Cobalt poisoning is a common problem in patients with artificial hips. 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. 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]. Chronic poisoning. It happens when there’s friction between metal surfaces. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. Cobalt metal ion values are typically reported in units of micrograms/liter (�g/L). 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. 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. Metal-on-metal hip resurfacing: advantages and disadvantages. 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]. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. 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. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Cobalt poisoning through chronic exposure may result in pulmonary fibrosis, cough, and dyspnea. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. Are Neurological Problems From Metallosis Limited to Metal-on-Metal Artificial 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. Symptoms come on slowly and can include: 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. Smith T, Edmonds CJ, Barbaby CF. These devices are made from a blend of several different metals, including chromium, cobalt, nickel, titanium and molybdenum. Letourneau EG, McCullough RS, Hollins JG. Health Phys. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. 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. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. The concentration of cobalt, in particular, was remarkably high. It is also recommended to perform cobalt metal ion testing and imaging studies for any patients that report painful hip replacements. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. Cobalt deficiency has never been described in humans, but cobalt toxicity has been well-documented. 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. Schirrmacher UO. 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. Does this settle the questions regarding artificial hip implants and metallosis? 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]. It has been proposed that many of the adverse effects of cobalt are secondary to its high affinity for sulfhydryl groups. There are three basic ways that cobalt can cause poisoning. Cobalt is a chemical element with the symbol Co and atomic number 27. 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. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. The Data on Cobalt Poisoning and Neuropsychiatric Complications. 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. 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). And clouded judgment hurts people. 2 Cobalt is employed industrially in certain grades of steel and in tungsten carbide tools, and cobalt compounds are used as pigments in paints. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al. Cobalt poisoning is intoxication caused by excessive levels of cobalt in the body. Cobalt has also been used as a treatment for anemia, because it stimulates red blood cell production. Cobalt poisoning is a common problem in patients with artificial hips. The main objective in treating symptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses is hardware revision or removal[1]. Schirrmacher UO. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … Following cessation of the chronic exposure, the concentration of cobalt decreases by 51±21% and 66±29% in … Cobalt Chromium Metal Poisoning from Hip Replacements. 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. 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]. When the metal parts rub against each other, they release microscopic metal particles into the blood and surrounding tiss… 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. Further studies validating these new proposed criteria are not currently available. 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. 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. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. In 2010, the first published report of arthroprosthetic cobaltism specifically attributed to cobalt alloy-containing metal-on-metal hip prostheses was described[13]. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. 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. Recently in November 2013, Pizon et al. 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. You can swallow too much of it, breathe too much into your lungs, or have it come in constant contact with your skin. 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]. Following a single dose of cobalt, the concentration in the blood and serum is initially high, but rapidly decreases to a low level within 24 hours due to the combination of tissue uptake, primarily in the liver and kidney, and urinary excretion. The neurological symptoms that occur with cobalt metal poisoning include: tremors 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]. What is Arthroplasty Cobalt Encephalopathy (ACE)? This finding, if true, could be a game changer. 2013 Jul 11 (ahead of print). J Bone Joint Surg Br 2007; 89: 567-573. Also, it is well past time for medical device companies to slow down and return to more extensive testing of new medical products. Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. 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. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. 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. Released January 17, 2013. 1989;7(3):307-315. As the metal builds up in your body, you can get sick. You can check out that article here. 2008;389:259-269. Schaffer AW, Pilger A, Engelhardt C, Zwelmueller, et al. Inhalation - Pulmonary toxicity following chronic cobalt exposure is associated typically with the hard metal (tungsten carbide) industry. According to some sources, hypothyroidism is also considered to be the most sensitive indicator of cobalt toxicity. 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. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Symptoms of cobalt poisoning can include neurological damages, irregularities of the heart and even seizures. 