Pancytopenia secondary to copper deficiency
A. Check serum trace element levels, including iron, copper, and zinc
The key to the correct diagnosis in this case is the patient’s history of gastric bypass surgery, a risk factor for micronutrient deficiencies including copper deficiency. As part of the workup for pancytopenia or suspected myelodysplastic syndrome (MDS), potentially reversible causes of bone marrow failure such as nutritional deficiencies must be ruled out. Workup for nutritional deficiency should be performed before serologic and endoscopic evaluation for celiac disease. In this patient, iron and zinc levels were normal; however, serum copper level was less than 5 µg/dL (reference range, 70-175). In asymptomatic cases of pancytopenia due to copper deficiency, a trial of copper repletion should precede treatment with blood transfusions or erythropoiesis-stimulating agent.