In these patients, they advise to consider serial cobalt metal ion testing, but also strongly advise interpretation of these levels in the context of the patient's clinical symptoms, baseline renal function, and potential alternative sources of cobalt. However, other studies have demonstrated persistence of neurologic symptoms even after the hardware is removed[1]. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. As the metal builds up in your body, you can get sick. At the time of revision increasing concentrations of the alloy elements cobalt, chromium, and molybdenum were measured in the serum and liquor. For some unclear reason, cobalt salts stimulate the production of erythropoietin, and before the availability of recombinant human erythropoietin, cobalt salts were regularly used in clinical practice for the treatment of anemia[6]. Although, I have focused on the hypothyroidism and cardiomyopathy, other things have been reported from chronic cobalt poisoning including pericardial effusions, deafness, optic nerve atrophy, and peripheral neuropathy. Cobalt(II) may become cobalt chloride or bind to proteins. Coleman RF, Herrington J, Scales JT. Skin Malady: Exposure to cobalt can occasionally produce dermatitis, but typically hypersensitivity reactions are less commonly associated with cobalt than other metals, such as nickel. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. 1999;37(7):839-844. Sci Total Environ. Chronic arsenic poisoning is due to repeated or continuous exposure to arsenic compounds, which leads to an accumulation of arsenic in the body. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. Med J Aust. Dr. Tower has concluded that this approach is wrong, or at least incomplete, and he has seen that often the first signs of trouble with hip replacement patients are neurological symptoms. cobalt levels, it is likely that they may represent previously undescribed complications of cobalt toxicity. These patients also presented with severe neurologic and cardiac symptoms, hip pain resulting from periprosthetic metallosis, and elevated serum cobalt concentrations, up to 122 �g/L. Cobalt metal ion values are typically reported in units of micrograms/liter (�g/L). The patient's neurologic complaints are certainly found in patients with cobalt toxicity, but they are mostly subjective, non-specific, and when put in the context of the relatively low serum cobalt metal ion level, are unlikely to be the result of cobalt toxicity. The United Sates Food and Drug Administration (2013). Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. Chronic Toxic Encephalopathy . According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … The concentration of cobalt, in particular, was remarkably high. Smith T, Edmonds CJ, Barbaby CF. Leggett RW. Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. After 20 days of hospitalization, the patient’s decreased visual acuity and hearing were only mildly improved, her Symptoms usually arise after several years and may manifest as pneumoconiosis (with dyspnoea and cough secondary to interstitial fibrosis), an allergic alveolitis or occupational asthma. The effects of the cobalt alloy hips were life-altering for Frances. The diagnosis of cobalt toxicity is based on the combination of clinical history and laboratory confirmation. Simonsen LO, Harbak H, Bennekou P. Cobalt metabolism and toxicology - a brief update. But Dr. Tower has observed neurological problems in several patients with metal-on-plastic hips, or hips utilizing a ceramic ball with a metal cup. Case of cobalt poisoning. What is the Prognosis of Cobalt Poisoning? The symptoms of cobalt toxicity documented in the literature are variable, but typically involve derangements of endocrine, cardiac, and neurological function[1]: Endocrinopathy: The classic endocrinopathy associated with cobalt toxicity is hypothyroidism. Interestingly, the impetus for the inquiry leading to these recommendations was an increase in metal-on-metal hip device failure, not to address patients with systemic cobalt toxicity. Schaffer AW, Pilger A, Engelhardt C, Zwelmueller, et al. (1) 1 Chronic exposure to cobalt by inhalation … The prognosis of Cobalt Poisoning is dependent on the amount of substance consumed, time between consumption and treatment, severity of the symptoms, as well as general health status of the patient. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. If you are reading this article, you probably already know that cobalt and chromium are two metals used in the construction of most metal-on-metal (MoM) artificial hip systems. Cobalt toxicity - an emerging clinical problem in patients with metal-on-metal hip prostheses? As the metal builds up in your body, you can get sick. J Bone Joint Surg Br 2007; 89: 567-573. Studies of whole-body retention of inorganic cobalt in physiologically normal adult human males after intravenous injection demonstrated that approximately 40% of the dose was eliminated within the first 24 hours, 70% by one week, after one month 20% was retained, and after one year 10% was retained[7-8]. The Data on Cobalt Poisoning and Neuropsychiatric Complications. Finally, there is no current consensus regarding the management of patients with cobalt alloy-containing metal-on-metal hip prostheses and elevated circulating cobalt metal ion levels, and there is little information available regarding the clinical course of arthroprosthetic cobaltism from cobalt alloy-containing metal-on-metal hip prostheses. The preferred method of testing is inductively coupled mass spectrometry for metal ion value determination, and the typical patient specimens tested include serum, whole blood, or urine. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. An individual is exposed to this chemical element via inhalation, ingestion, or dermal exposure and, in general, chronic exposure is required for most of the adverse effects to develop.. Quesada MJ, Marker DR, Mont MA. Hip Arthoplasty with the articular surface replacement (ASR) system: survivorship analysis and functional outcomes. Cobalt poisoning is a common problem in patients with artificial hips. