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. 2012;23(1):50-58. 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]. 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. You get this after contact with a low dose over a long time. What is Arthroplasty Cobalt Encephalopathy (ACE)? What is the Prognosis of Cobalt Poisoning? These questions usually arise after clients get blood work done and the test reveals abnormally high metal levels. A 2017 study in BMC Psychiatry looked at ten cases of metal-on-metal hip replacements. A deficiency of cobalt, which is very rare, is also potentially lethal, leading to pernicious anemia. 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. 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. 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). cobalt toxicity . One issue Dr. Tower discovered was that ACE could occur with lower readings of cobalt in the body. Health risks of chronic exposure . Conventional total hip prostheses are composed of a metal head that fits into a plastic, polyethylene cup. Witzleb WC, Ziegler J, Krummenauer F, Neumeister V, et al. (1) 1 Chronic exposure to cobalt by inhalation … Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. Leavelle DE, editor. 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. 2013 Nov 13 [Epub ahead of print]. Tower SS. 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. Does this settle the questions regarding artificial hip implants and metallosis? Sunderman FW Jr, Hopfer SM, Swift T, Rezuke WN, et al. Neurologic dysfunction: There are various neurotoxic symptoms described in patients with presumed cobalt toxicity, including hearing loss, tinnitus, optic nerve atrophy, visual impairment, convulsions, vertigo, headaches, tremors, polyneuropathy, incoordination, cognitive decline, and depression. 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? Smith T, Edmonds CJ, Barbaby CF. Eur J Orthop Surg Traumatol. The effects of the cobalt alloy hips were life-altering for Frances. 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. ACE is meant to identify a brain disease or associated neurological symptoms caused by elevated levels of cobalt from a metal artificial hip. 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]. J Bone Joint Surg Br 2007; 89: 567-573. Chronic Toxic Encephalopathy . He discovered that 57 were cobalt positive, meaning the cobalt urine test revealed 1 part per billion (ppb) or higher. The friction releases tiny metal particles into your bloodstream that could trigger a hypersensitive immune response in your body. 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]. Br Med J. But now a thoughtful surgeon is saying, “Hold up. Curr Orthop Pract. 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. Queally JM, Devitt BM, Butler JS, et al. Arch Environ Health. Adverse reaction to metal debris: metallosis of the resurfaced hip. Sci Total Environ. Therefore, elevated cobalt metal ion levels should always be interpreted within the context of the patient's clinical history. Further studies validating these new proposed criteria are not currently available. 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. Cobalt is a naturally occurring element in the earth’s crust. While elevated levels of chromium do not appear to result in heart problems, they can wreak havoc with the reproductive system. Acute poisoning is likely to occur through the oral route, whereas chronic poisoning is mainly from inhalation or skin contact [Meditext 2005]. Yet, even if a patient is symptomatic and highly suspicious for arthroprosthetic cobaltism, there is inadequate information provided by the FDA to guide clinical decision making because no consensus has been reached in regard to treatment of these patients. The Data on Cobalt Poisoning and Neuropsychiatric Complications. Cobalt toxicity - an emerging clinical problem in patients with metal-on-metal hip prostheses? Schirrmacher UO. Cobalt poisoning can occur when you are exposed to large amounts of it. As the metal builds up in your body, you can get sick. The metabolism of cobalt by the normal human male: whole body retention and radiation dosimetry. Although cobalt is an essential element in dogs, an excess of cobalt can be fatal if not treated right away. The main objective in treating symptomatic patients with cobalt alloy-containing metal-on-metal hip prostheses is hardware revision or removal[1]. Contributed by Jessica Dwyer, MD and Octavia Peck Palmer, PhD, http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. The concentration of cobalt, in particular, was remarkably high. Cobalt is a chemical element with the symbol Co and atomic number 27. J Bone Joint Surg Br 2007; 89: 567-573. 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. Pritchett JW. Mayo Medical Laboratories interpretive handbook: interpretive data for diagnostic laboratory tests. J Orthop Res. You can swallow too much of it, breathe too much into your lungs, or have it come in constant contact with your skin. It is also dependent on whether the toxic effects of cobalt are from an acute or chronic exposure Cobalt deficiency has never been described in humans, but cobalt toxicity has been well-documented. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al. 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]. 2013 Jul 11 (ahead of print). 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]. Absorption and retention of cobalt in man by whole-body counting. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. As recently as five years ago, the medical community mostly believed that metallosis derived from metal-on-metal artificial hips. Total hip replacement using implantable metal components is a common medical surgery that has been performed in North America for more than 50 years. 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]. Arsenic poisoning, or arsenicosis, occurs after the ingestion or inhalation of high levels of arsenic. Cobalt ions induce chemokine secretion in primary human osteoblasts. Arsenic is a type of carcinogen that’s gray, silver, or white in color. Most of what is known about cobalt toxicity comes from cases of ingestion or inhalation of excess cobalt. 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]. 2010;92(17):2847-2851. Sci Total Environ. Learmonth ID, Case CP (2007) Metallic debris from orthopaedic implants. Health Phys. There are three basic ways that cobalt can cause poisoning. However, this practice was discontinued after some patients developed systemic symptoms of cobalt toxicity. Post-mortem studies of the heart in these patients confirmed accumulation of cobalt within the myocardium. 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. 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 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]. There are three basic ways that cobalt can cause poisoning. 7. Cobalt poisoning is a common problem in patients with artificial hips. 