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. 1972;222:451-459. For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. This would include products such as the DePuy ASR hip and the Zimmer Durom hip (and several other metal-on-metal hip products, about which I have written often on this website). We are finding cobalt poisoning in too many patients with metal-on-plastic and metal-on-ceramic hips. During this appointment, he reported symptoms of intermittent confusion, short-term memory loss, difficulty concentrating, poor attention, dysthymia, increased falling episodes, fatigue, and chronic headaches since his bilateral hip replacements in 2008. Therefore, elevated cobalt metal ion levels should always be interpreted within the context of the patient's clinical history. Br Med J. Chronic arsenic poisoning is due to repeated or continuous exposure to arsenic compounds, which leads to an accumulation of arsenic in the body. But now a thoughtful surgeon is saying, “Hold up. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. 2010;92(17):2847-2851. And clouded judgment hurts people. Devlin JJ, Pomerleau AC, Brent J, Morgan BW, et al. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. from the Division of Toxicology at the University of Pittsburgh School of Medicine (Pittsburgh, PA, USA) proposed diagnostic criteria for arthroprosthetic cobaltism secondary to cobalt alloy-containing metal hip prostheses[18]. Cobalt is a naturally occurring element in the earth’s crust. Cobalt Chromium Metal Poisoning from Hip Replacements. The Data on Cobalt Poisoning and Neuropsychiatric Complications. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. The United Sates Food and Drug Administration (2013). Breathing in this cobalt dust can lead to chronic lung problems. Conventional total hip prostheses are composed of a metal head that fits into a plastic, polyethylene cup. However, this practice was discontinued after some patients developed systemic symptoms of cobalt toxicity. 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]. 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. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. Unfortunately, no. Cobalt poisoning symptoms may include: Rochester, MN: The Laboratories; 2001. However, studies comparing the clinical and laboratory features of patients with cobalt alloy-containing metal-on-metal hip prostheses and suspected cobalt toxicity to asymptomatic patients with metal-on-metal hip prostheses have not been performed. 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. For your dog to have a toxic amount of cobalt, they would have to swallow it, breathe too much into his lungs, or have constant contact with it. However, caution must be applied when testing and interpreting cobalt levels in patients with cobalt alloy-containing metal-on-metal prostheses since these patients tend to have incidentally higher circulating cobalt metal ion concentrations, sometimes greater than 5 �g/L, but may not have symptoms of cobalt toxicity. Queally JM, Devitt BM, Butler JS, et al. Chronic poisoning. He discovered that 57 were cobalt positive, meaning the cobalt urine test revealed 1 part per billion (ppb) or higher. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. 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]. This value was not derived from a comparison of symptomatic to asymptomatic patients with cobalt alloy-containing metal-on-metal prostheses, and thus does not serve as a threshold value to evaluate for systemic cobalt toxicity. Leggett RW. If the whole blood cobalt metal ion concentration in these patients is greater than 7 �g/L, a second metal ion test should be performed three months later and the patient should be assessed for cardiac and neurologic symptoms[1]. Nearly 400,000 hip arthroplasty procedures are performed annually in the United States, and over the past decade, there has been an increasing trend of utilizing cobalt alloy-containing metal-on-metal prosthetic hip joints[1]. Coleman RF, Herrington J, Scales JT. Simonsen LO, Harbak H, Bennekou P. Cobalt metabolism and toxicology - a brief update. Arsenic is a type of carcinogen that’s gray, silver, or white in color. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. It is also recommended to perform cobalt metal ion testing and imaging studies for any patients that report painful hip replacements. Toxins include organic solvents (with high blood-brain permeability) and metals (with sometimes poorly understood mechanisms of neural uptake). 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. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. The toxicologist evaluating the patient mentioned that the patient exhibited tangential speech, and that it was extremely difficult to elucidate a clear clinical history and progression of symptoms from the patient. 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. (1) 1 Chronic exposure to cobalt by inhalation … A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. In the United States, the FDA defines "symptomatic patients" as patients experiencing localized symptoms, such as pain or swelling at the hip, change in walking ability, and noise from the joint, after more than 3 months following implantation of the cobalt alloy-containing metal-on-metal hip prosthesis[17]. 1988;43:299-303. For many years my clients with failing artificial hips have asked me about the health effects of high cobalt and chromium levels in the body. 2013 Nov 22 [Epub ahead of print]. Curr Orthop Pract. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al. Released January 17, 2013. Therefore, the cobalt metal ion concentration value of concern is unknown. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. Therefore, metal-on-metal bearings have gained widespread popularity and have been used extensively, especially among younger, still active patients. The main objective of treatment is to eliminate the exposure to cobalt and to treat the systemic symptoms supportively, such as thyroid replacement therapy, beta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), diuresis, corticosteroid therapy, etc[1]. occurred. Their criteria are defined as: The authors explain that these criteria are not a means to evaluate for prosthetic hardware failure, but are a means to specifically identify systemic cobalt toxicity by eliminating potentially subjective clinical symptoms. Metallosis is not a good thing, as it is often a cause of early prosthesis failure, and the tissue damage resulting from metallosis can compromise subsequent revision arthroplasties[5]. One issue Dr. Tower discovered was that ACE could occur with lower readings of 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. J Bone Joint Surg Br 2007; 89: 567-573. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. 2012;432:210-215. 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. Dr. Steven Tower, an orthopedic surgeon in Alaska, recently gave a fascinating (and alarming) talk about the many neurological problems he has observed in hip patients with elevated cobalt levels in the body. Toxins include organic solvents (with high blood-brain permeability) and metals (with sometimes poorly understood mechanisms of neural uptake). 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? 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]. Cobalt poisoning from hip prosthesis is rare but debilitating. (1) 1 Chronic exposure to cobalt by inhalation … Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. 