Neutropenia due to copper deficiency in total parenteral nutrition

Copper (Cu) deficiency has been reported both in pediatric and adult patients on total parenteral nutrition (TPN). Manifestations of Cu deficiency are usually hematologic in the adult. A 56-yr-old patient with a history of subtotal gastrectomy underwent massive small bowel resection and partial colectomy in 1977. TPN was initiated. Intravenous (iv) trace mineral supplements were not available in 1977 at our institution. By June 1978, the patient manifested neutropenia with a white blood cell (WBC) count of 2000/mm3 and 39% neutrophils or a total neutrophil count (TNC) of 780/mm3. The serum Cu level at that time was 5 micrograms/dl (normal, 70-140), and the serum zinc (Zn) level was low, although within normal limits. Oral supplementation with Cu and Zn tablets proved ineffective. Twice weekly infusions of fresh frozen plasma were begun in April 1979, and intravenous chromium supplementation started in September 1979, but neither the WBC count nor the TNC improved. Intravenous Cu and Zn were approved in October 1979, and were added to the TPN formula. Within 2 weeks, the WBC count rose to 6300/mm3, and the neutrophils increased to 83% with a TNC of 5229. After 12 weeks, the serum Cu level rose to 80 micrograms/dl. The increase in WBC count and percentage of neutrophils can be attributed to the addition of Cu to the TPN infusate.