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chronic cobalt poisoning

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). This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Yet, more importantly, these patients with cobalt alloy-containing metal-on-metal hip prostheses that require revision surgeries due to metallosis have elevated circulating cobalt levels and may be at risk for systemic cobalt toxicity. 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. 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). 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? The effects of the cobalt alloy hips were life-altering for Frances. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. Smith T, Edmonds CJ, Barbaby CF. Too often the pursuit of a blockbuster medical device or new prescription drug clouds a corporate board’s better judgment. Since cobalt has been shown to be carcinogenic and mutagenic in human and animal models, the potential for systemic toxicity and cancer risk are valid safety concerns for patients with these prostheses[4]. For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. 2013 Nov 22 [Epub ahead of print]. 2008;389:259-269. 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. Cobalt poisoning is a common problem in patients with artificial hips. He discovered that 57 were cobalt positive, meaning the cobalt urine test revealed 1 part per billion (ppb) or higher. Are Neurological Problems From Metallosis Limited to 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. A precise, unifying mechanism of cobalt toxicity remains unclear. Schirrmacher UO. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. In his assessment, the toxicologist noted that in the documented cases of arthroprosthetic cobaltism secondary to cobalt alloy-containing metal-on-metal hip prostheses, the serum cobalt metal ion concentration is often close to, if not greater than, 100 �g/L. Health risks of chronic exposure . Among the patients who were diagnosed with ACE, the median length of time for onset of neurological symptoms was around seven years. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. 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]. Chronic poisoning. Sometimes, metal particles (cobalt) are released … 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. 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.. Cobalt poisoning through chronic exposure may result in pulmonary fibrosis, cough, and dyspnea. Acta Orthop. 2011;194:649-651. J Orthop Res. Br Med J. 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. Cobalt Chromium Metal Poisoning from Hip Replacements. Health Phys.1972;22:359-367. Therefore, elevated cobalt metal ion levels should always be interpreted within the context of the patient's clinical history. 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. 7. There are three basic ways that cobalt can cause poisoning. Since these reports, DePuy Orthopaedics, Inc (Warsaw, IN) recalled their ASRTM metal-on-metal bearings because of a five year-prosthetic failure rate of more than 12% due to metallosis[3]. 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. Cobalt poisoning can occur when you are exposed to large amounts of it. It is a very small part of our environment and very small amounts are needed for many animals and humans to stay healthy.Cobalt poisoning can occur when you are exposed to large amounts of cobalt. Arch Environ Health. 3. Symptoms come on slowly and can include: It is an integral part of vitamin B12, and is required for oxygen transport in metabolism. Conventional total hip prostheses are composed of a metal head that fits into a plastic, polyethylene cup. 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. The goal of total hip replacement is to maintain a functional joint while simultaneously delaying the need for surgical revision or replacement for as long as possible. Health risks of chronic exposure . At the time of revision increasing concentrations of the alloy elements cobalt, chromium, and molybdenum were measured in the serum and liquor. Oral intake of Cr (VI) compound may cause Cobalt poisoning is intoxication caused by excessive levels of cobalt in the body. Multiple studies have confirmed that patients with cobalt alloy-containing metal-on-metal hip prostheses, especially bilateral and/or malfunctioning prostheses, have significantly higher concentrations of circulating cobalt metal ions, usually greater than 10 �g/L and even sometimes up to 100 times that of physiologic levels4, [14-16]. Case of cobalt poisoning. Eur J Orthop Surg Traumatol. The United Sates Food and Drug Administration (2013). 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. Queally JM, Devitt BM, Butler JS, et al. 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. In the blood, cobalt metal ions bind to albumin with an estimated free fraction of approximately 5 to 12%[6]. J Arthroplasty. 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]. 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. However, other studies have demonstrated persistence of neurologic symptoms even after the hardware is removed[1]. Health Phys. J Bone Joint Surg Br 2007; 89: 567-573. 2006;77(5):697-704. The concentration of cobalt, in particular, was remarkably high. Remember I am not a doctor and this is not medical advice. Sci Total Environ. Cobalt toxicity - an emerging clinical problem in patients with metal-on-metal hip prostheses? Tower SS. According to some sources, hypothyroidism is also considered to be the most sensitive indicator of cobalt toxicity. Following cessation of the chronic exposure, the concentration of cobalt decreases by 51�21% and 66�29% in the blood and urine, respectively[10]. Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. 2 Cobalt is employed industrially in certain grades of steel and in tungsten carbide tools, and cobalt compounds are used as pigments in paints. Instead, he attributed the slightly elevated serum cobalt metal ion level to mild leeching of cobalt from the prosthetic hip, a common occurrence in patients with prosthetic hips. 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. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. 