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … However, this practice was discontinued after some patients developed systemic symptoms of cobalt toxicity. 2008;389:259-269. Treatment options in cases with chronic cobalt poisoning include chelation therapy with EDTA or BAL/DMPS. Symptoms come on slowly and can include: The neurological symptoms that occur with cobalt metal poisoning include: Dr. Tower did a post-surgical study of his patients with artificial hips containing at least one component made from chromium/cobalt. These patients presented with combinations of deafness, blindness, cognitive decline, headaches, convulsions, fatigue, heart failure, and hypothyroidism, all had hip pain resulting from periprosthetic metallosis, and all had serum cobalt concentrations of more than 60 �g/L. Remember I am not a doctor and this is not medical advice. Cobalt toxicity can present with haematological, cardiovascular, immunological, gastrointestinal, endocrinological, dermatological, ophthalmological and neurological effects. Arsenic is a type of carcinogen that’s gray, silver, or white in color. Further studies validating these new proposed criteria are not currently available. Of course not. Studies on both animals and humans have shown that toxicity can happen in all organs of the body with exposure to non-radioactive cobalt. 1988;43:299-303. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. Queally JM, Devitt BM, Butler JS, et al. Schirrmacher UO. There are three basic ways that cobalt can cause poisoning. Metallosis is a type of metal poisoning that can occur as a side effect of joint replacement devices with metal components, such as metal-on-metal hip implants or some knee implants. And clouded judgment hurts people. You get this after contact with a low dose over a long time. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. Chronic tungsten poisoning. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. J Arthroplasty. J Bone Joint Surg Br 2007; 89: 567-573. Studies comparing the symptoms of patients pre-exposure, during exposure, at the point of maximal symptoms, and following hardware removal would be the most helpful in defining the clinical course of arthroprosthetic cobaltism, but these have not been performed. It is also recommended to perform cobalt metal ion testing and imaging studies for any patients that report painful hip replacements. This usually will only happen in industrial settings where large amounts of drilling, polishing, or other processes release fine particles containing cobalt into the air. Hard metal workers (involved, for example, in grinding metals) and soldiers with embedded shrapnel may be exposed to the risk of long-term tungsten exposure. J Med Toxicol. We are finding cobalt poisoning in too many patients with metal-on-plastic and metal-on-ceramic hips. The biggest concern is that corrosion, wear, and other mechanical factors of the cobalt alloy-containing metal-on-metal prosthetic produce metal debris in the form of wear particles, which subsequently release soluble cobalt metal ions into the joint space and into the systemic circulation[4]. Oral intake of Cr (VI) compound may cause Br Med J. When these criteria are applied to the currently published cases of arthroprosthetic cobaltism secondary to cobalt alloy-containing metal-on-metal hip prostheses, the circulating serum cobalt metal ion concentrations are typically very high, usually approaching 100 �g/L, before systemic cobalt toxicity is objectively identified. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. BMJ 1967; 1: 544-545. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al. The main objective in treating symptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses is hardware revision or removal[1]. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. This finding was well-documented in the 1960s among heavy beer drinkers after local breweries added cobalt chloride or cobalt sulfate to their beer as a foam stabilizer, so called beer drinkers' cardiomyopathy6. Cobalt poisoning is an intoxication brought on by having too much cobalt in the body. Over time, deposition of wear particles and metal ions in the joint space causes grey-black discoloration of the joint and elicits a localized chronic inflammatory response, findings referred to as metallosis. Recently in November 2013, Pizon et al. Adverse reaction to metal debris: metallosis of the resurfaced hip. So, does the patient described in the previous clinical vignette have arthroprosthetic cobaltism secondary to his bilateral cobalt alloy-containing metal-on-metal hip prostheses? ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. It has generally been accepted that cobalt readings below 4 ppb was not cause for concern, and some surgeons would not order further testing until the cobalt readings exceeded 7 ppb or even 10 ppb. Tower SS. Chronic poisoning. Health Phys. Symptoms of cobalt poisoning can include neurological damages, irregularities of the heart and even seizures. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. While elevated levels of chromium do not appear to result in heart problems, they can wreak havoc with the reproductive system. B-Chronic Toxicity 1-Non-Occupational Intoxication : Endemic outbreaks of cardiomyopathy with mortality rates up to 50% have been described among heavy consumers (up to 10L/day) of cobalt-contaminated beer giving an exposure of a few milligrams per day. Chronic cobalt poisoning may cause polycythemia, hyperplasia of the bone marrow and thyroid gland, pericardial effusion, and damage to the alpha cells of the pancreas. Following cessation of the chronic exposure, the concentration of cobalt decreases by 51�21% and 66�29% in the blood and urine, respectively[10]. Breathing in this cobalt dust can lead to chronic lung problems. In fact, cobalt and chromium are used to make artificial hips that are not metal-on-metal but instead use polyethylene liners, or ceramic heads, or other non-metal components. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. Injured by artificial hips suicide ), and are rarely occupational or.., which leads to an accumulation of arsenic in the serum and liquor based on the combination of history. 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