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. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. 3. Unfortunately, most neurologic symptoms are highly subjective, but some can be proven objectively, including optic nerve atrophy, audiometry-confirmed hearing loss, and abnormal neurologic function illustrated by electrodiagnostic studies such as an electroencephalograms (EEG) or electromyograms (EMG). Case of cobalt poisoning. In fact, if any part of an artificial hip contains chrome or cobalt materials, the patient is at risk for higher metal levels in the blood and neurological symptoms as a result. The FDA does not provide specific metal ion values that should trigger medical action, mostly because there is insufficient evidence to demonstrate a correlation between a specific cobalt metal ion level and specific pathology[17]. Most of what is known about cobalt toxicity comes from cases of ingestion or inhalation of excess cobalt. As recently as five years ago, the medical community mostly believed that metallosis derived from metal-on-metal artificial hips. These criteria were created as an objective approach to making the diagnosis of arthroprosthetic cobaltism since the evaluation of systemic cobalt toxicity in patients with metal hip prostheses is often complicated by limited published data, subjective patient symptoms, comorbid conditions, or secondary financial gain. Severe exposures to Cr (VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental. The biokinetics of inorganic cobalt in the human body. At least two test-confirmed symptoms that are consistent with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal ophthalmologic evaluation. 2011;194:649-651. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. J Bone Joint Surg Am. 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 has also been used as a treatment for anemia, because it stimulates red blood cell production. There are no established indications for chelation therapy[1]. 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. Adverse reaction to metal debris: metallosis of the resurfaced hip. Chronic Toxic Encephalopathy . The effects of the cobalt alloy hips were life-altering for Frances. Alexandersson R. Blood and urinary concentrations as estimators of cobalt exposure. More importantly though, wear particles from the prosthesis also release soluble cobalt metal ions into the systemic circulation, creating incidentally elevated circulating concentrations of cobalt metal ions in these patients. Lancet 369:542-544. This finding, if true, could be a game changer. Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. The patient described in the preceding clinical vignette is an excellent example of a concerning medical topic emerging in the current news. Among the patients who were diagnosed with ACE, the median length of time for onset of neurological symptoms was around seven years. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. A few studies have been conducted regarding the role of chelation therapy in arthroprosthetic cobaltism, but there is no reliable data to suggest its efficacy[1]. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. Symptoms come on slowly and can include: Cobalt toxicity can present with haematological, cardiovascular, immunological, gastrointestinal, endocrinological, dermatological, ophthalmological and neurological effects. When metal components grind together, as they naturally do when a MoM artificial hip is implanted in a person, very small metal particles can be released into the tissue and the bloodstream. Cobalt poisoning is a common problem in patients with artificial hips. He notes that the onset of symptoms with metal on plastic or ceramic occurs more slowly, but the symptoms themselves can be just as severe. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. What is Arthroplasty Cobalt Encephalopathy (ACE)? Health risks of chronic exposure . However, there have been recent safety concerns regarding these prostheses, including excessive revision rates, local reactions to the prosthetic device, and high circulating metal ion levels in patients, which have led to product recalls, a medical device alert, and issuance of clinical guidelines by the United States' Food and Drug Administration (FDA). To this day, it is unclear whether elevated cobalt metal ion levels should be considered toxic in patients with cobalt alloy-containing metal-on-metal prostheses, especially if they are asymptomatic, since no clear correlation has even been made between cobalt concentration and physiologic effects (to be discussed later)[12]. BMJ 1967; 1: 544-545. 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. It has been proposed that many of the adverse effects of cobalt are secondary to its high affinity for sulfhydryl groups. Inhalation - Pulmonary toxicity following chronic cobalt exposure is associated typically with the hard metal (tungsten carbide) industry. Chronic poisoning. 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.. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. There is no consensus regarding the treatment of patients with systemic symptoms of cobalt toxicity, and clinical response to these treatments is inconsistently documented in the current literature[1]. This paper considers the increased risk of the development of lymphoma in patients with chronic inflammatory disease who undergo metal-on-metal arthroplasty. You can swallow too much of it, breathe too much into your lungs, or have it come in constant contact with your skin. Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. Schirrmacher UO. In addition, he noted that the patient lacked other symptoms of systemic cobalt toxicity including hypothyroidism and cardiomyopathy. It happens when there’s friction between metal surfaces. 2 Cobalt is employed industrially in certain grades of steel and in tungsten carbide tools, and cobalt compounds are used as pigments in paints. Following cessation of the chronic exposure, the concentration of cobalt decreases by 51�21% and 66�29% in the blood and urine, respectively[10]. Smith T, Edmonds CJ, Barbaby CF. What is Arthroplasty Cobalt Encephalopathy (ACE)? Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. That’s a promising sign. Of the 57 patients with a cobalt positive test, 28 had symptoms consistent with Arthroplasty Cobalt Encephalopathy. When inhaled through the lungs, usually in the form of inorganic cobalt and cobalt oxide in dust and welding fumes, there is systemic dissemination of cobalt metal ions through the lymphatic and vascular system[6]. Cobalt is acutely toxic in large doses, and in cumulative long-term, low level exposure, i.e occupational exposure from cobalt processing plants, hard metal industry, diamond polishing, and the ceramic industry. 1999;37(7):839-844. However, other studies have demonstrated persistence of neurologic symptoms even after the hardware is removed[1]. Exposure to chromium, cobalt, and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. After 20 days of hospitalization, the patient’s decreased visual acuity and hearing were only mildly improved, her The main objective in treating symptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses is hardware revision or removal[1]. 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