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. Metal-on-metal hip resurfacing: advantages and disadvantages. Of the 57 patients with a cobalt positive test, 28 had symptoms consistent with Arthroplasty Cobalt Encephalopathy. 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 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]. (1) 1 Chronic exposure to cobalt by inhalation … Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. 2012;23(1):50-58. Therefore, metal-on-metal bearings have gained widespread popularity and have been used extensively, especially among younger, still active patients. 1973;5852:527-529. 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]. The diagnosis of cobalt toxicity is based on the combination of clinical history and laboratory confirmation. Absorption and retention of cobalt in man by whole-body counting. Increased Blood Cobalt and Chromium After Total Hip Replacement. It’s caused when the metal wears and introduces cobalt into the bloodstream. 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]. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. In addition, he noted that the patient lacked other symptoms of systemic cobalt toxicity including hypothyroidism and cardiomyopathy. 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. This finding, if true, could be a game changer. And clouded judgment hurts people. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. Leggett RW. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. Simonsen LO, Harbak H, Bennekou P. Cobalt metabolism and toxicology - a brief update. There are no established indications for chelation therapy[1]. November 3, 2016: (National Institute of Health) Seven substances added to 14th Report on Carcinogens Cobalt and cobalt compounds that release cobalt ions* in the body are being listed as reasonably anticipated to be a human carcinogen. As the metal builds up in your body, you can get sick. 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. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. You can check out that article here. What is Arthroplasty Cobalt Encephalopathy (ACE)? With chronic systemic exposure, cobalt accumulates in tissue, again primarily the liver and kidney, and the cobalt level will be elevated in the serum, whole blood, and urine[9]. BMJ 1967; 1: 544-545. 09: Signs Your Artificial Hip May Be Defective, Aqueous Film-Forming Foam (AFFF) and Cancer: What You Need to Know, Physical Therapist: Problems with Metal-on-Metal Hip Failures (Part 3), Physical Therapist: What It Feels Like When Artificial Hips Fail (Part 2), Physical Therapist Discusses Hip Replacement Surgery, Recovery (Part 1). Curr Orthop Pract. 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. Med J Aust. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. Laboratory confirmation of elevated serum or whole blood cobalt metal ion levels due to an implanted prosthetic hip. 1989;7(3):307-315. Therefore the 7 �g/L threshold was derived from a population reference range, and indicates a potential for periprosthetic soft tissue reaction/metallosis and a need for closer surveillance[1]. The patient’s vision loss was attributed by ophthalmology to optic neuropathy and possible retinal toxicity from cobalt. But now a thoughtful surgeon is saying, “Hold up. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … The benefits touted by metal-on-metal prostheses is that there is less device wear since cobalt-alloy containing metal prostheses have a higher resistance to wear than polyethylene, a decreased risk of dislocation because of new designs and engineering modifications, and a decreased risk of device fracture[2-3]. Chronic Toxic Encephalopathy . Some of the mechanisms proposed include inhibition of crucial enzymes in mitochondrial oxidative phosphorylation, inhibition of thyroid iodinase, inhibition and competition with calcium binding and signaling, generation of reactive oxygen species, and direct cytotoxicity[1, 6]. 8. Since 2006, there have been increasing reports in the literature of patients with cobalt alloy-containing metal prostheses developing systemic symptoms of cobalt toxicity, termed athroprosthetic cobaltism[13]. Cobalt poisoning is an intoxication brought on by having too much cobalt in the body. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. 2010;92(17):2847-2851. 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. Symptoms come on slowly and can include: 1988;43:299-303. J Med Toxicol. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. The patient described in the preceding clinical vignette is an excellent example of a concerning medical topic emerging in the current news. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. 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. 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]. Does this settle the questions regarding artificial hip implants and metallosis? Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. This paper considers the increased risk of the development of lymphoma in patients with chronic inflammatory disease who undergo metal-on-metal arthroplasty. Post-mortem studies of the heart in these patients confirmed accumulation of cobalt within the myocardium. According to one reference, a serum cobalt metal ion concentration greater than 1 �g/L is suggestive of excessive cobalt exposure, and a value greater than 5 �g/L is considered likely toxic[11]. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. You get this after contact with a low dose over a long time. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. 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. Pritchett JW. Cobalt poisoning is a common problem in patients with artificial hips. 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]. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. Cobalt or chromium poisoning can occur from the wear and tear of cobalt/chromium metal-on-metal hip implants. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. Also, it is well past time for medical device companies to slow down and return to more extensive testing of new medical products. 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