(P08-023-23) A Collision of Risks: Copper Deficiency Due to Chronic Malnutrition, Intestinal Malabsorption, and COVID -19 Infection

Objectives: Copper deficiency is rare due to tight regulation of absorption and excretion. When risk factors collide, however, one should consider this deficiency if classic features present.

Methods: A 13-year-old male with cerebral palsy, chronic lung disease, gastrostomy tube dependence, Inflammatory Bowel Disease with ileostomy and pancreatic insufficiency was hospitalized for high ostomy output, oxygen desaturations and malaise due to SARS-CoVID2 infection.  He had lost 22lbs over 17 months due to receiving< 50% of the recommended dietary allowance for age (RDA) for energy and 50 -75% of the RDA for protein. He was switched to a non-nutritionally complete food-based formula 6 months ago but continued a daily multivitamin.

He was pale with thin hair, bald patches, but no breakage nor scaling. His brown eyebrows were now sparse and blond. His proximal hair shafts were white, revealing the "flag sign". His pubic hair was ginger in color. There were no rashes, bone pain, nor cardiac arrhythmia.

He had low protein and albumin levels, elevated transaminases, neutropenia (1,490), macrocytic hypochromic anemia, and thrombocytopenia. Folate, vitamin B12, zinc, vitamin E, retinol, and triene:tetrene ratio were normal. He was iron replete. Serum copper was 0.53mcg/ml (low).

Copper deficiency was diagnosed. He began a nutritionally complete food-based formula and multivitamin with treatment doses of elemental copper (2mg/day). He received respiratory support, volume repletion, and care for chronic conditions.

Results: Malnutrition impairs intestinal absorption, immune function, and antioxidant response, increasing infection risk. The SARS-CoV2 virus causes intestinal dysbiosis, increases inflammatory and reactive oxygen species, and depletes antioxidants. This patient had classic signs of copper deficiency, (i.e., pallor, hair depigmentation, neutropenia, hypochromic anemia, and thrombocytopenia) seen with protein energy malnutrition, severe infection, and intestinal malabsorption. Though rare, macrocytic, hypochromic anemia can be seen with copper deficiency as in this case.

Conclusions: Adverse outcomes result in medically complex patients dependent on prescribed enteral diets if nutritional management is altered, with consequences that predispose to further disease susceptibility and sequelae.

Funding Sources: Childrens Hospital of Colorado