A Perfect MDS Mimic: Zinc-Driven Copper Deficiency After Gastric Bypass in a Patient Using Denture Adhesive

BACKGROUND Copper deficiency-an underrecognized cause of anemia, neutropenia, and neuropathy-can mimic myelodysplastic syndrome (MDS), particularly in patients with prior bariatric surgery or excess zinc exposure. Recognition is critical because hematologic and neurologic manifestations may resemble clonal bone marrow disorders but are potentially reversible with appropriate treatment. CASE REPORT A 58-year-old woman with prior Roux-en-Y gastric bypass displayed progressive fatigue, exertional dyspnea, and distal paresthesias. Laboratory evaluation revealed severe hypoproliferative anemia (hemoglobin 5.8 g/dL) and neutropenia (absolute neutrophil count 980/µL; nadir <500/µL). Peripheral smear showed anisopoikilocytosis and pseudo-Pelger-Huët-like changes, suggesting MDS. Subsequently, the patient developed febrile neutropenia and coronavirus disease 2019. Vitamin B12 (910 pg/mL) and folate (6.8 ng/mL) levels were normal. Hemolysis markers were not significantly elevated (lactate dehydrogenase 149 U/L, haptoglobin 205 mg/dL). Serum copper was below 10 µg/dL (reference, 77-206 µg/dL), ceruloplasmin was below 60 mg/L (reference, 200-600 mg/L), and serum zinc was elevated (130 µg/dL [reference, 60-106 µg/dL]). Bone marrow biopsy showed preserved trilineage hematopoiesis without increased blasts, supporting a nutritional etiology. Further assessment revealed nonadherence to recommended multivitamin and mineral supplementation, along with chronic excessive use of zinc-containing denture adhesive. The patient received intravenous followed by oral copper supplementation and underwent discontinuation of zinc exposure, resulting in rapid hematologic improvement and partial resolution of neurologic symptoms. CONCLUSIONS Copper deficiency should be considered in patients with unexplained cytopenias and neurologic symptoms, especially after bariatric surgery or under chronic zinc exposure. With early recognition, this condition is reversible; patients can avoid unnecessary evaluation, misdiagnosis, and complications.