J Med Toxicol. Queally JM, Devitt BM, Butler JS, et al. occurred. 3. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. 1988;43:299-303. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. The neurological symptoms that occur with cobalt metal poisoning include: Smith T, Edmonds CJ, Barbaby CF. Curr Orthop Pract. Arch Environ Health. J Toxicol Clin Toxicol. Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. 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). Based on the most recent level, which is really only about 2-3 times the normal limit, the toxicologist was not convinced that this was consistent with cobalt toxicity. 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. J Bone Joint Surg Br 2007; 89: 567-573. 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. 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. It is also dependent on whether the toxic effects of cobalt are from an acute or chronic exposure 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]. We are finding cobalt poisoning in too many patients with metal-on-plastic and metal-on-ceramic hips. For example, a notable historical example of cobalt toxicity is the cohorts of patients given cobalt chloride nearly 40 years ago to treat refractory anemia. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. Mao X, Wong AA, Crawford RW. You get this after contact with a low dose over a long time. And clouded judgment hurts people. This finding, if true, could be a game changer. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. 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. 7. What is Arthroplasty Cobalt Encephalopathy (ACE)? Arsenic poisoning, or arsenicosis, occurs after the ingestion or inhalation of high levels of arsenic. 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. 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. One issue Dr. Tower discovered was that ACE could occur with lower readings of cobalt in the body. Pritchett JW. 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]. Also, it is well past time for medical device companies to slow down and return to more extensive testing of new medical products. Recently in November 2013, Pizon et al. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. Cobalt toxicity can present with haematological, cardiovascular, immunological, gastrointestinal, endocrinological, dermatological, ophthalmological and neurological effects. Treatment options in cases with chronic cobalt poisoning include chelation therapy with EDTA or BAL/DMPS. 1999;37(7):839-844. These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. 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. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … ACE symptoms usually occurred one year before hip symptoms (pain, weakness, clicking, loosening, etc.) 2011;194:649-651. 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 has also been used as a treatment for anemia, because it stimulates red blood cell production. 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. Chronic poisoning. The effects of the cobalt alloy hips were life-altering for Frances. Cobalt poisoning is a common problem in patients with artificial hips. 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. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. 1973;5852:527-529. Therefore, the final recommendations for this patient were that he be re-evaluated by his pain specialist, undergo extensive psychiatric testing, and have his hips re-assessed by orthopedic surgery. Most of what is known about cobalt toxicity comes from cases of ingestion or inhalation of excess cobalt. Metal-on-metal hip resurfacing: advantages and disadvantages. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. 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. BMJ 1967; 1: 544-545. Health risks of chronic exposure . What is the Prognosis of Cobalt Poisoning? Letourneau EG, McCullough RS, Hollins JG. The more commonly reported value for cobalt metal ion concentration is the serum value, which is considered to be reflective of the extracellular fluid levels. 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. Instead, the toxicologist alluded to the fact that the patient was not taking his pain medication and was endorsing symptoms of worsening anxiety and depression, medical conditions he was diagnosed with prior to his bilateral hip replacements in 2008. Health risks of chronic exposure . In the United Kingdom, the Medicines and Healthcare Products Regulatory Agency (MHRA) recommends following patients with cobalt alloy-containing metal-on-metal hip prostheses for cobalt toxicity symptoms at least annually for five years post-implantation[1]. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. 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]. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. 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. Leggett RW. It happens when there’s friction between metal surfaces. You can swallow too much of it, breathe too much into your lungs, or have it come in constant contact with your skin. Therefore, elevated cobalt metal ion levels should always be interpreted within the context of the patient's clinical history. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. In 2010, the first published report of arthroprosthetic cobaltism specifically attributed to cobalt alloy-containing metal-on-metal hip prostheses was described[13]. The risk to the patient occurs with any artificial hip containing a cobalt component.” Conventional wisdom has been that eliminating the metal on metal contact should eliminate the risk of metallosis, but Dr. Tower at least does not accept this thinking. In general, improved case definitions, controlled studies, and improved surveillance are needed to fully elucidate the course of this relatively new disease and direct further investigations. It is used by the body in small amounts as part of vitamin B-12, to help make red blood cells and maintain the nervous system. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Learmonth ID, Case CP (2007) Metallic debris from orthopaedic implants. 