Severe Ataxia Secondary to Copper Deficiency Myelopathy in a Patient with History of Gastric Bypass Surgery: A Case Report

Author(s): Minh C. Nguyen MD, MPH, Mohammad I. Murtuza, MD, Nguyen T. Tran, MD, Kinjal R. Parikh, DO

This is a 46-year-old female with significant past history notable for systemic lupus erythematous, gastric bypass surgery, and anterior cervical diskectomy and fusion at cervical 5-6 who presents to clinic with months of progressive difficulty with ambulation and falls. Patient initially misdiagnosed with severe cervical stenosis and then vitamin B12 deficiency as the cause of her gait ataxia. Subsequent workup later proved patient was suffering from copper deficiency leading to subacute combined degeneration of the spinal cord. Copper deficiency is a rare and often overlooked cause of spinal cord injury especially in the context of gastric bypass and zinc supplementation for wellness in today’s COVID era. More attention should be placed on copper deficiency as a root cause of gait ataxia.