The neurological symptoms that occur with cobalt metal poisoning include: tremors Although cobalt is an essential element in dogs, an excess of cobalt can be fatal if not treated right away. 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. Cobalt poisoning through chronic exposure may result in pulmonary fibrosis, cough, and dyspnea. Chronic persistent diffuse injury to the brain with clinical manifestations involving cognitive impairment. 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. Cobalt(II) may become cobalt chloride or bind to proteins. 2012;23(1):50-58. cobalt toxicity . It is also recommended to perform cobalt metal ion testing and imaging studies for any patients that report painful hip replacements. Sometimes, metal particles (cobalt) are released … Therefore, elevated cobalt metal ion levels should always be interpreted within the context of the patient's clinical history. The patient described in the preceding clinical vignette is an excellent example of a concerning medical topic emerging in the current news. Shemesh S, Kosashvili Y, Heller S, Sidon E, et al. Health Phys. 2013 Jul 11 (ahead of print). 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]. For years the focus following hip replacement surgeries has been on the physical condition of the hip itself. Orthopaedic metals and their potential toxicity in the arthroplasty patient: a review of current knowledge and future strategies. 2006;77(5):697-704. Symptoms come on slowly and can include: You get this after contact with a low dose over a long time. Does this settle the questions regarding artificial hip implants and metallosis? 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. Clinical Features, Testing, and Management of Patients with Suspected Prosthetic Hip-Associated Cobalt Toxicity: a Systematic Review of Cases. Acta Orthop. 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. 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. Recently in November 2013, Pizon et al. 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]. Schaffer AW, Pilger A, Engelhardt C, Zwelmueller, et al. 8. Concentration of Wear Products in Hair, Blood, and Urine after Total Hip Replacement. 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. Cobalt poisoning is a common problem in patients with artificial hips. 7. Arthroprosthetic cobaltism: Neurological and Cardiac Manifestations in Two Patients with Metal-on-Metal Arthroplasty. Serum concentrations >1 mcg/L indicate possible environmental or occupational exposure, and concentrations >5 mcg/L are considered toxic. (1) 1 Chronic exposure to cobalt by inhalation … Cobalt ions induce chemokine secretion in primary human osteoblasts. Essentially, they suggest that these patients should be followed carefully and specifically questioned regarding alterations in neurological, cardiac, and endocrine function. Unfortunately, her story is one lived by the many who cope with neurological issues as a result of cobalt toxicity. 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. Vaping and Cobalt Poisoning. What is Arthroplasty Cobalt Encephalopathy (ACE)? It has been proposed that many of the adverse effects of cobalt are secondary to its high affinity for sulfhydryl groups. 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. Cobalt is an essential element for health in animals in minute amounts as a component of Vitamin B12. The neurological symptoms that occur with cobalt metal poisoning include: 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]. Alexandersson R. Blood and urinary concentrations as estimators of cobalt exposure. Cobalt poisoning is an intoxication brought on by having too much cobalt in the body. This finding, if true, could be a game changer. cobalt toxicity . When the metal parts rub against each other, they release microscopic metal particles into the blood and surrounding tiss… 1973;5852:527-529. An essential trace element, cobalt an cause serious adverse c health effects at high exposure levels. 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. Exposure to chromium, cobalt, and molybdenum from metal-on-metal total hip replacement and hip resurfacing arthroplasty. The heavy metal cobalt is used in making items like jet engines and diamond polishers. Cobalt poisoning is intoxication caused by excessive levels of cobalt in the 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. Chronic poisoning. 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]. 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. 2013 Nov 22 [Epub ahead of print]. 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. Learmonth ID, Case CP (2007) Metallic debris from orthopaedic implants. Cobalt-induced myocardial injury was also implicated in a study of hard metal workers chronically exposed to cobalt, and another study of Finnish cobalt workers revealed that cumulative cobalt exposure was associated with subclinical echocardiographic changes[6]. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. Cobalt toxicity - an emerging clinical problem in patients with metal-on-metal hip prostheses? One issue Dr. Tower discovered was that ACE could occur with lower readings of cobalt in the body. It’s caused when the metal wears and introduces cobalt into the bloodstream. Cobalt is an essential, transition group metal present in trace amounts in the human diet, notably in fish, vegetables, and drinking water. This paper considers the increased risk of the development of lymphoma in patients with chronic inflammatory disease who undergo metal-on-metal arthroplasty. J Arthroplasty. 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. 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 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. Lancet 369:542-544. 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). This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. The most worrisome form of cobalt poisoning occurs when you breathe too much into your lungs. Of course not. He discovered that 57 were cobalt positive, meaning the cobalt urine test revealed 1 part per billion (ppb) or higher. Devlin JJ, Pomerleau AC, Brent J, Morgan BW, et al. Queally JM, Devitt BM, Butler JS, et al. Cobalt toxicity can present with haematological, cardiovascular, immunological, gastrointestinal, endocrinological, dermatological, ophthalmological and neurological effects. The patient’s vision loss was attributed by ophthalmology to optic neuropathy and possible retinal toxicity from cobalt. 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. Cobalt is a chemical element with the symbol Co and atomic number 27. Health risks of chronic exposure . 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. Tower SS. ELEVATED BLOOD COBALT LEVELS IN A PATIENT WITH BILATERAL METAL-ON-METAL HIP PROSTHESES. 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]. 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. Others suggest that whole blood values provide a more accurate assessment of systemic exposure[1, 6]. In 2010, the first published report of arthroprosthetic cobaltism specifically attributed to cobalt alloy-containing metal-on-metal hip prostheses was described[13]. Chronic Toxic Encephalopathy . Coleman RF, Herrington J, Scales JT. 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. Further studies validating these new proposed criteria are not currently available. 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). 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]. 8. 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. There are no established indications for chelation therapy[1]. This type of implant is an artificial hip socket that is created by fitting a metal ball into a metal cup. After 20 days of hospitalization, the patient’s decreased visual acuity and hearing were only mildly improved, her As the metal builds up in your body, you can get sick. Absorption and retention of cobalt in man by whole-body counting. Cobalt poisoning from hip prosthesis is rare but debilitating. Simonsen LO, Harbak H, Bennekou P. Cobalt metabolism and toxicology - a brief update. 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. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. J Toxicol Clin Toxicol. 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 Data on Cobalt Poisoning and Neuropsychiatric Complications. 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 deficiency has never been described in humans, but cobalt toxicity has been well-documented. Chronic Effects (Noncancer): Cobalt is an essential element in humans and animals as a constituent of vitamin B 2. As the metal builds up in your body, you can get sick. Acute exposures are generally characterized by an allergic dermatitis. 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]. Chronic Toxic Encephalopathy . 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. Untreated chronic pain and depression are both known to contribute to cognitive changes and somatic symptoms. Cobalt is also component of cyanocobalamin also known as vitamin B12, which is widely consumed. I am a product liability lawyer with many clients who were injured by artificial hips containing cobalt and chromium. 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]. Chronic tungsten poisoning. Cobalt is a naturally occurring element in the earth’s crust. J Bone Joint Surg Br 2007; 89: 567-573. Cobalt chromium poisoning is a risk for anyone with a metal on metal (MoM) hip replacement. 1989;7(3):307-315. 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. Schirrmacher UO. Dr. Tower found that patients could have serious neurological issues caused by cobalt with readings of 1 ppb. 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