Epiphyseal separation simulating pyarthrosis, secondary to copper deficiency, in an infant receiving total parenteral nutrition

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Abstract
In 1953 Baxter, Van Wyck and colleagues (Baxter & Van Wyck, 1953; Baxter et al, 1953) reported on a bone disorder in puppies fed a diet low in copper; the animals developed osteoporosis, fractures, epiphyseal separations. The bone changes had a striking resemblance to scurvy and healed completely with addition of copper to the animal's feeds. In the next three decades, a small number of clinical reports were published recording a syndrome in infants of anaemia, bone disease and hypocupraemia. Some of the infants developed this on the basis of malnutrition (Sturgeon & Brubaker, 1956; Cordano et al, 1964; Ashkenazai et al, 1971; Kozlowski & Walker-Smith, 1973) while others were patients receiving long-term total parenteral nutrition (TPN) (Karpel & Peden, 1972; Heller et al, 1978). Griscom and colleagues (1971) recorded a systemic bone disease occurring in premature infants, with X-ray findings of osteoporosis, fractures and epiphyseal slippage, despite adequate vitamin intake. They referred to Baxter and Van Wyck (1953) but did not know if their patients indeed had copper deficiency. We have had two cases of bone disease in infants receiving long-term total parenteral nutrition low in copper. The first patient had intractable diarrhoea and developed typical bone changes identical to scurvy. Our second case, reported in detail in this communication, concerns an infant on low-copper total parenteral nutrition (TPN) whose first clinical sign of copper deficiency was an epiphyseal shoulder separation that was confused clinically with pyarthrosis.