1988;43:299-303. Cobalt is an essential element for health in animals in minute amounts as a component of Vitamin B12. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. Cobalt ions induce chemokine secretion in primary human osteoblasts. 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). That’s a promising sign. Signs and symptoms of cobalt poisoning can include visual 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. 3. 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. Sci Total Environ. 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. Of course not. You get this after contact with a low dose over a long time. Arch Environ Health. As the metal builds up in your body, you can get sick. J Med Toxicol. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. 8. Cobalt is also component of cyanocobalamin also known as vitamin B12, which is widely consumed. Quesada MJ, Marker DR, Mont MA. Cardiovascular dysfunction: A notable toxic effect of cobalt exposure is a severe and often fatal cardiomyopathy. The effects of the cobalt alloy hips were life-altering for Frances. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. J Med Toxicol. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. Sunderman FW Jr, Hopfer SM, Swift T, Rezuke WN, et al. In the blood, cobalt metal ions bind to albumin with an estimated free fraction of approximately 5 to 12%[6]. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. 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. Witzleb WC, Ziegler J, Krummenauer F, Neumeister V, et al. 2010;92(17):2847-2851. Pritchett JW. Queally JM, Devitt BM, Butler JS, et al. Chronic arsenic poisoning is due to repeated or continuous exposure to arsenic compounds, which leads to an accumulation of arsenic in the body. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. Therefore, the cobalt metal ion concentration value of concern is unknown. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. J Bone Joint Surg Br 2007; 89: 567-573. Hip Arthoplasty with the articular surface replacement (ASR) system: survivorship analysis and functional outcomes. 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. Cobalt poisoning can occur when you are exposed to large amounts of it. 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. Post-mortem studies of the heart in these patients confirmed accumulation of cobalt within the myocardium. 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]. Chronic tungsten poisoning. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. Leavelle DE, editor. Breathing in this cobalt dust can lead to chronic lung problems. Absorption and retention of cobalt in man by whole-body counting. 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. cobalt toxicity . Mayo Medical Laboratories interpretive handbook: interpretive data for diagnostic laboratory tests. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. Simonsen LO, Harbak H, Bennekou P. Cobalt metabolism and toxicology - a brief update. 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. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Health Phys.1972;22:359-367. Acute exposures are generally characterized by an allergic dermatitis. Cobalt is a naturally occurring element in the earth’s crust. Sci Total Environ. 2013 Nov 22 [Epub ahead of print]. Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. Cobalt or chromium poisoning can occur from the wear and tear of cobalt/chromium metal-on-metal hip implants. The heavy metal cobalt is used in making items like jet engines and diamond polishers. 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]. 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 friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. 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. (1) 1 Chronic exposure to cobalt by inhalation … 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). You get this after contact with a low dose over a long time. Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. 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]. 2006;77(5):697-704. Mao X, Wong AA, Crawford RW. 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. But we need to start looking much more closely at the things we put into our bodies, whether it’s a Twinkie, a sleeping pill, or a metal artificial hip. J Arthroplasty. 2013 Nov 13 [Epub ahead of print]. The contact form sends information by non-encrypted email, which is not secure. 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. 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. It’s caused when the metal wears and introduces cobalt into the bloodstream. However, this practice was discontinued after some patients developed systemic symptoms of cobalt toxicity. Symptoms come on slowly and can include: 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. ACE symptoms usually occurred one year before hip symptoms (pain, weakness, clicking, loosening, etc.) Studies on both animals and humans have shown that toxicity can happen in all organs of the body with exposure to non-radioactive cobalt. BMJ 1967; 1: 544-545. 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]. 2011;194:649-651. Severe exposures to Cr (VI) compounds are usually accidental or intentional (suicide), and are rarely occupational or environmental. Rochester, MN: The Laboratories; 2001. 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. Lancet 369:542-544. 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.. J Bone Joint Surg Am. The diagnosis of cobalt toxicity is based on the combination of clinical history and laboratory confirmation. Although cobalt is an essential element in dogs, an excess of cobalt can be fatal if not treated right away. 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. Adverse reaction to metal debris: metallosis of the resurfaced hip. Laboratory confirmation of elevated serum or whole blood cobalt metal ion levels due to an implanted prosthetic hip. Queally JM, Devitt BM, Butler JS, et al. Signs and symptoms of cobalt poisoning can include visual Among the patients who were diagnosed with ACE, the median length of time for onset of neurological symptoms was around seven years. Case of cobalt poisoning. 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