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. Rochester, MN: The Laboratories; 2001. Absorption and retention of cobalt in man by whole-body counting. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. Health Phys.1972;22:359-367. The biokinetics of inorganic cobalt in the human body. Pizon AF, Abesamis M, King AM, Menke N. Prosthetic Hip-Associated Cobalt Toxicity. The contact form sends information by non-encrypted email, which is not secure. Cobalt ions induce chemokine secretion in primary human osteoblasts. 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. In his discussion Dr. Tower noted that after nine of his patients had revision surgeries, seven patients no longer showed signs of being cobalt-positive, and five of those seven improved neurologically. 2013 Nov 22 [Epub ahead of print]. What is Arthroplasty Cobalt Encephalopathy (ACE)? Br Med J. 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 a common problem in patients with artificial hips. It happens when there’s friction between metal surfaces. Vaping and Cobalt Poisoning. Therefore, the cobalt metal ion concentration value of concern is unknown. 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. 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. 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. I wrote about the health effects of metallosis on the body over a year ago. 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]. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. The diagnosis of cobalt toxicity is based on the combination of clinical history and laboratory confirmation. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. 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. Mayo Medical Laboratories interpretive handbook: interpretive data for diagnostic laboratory tests. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. Cobalt poisoning is a common problem in patients with artificial hips. 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. In the blood, cobalt metal ions bind to albumin with an estimated free fraction of approximately 5 to 12%[6]. 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. 1989;7(3):307-315. Post-mortem studies of the heart in these patients confirmed accumulation of cobalt within the myocardium. The main objective in treating symptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses is hardware revision or removal[1]. Case of cobalt poisoning. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. 2010;92(17):2847-2851. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. Cobalt ions induce chemokine secretion in primary human osteoblasts. The United Sates Food and Drug Administration (2013). Arsenic is a type of carcinogen that’s gray, silver, or white in color. Cobalt is an essential, transition group metal present in trace amounts in the human diet, notably in fish, vegetables, and drinking water. Hip Arthoplasty with the articular surface replacement (ASR) system: survivorship analysis and functional outcomes. 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. Toxins include organic solvents (with high blood-brain permeability) and metals (with sometimes poorly understood mechanisms of neural uptake). Released January 17, 2013. However, other studies have demonstrated persistence of neurologic symptoms even after the hardware is removed[1]. 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. 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]. He discovered that 57 were cobalt positive, meaning the cobalt urine test revealed 1 part per billion (ppb) or higher. 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). 2006;77(5):697-704. At the time of revision increasing concentrations of the alloy elements cobalt, chromium, and molybdenum were measured in the serum and liquor. Studies following patients with arthroprosthetic cobaltism have demonstrated symptom improvement and declining circulating cobalt metal ion levels after removal of the implanted hardware, especially in patients with endocrinopathies and cardiomyopathy. Case of cobalt poisoning. Symptoms come on slowly and can include: Leavelle DE, editor. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. Acute exposures are generally characterized by an allergic dermatitis. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. Cobalt poisoning is an intoxication brought on by having too much cobalt in the body. Signs and symptoms of cobalt poisoning can include visual 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. Does this settle the questions regarding artificial hip implants and metallosis? Instead, if there is a gradual increase in circulating cobalt metal ion concentrations or there are concerning systemic symptoms, the patient should be promptly evaluated by an orthopedic surgeon for appropriate further medical action. There are three basic ways that cobalt can cause poisoning. Instead, government authorities in the United States and United Kingdom have released recommendations for management of both symptomatic and asymptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses and elevated circulating cobalt metal ion concentrations. Unfortunately, no. The patient’s vision loss was attributed by ophthalmology to optic neuropathy and possible retinal toxicity from cobalt. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. This paper considers the increased risk of the development of lymphoma in patients with chronic inflammatory disease who undergo metal-on-metal arthroplasty. 1972;222:451-459. 7. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. Adverse reaction to metal debris: metallosis of the resurfaced hip. Cardiovascular dysfunction: A notable toxic effect of cobalt exposure is a severe and often fatal cardiomyopathy. (1) 1 Chronic exposure to cobalt by inhalation … 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 poisoning is intoxication caused by excessive levels of cobalt in the body. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. 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]. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Witzleb WC, Ziegler J, Krummenauer F, Neumeister V, et al. 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