are discussed.