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]. In addition, he noted that the patient lacked other symptoms of systemic cobalt toxicity including hypothyroidism and cardiomyopathy. The effects of the cobalt alloy hips were life-altering for Frances. Schirrmacher UO. 3. Therefore, metal-on-metal bearings have gained widespread popularity and have been used extensively, especially among younger, still active patients. Pizon AF, Abesamis M, King AM, Menke N. Prosthetic Hip-Associated Cobalt Toxicity. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … The biokinetics of inorganic cobalt in the human body. Cobalt poisoning is a common problem in patients with artificial hips. 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.. Among the patients who were diagnosed with ACE, the median length of time for onset of neurological symptoms was around seven years. 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). Cobalt poisoning can manifest with symptoms of varying degrees of severity and can even cause death. 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. 1999;37(7):839-844. This is a known risk with metal-on-metal implants, but newer data are showing that it is also a risk with metal-on-polyethylene implants. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. 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. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. Breathing in this cobalt dust can lead to chronic lung problems. 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]. 1972;222:451-459. 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. For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. Released January 17, 2013. 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 has also been used as a treatment for anemia, because it stimulates red blood cell production. 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. According to the CDC, "chronic exposure to cobalt-containing hard metal (dust or fume) can result in a serious … 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. Lancet 369:542-544. J Med Toxicol. That’s a promising sign. It happens when there’s friction between metal surfaces. 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. This finding, if true, could be a game changer. 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. 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. Chronic arsenic poisoning is due to repeated or continuous exposure to arsenic compounds, which leads to an accumulation of arsenic in the body. Exposure to chromium, cobalt, and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. 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. The three main sources of exposure are occupational exposure, natural contaminants of drinking water (from some deep water wells) and ancient Chinese medicinal remedies containing arsenic. Quesada MJ, Marker DR, Mont MA. He has even given it a name: Arthroplasty Cobalt Encephalopathy, or ACE. 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. Health Phys.1972;22:359-367. Cobalt poisoning can also occur from the wear and tear of some cobalt/chromium metal-on-metal hip implants. Unfortunately, no. There are no established indications for chelation therapy[1]. 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. Med J Aust. 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. 2008 Oct 23:69-73. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. 3. Rochester, MN: The Laboratories; 2001. At least two test-confirmed symptoms that are consistent with cobalt toxicity, i.e comprehensive neuro-cognitive testing, EMG, and/or formal ophthalmologic evaluation. You get this after contact with a low dose over a long time. 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. 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. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. The contact form sends information by non-encrypted email, which is not secure. It has, however, been noted that tungsten carbide appears to modify the toxicity of cobalt and that cobalt alone does not have the same potent toxic effects. And clouded judgment hurts people. 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. 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. 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. Cobalt is an essential, transition group metal present in trace amounts in the human diet, notably in fish, vegetables, and drinking water. 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. Therefore, the cobalt metal ion concentration value of concern is unknown. Therefore, there are no current definitive conclusions regarding the association of suspected arthroprosthetic cobaltism with specific clinical, physical, imaging, or laboratory findings. 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. Mao X, Wong AA, Crawford RW. Vaping and Cobalt Poisoning. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. ACE symptoms usually occurred one year before hip symptoms (pain, weakness, clicking, loosening, etc.) 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. The medical community has (slowly) accepted that MoM hips were a health problem and have moved away from their use. The neurological symptoms that occur with cobalt metal poisoning include: Following cessation of the chronic exposure, the concentration of cobalt decreases by 51�21% and 66�29% in the blood and urine, respectively[10]. Cobalt poisoning is a common problem in patients with artificial hips. Symptoms of cobalt poisoning can include neurological damages, irregularities of the heart and even seizures. 2013 Nov 22 [Epub ahead of print]. 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. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. 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]. Cobalt or chromium poisoning can occur from the wear and tear of cobalt/chromium metal-on-metal hip implants. Are Neurological Problems From Metallosis Limited to Metal-on-Metal Artificial Hips? Sometimes, metal particles (cobalt) are released … 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]. Acta Orthop. Laboratory confirmation of elevated serum or whole blood cobalt metal ion levels due to an implanted prosthetic hip. Cobalt and chromium can be released as the metal ball grinds against the metal cup when a person walks or moves. Inhalation - Pulmonary toxicity following chronic cobalt exposure is associated typically with the hard metal (tungsten carbide) industry. The United Sates Food and Drug Administration (2013). 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]. Health risks of chronic exposure . 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. Schaffer AW, Pilger A, Engelhardt C, Zwelmueller, et al. Also, it is well past time for medical device companies to slow down and return to more extensive testing of new medical products. The patient’s vision loss was attributed by ophthalmology to optic neuropathy and possible retinal toxicity from cobalt. 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. 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