ABSTRACT
While copper deficiency is rare, it can have serious consequences, including pancytopenia and neuropathy. This treatable micronutrient deficiency can present very similarly to myelodysplastic syndrome (MDS), a group of myeloid neoplasms which can carry devastating prognoses. Copper deficiency is an essential differential diagnosis in suspected MDS, as it can present with similar laboratory findings, bone marrow biopsy, and clinical picture. While copper deficiency has multiple potential causes, it typically occurs in patients with a predisposing gastrointestinal pathology. One possible cause of copper deficiency is zinc overload. Interestingly, zinc over-supplementation has been prevalent during the COVID-19 pandemic, as some believe that zinc can help prevent COVID-19 infection. Multiple case reports have illustrated the similarities between copper deficiency and MDS. They have also highlighted zinc over-supplementation as a potential cause. The following case report is unique in that our patient lacked gastrointestinal pathology. He still presented with the clinical and laboratory findings of MDS in the setting of copper deficiency. These include anemia, leukopenia, fatigue, and neuropathy. Further, this deficiency was caused by zinc over-supplementation in efforts to prevent COVID-19. The deficiency and the accompanying symptoms were treated with copper supplementation and cessation of zinc intake.
ABSTRACT
Background: Patients with inadequate amounts of copper often present with cytopenias and exhibit dysplasia on bone marrow, mimicking myelodysplastic syndrome (MDS) and pose diagnostic difficulties. Method(s): This cross-sectional observational study was performed from January 2020 to June 2021. Patients diagnosed with MDS were included in the study and serum copper levels were measured by the Inductively Coupled Plasma Mass Spectrometry (ICPMS) method. Copper supplementation with intravenous copper chloride 2.5mg daily for the first two weeks, followed by oral 3mg copper sulfate thrice daily for the next three months, was given for copper-deficient patients. Response assessment was performed with repeat hemogram and serum copper levels. Result(s): A total of 57 patients were diagnosed with MDS, of these, 33 (57.89%) were males and 24 (42.10%) were females. The mean age was 54.3+/-14.6 years (13-81). The distribution of patients in different types of MDS was MDS-SLD in 15, MDS-MLD in 18, MDS-EB1 in 7, MDS-EB2 in 8, and MDS-U in 9 patients. Anemia was seen in (87.71%) of patients, with mean hemoglobin 7.6+/-2.1g/dL (4.6-14.5g/dL). Neutropenia was seen in 31 (54.38%) with a mean absolute neutrophil count(ANC) of 2073+/-2139/muL (211-10,952/muL). Thirty seven (64.91%) patients had thrombocytopenia with a mean platelet count of 1,05,298+/-1,21,769/muL (9,000-6,74,000/muL). The mean serum copper levels were 146.69+/-42.36mug/dL (54.2-254.0mug/dL). Only three (5.26%) patients out of 57 were found to have copper deficiency. All three patients with low copper levels were found to have anemia, thrombocytopenia, and mildly raised serum erythropoietin levels. All three patients had dyserythropoiesis on bone marrow examination, and only one patient each had cytoplasmic vacuolations in erythroid precursors and dysmegakaryopoiesis. Among the three patients with copper deficiency, two patients had significant improvement in cytopenias after copper supplementation, and one had lost follow-up due to COVID-19. Conclusion(s): This study is the first from India to evaluate the role of copper in patients presenting with predominantly hematological manifestations. For patients presenting with cytopenias or marrow dysplasia resembling MDS, copper deficiency should be considered in the differential diagnosis. Legal entity responsible for the study: The authors. Funding(s): Has not received any funding. Disclosure: All authors have declared no conflicts of interest. Copyright © 2022
ABSTRACT
Introduction: This living rapid review aims to systematically update evidence from randomised controlled trials (RCTs) on the efficacy and safety of any zinc formulation or dose compared to any control, for preventing or treating SARS-CoV-2 and other acute viral respiratory tract infections (RTIs) in adults. Methods: Protocol registration was 27-April-2020 (PROSPERO: CRD42020182044). Eight databases (one Chinese), four clinical trial registries (one Chinese) and two pre-print servers were then searched with no language or date restrictions. Post-protocol/pre-data extraction, the inclusion criteria was restricted to adults. Meta-analysis used weighted, random-effects models. Cochrane RoB 2.0 tool and GRADE were used to appraise evidence certainty. Searches for COVID-19 evidence are updated 6-monthly. Results: As of Oct-2020, 1,907 articles and protocols were screened, and 28 RCTs involving 5,403 participants (none with SARS-CoV-2 infections) were included. Compared to placebo, oral or intranasal zinc prevented 5 RTIs/100 person-months (95%CI: 1-9, NTT=20) in adults without zinc deficiency (moderate-certainty), but not pre/post exposure prevention following human rhinovirus inoculation (RR 0.96, 95%CI: 0.77-1.21, moderate-certainty). There was low-certainty evidence of clinically important RTI treatment outcomes. Compared to placebo, sublingual or intranasal zinc improved day-3 symptom severity (MD 1.2 points lower, 95%CI: 0.7-1.7) and reduced symptom duration (MD 2 days shorter, 95%CI: 0.2-3.5;HR 0.55 over 7-days, 95% CI: 0.32-0.91, NNT=5). There was an increased risk of non-serious adverse events (e.g. nausea, or mouth or nasal irritation) (ARR 14/100 adults, 95%CI: 4-16, NNH=7). In the 25 RCTs that reported adverse events, none were serious, including copper deficiency or anosmia. The April-2021 update search identified, four COVID-19 RCTs with 572 participants and 7 registered RCTs. These results will be included in the next update. Conclusion: Preliminary evidence suggests there may be a role for zinc in the COVID-19 pandemic. Further research and regular updating of the evidence is warranted. Keywords: Zinc, Complementary medicine, Common cold, Respiratory infections, Viral infections, COVID-19