A Winged Scapula and Dropped Wrist: Cervical Radiculomyelopathy as an Unusual Presenting Manifestation of Copper Deficiency (P4.034)

OBJECTIVE: To describe a patient with an atypical neurological presentation of copper deficiency. BACKGROUND: Copper deficiency is rare, but has been well documented in humans. The most common neurologic presentation of acquired copper deficiency is that of a myelopathy or myelo-neuropathy. Here we report the first patient who presented uniquely with scapular winging and wrist drop secondary to cervical radiculo-myelopathy. We are unaware of similar published cases of radiculo-myelopathy as a presenting manifestation of copper deficiency. DESIGN/METHODS: Case report and review of literature. RESULTS: A 63-year old gentleman with history of gastrectomy 11 years ago presented with sub-acute onset shoulder pain and his right scapula becoming increasingly prominent. He also noticed recent inability in moving his right wrist upwards. On further questioning, he reported burning sensation of his legs and a sense of imbalance. On examination, he had right-sided scapular winging and wrist drop. He was diffusely hyper-reflexic with bilateral patellar and ankle clonus along with Babinski responses. He had dissociated large fiber sensory impairment below his umbilicus. Following an exhaustive workup for nutritional, inflammatory, immunologic, infectious, and malignant etiology (all of which were found to be normal), his serum copper (39μg/dL) and ceruloplasmin (17mg/dL) levels were found to be low. Nerve conduction study revealed acute on chronic right C7-C8 radiculopathy. Radial nerve biopsy showed non-specific decrease in the number of small and large myelinated axons. Two months later, after receiving copper supplementation, the patient reported improved shoulder movements, less pain and resolution of his wrist drop. However he still continued to have clinical features of myelopathy. CONCLUSIONS: Winging of scapula and wrist drop are common physical signs, although they could indeed be a clue to an underlying systemic disease. Clinicians should have a high index of suspicion for copper deficiency, in the context of known risk factors for malabsorption, especially in the setting of additional findings of a myelopathic process. Disclosure: Dr. Jacob has nothing to disclose. Dr. Gupta has nothing to disclose. Dr. Archer has nothing to disclose. Dr. Gundogdu has nothing to disclose.